Meningitis – Emergency management in children

Purpose

This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with suspected acute meningitis in Queensland.

It has been developed by senior ED clinicians and Paediatricians across Queensland and endorsed for use across Queensland by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.

Introduction

Meningitis is a rare but serious paediatric ED presentation in which the membranes that surround the brain and spinal cord become inflamed. A variety of different microorganisms, including both viruses and bacteria can cause meningitis.¹

Bacterial meningitis

The mortality rate from bacterial meningitis ranges from 2% in children to 20% in neonates with up to a third of survivors experiencing transient or permanent neurological sequelae.² Approximately 90% of bacterial meningitis occurs in children less than five years of age.²

Bacterial infection in infants up to three months of age (corrected for prematurity) is typically acquired during birth through aspiration of intestinal and genital tract secretions from the mother (vertical transmission).³ Group B streptococci (subtype III), gram-negative enteric bacilli (Eschericha coli, Klebsiella and Enterobacter and in unvaccinated infants, Haemophilus influenzae), and Listeria monocytogenes (serotype IVb) are the most common causes of bacterial meningitis in this age group.

In the older child, the rates of meningitis are much lower with an estimated incidence of 1 per 5,901 febrile children aged 2 to 24 months.⁴ In older infants and children, bacterial meningitis usually develops after encapsulated bacteria (that have colonised the nasopharynx) are disseminated in the blood stream. The most common pathogens in children aged over three months are Streptococcus pneumoniae and Neisseria meningitidis. The incidence of bacterial meningitis has markedly declined in Australia with the introduction of the Hib and pneumococcal vaccines in the National Immunisation Program.^5-7

Viral meningitis

Viral meningitis is usually diagnosed following exclusion of bacterial meningitis, with enterovirus and coxsackie virus being the major causes.³ Parechovirus is also common in infants less than three months of age.

Herpes simplex virus meningitis without encephalitis is an infrequent cause of viral meningitis in children and usually has an excellent outcome even without antiviral therapy. HSV encephalitis however, is a particularly devastating form of herpes infection (especially in neonates) with significant morbidity and mortality if not treated appropriately. Patients may have a history of HSV in close contacts.

Patients with HSV meningoencephalitis can have disseminated disease, but specific features include:

• focal neurological signs e.g. dysphasia or hemiparesis
• focal seizures
• predominance of lymphocytes in the CSF
• skin lesions (may not be present)
• Altered mental state i.e. unusual behaviour, confusion, personality changes or emotional lability

Assessment

The aim of the assessment (history and clinical examination) is to identify children with meningitis promptly to enable appropriate management. Distinguishing between viral and bacterial meningitis on initial assessment can be difficult. Given the importance of early antibiotic treatment, it is safest to assume a bacterial cause until proven otherwise, especially in children less than five years.

Consider seeking senior emergency/paediatric advice as per local practice if meningitis is suspected.

Seek urgent senior emergency/paediatric advice as per local practice for a child with suspected meningitis who is unstable/toxic.

History

The clinical presentation of bacterial meningitis may be acute (hours to 1 – 2 days) or insidious (over a few days). A preceding upper respiratory tract infection is reported in up to 75% of patients.⁸ Apparent improvement with Paracetamol should not be used to exclude the diagnosis.

History should include specific information on:

• immunisations (reduces but not eliminates risk of infection)
• prior use of oral antibiotics (may modify clinical features and CSF findings resulting in a delay in diagnosis)⁹
• risk factors for infection

Examination

While the classic triad of fever, neck stiffness and headache is suggestive of meningitis, it is found in less than 50% of cases in older children and adolescents.^3,10 Older children may present with any combination of these and/or other symptoms including rash, upper or lower respiratory tract symptoms, myalgia and abdominal pain. In preverbal children, symptoms are even more nonspecific, and a high index of suspicion is required to avoid missing cases.⁷ A collection of nonspecific symptoms that include fever, neck stiffness and headache are more common in viral meningitis while neurological complications (including seizures and coma) are rare.¹¹

The presence of an apparent explanation for fever such as pharyngitis, UTI or otitis media does not rule out diagnosis.¹²

A high index of suspicion for meningitis is required for:

• all sick, febrile or hypothermic neonates (with or without the features described)
• all children presenting with fever and convulsions especially if aged less than two years.

Whilst the presentation varies with age, bacterial meningitis should be considered for any child with the clinical features outlined in the table below.

Fever and rash

The presence of a rash in a febrile child is often nonspecific and more likely to be caused by a viral illness than acute bacterial meningitis. Clinical judgement and decision making should be based on the entire clinical presentation and not just the rash. The rash associated with meningococcal disease may be maculopapular (in the earlier stages), petechial, or purpuric. Refer to Fever guideline and the Petechiae and Pupura Guideline [PDF 365.08 KB].

*May also occur in infants greater than three months.
Adapted from: van de Beek et al¹⁰ and Oostenbrink et al¹³ and Feigin et al ¹⁴

Differential diagnosis

• viral encephalitis
• viremia
• sepsis
• intracranial collections e.g. subdural empyema and brain abscess
• eosinophilic meningitis
• acute disseminated encephalomyelitis
• other infectious diseases e.g. pneumonia, otitis media, gastroenteritis, sinusitis and pharyngitis

Investigations

The definitive diagnosis of acute bacterial or viral meningitis is made on analysis of cerebrospinal fluid (CSF) obtained via lumbar puncture (LP). Where a LP is contraindicated or clinically unsafe (see box below), investigations such as blood cultures may be useful to diagnose bacterial infections and PCR testing on blood may be useful to diagnose meningococcal, pneumococcal or parechovirus infection.

Consider a clotting profile prior to LP if any clinical concerns around pre-existing coagulopathy e.g. sepsis, thrombocytopenia.

Ensure continuous pulse oximetry and heart rate monitoring during LP, due to the risk of airway obstruction and bradycardia. Avoid using procedural sedation if possible.

Lumbar puncture

Laboratory request

Request urgent CSF microscopy (includes Gram stain, WCC and differential), CSF protein and glucose, culture & sensitivity and PCR studies. In addition, if suspect viral aetiology, request viral PCR for enterovirus (and parechovirus if less than six months) and HSV plus VZV PCR (if varicella zoster virus is suspected). 10 drops of CSP in each of 3 numbered tubes is usually adequate to perform these tests.

CSF analysis

Consider seeking senior emergency/paediatric advice as per local practice if unsure of CSF interpretation.

No single CSF test parameter reliably identifies bacterial meningitis. Very rarely, culture proven bacterial meningitis can occur in a child with normal CSF findings.

Children with parechovirus are likewise less likely to have pleocytosis in the CSF¹⁹. Always correlate CSF results with clinical findings.

Traumatic tap

There are studies which can correlate white cell count to red cell count and protein ratios to red cells. However, rules based on a ‘predicted’ white cell count in the CSF are not reliable²⁰.

In order not to miss any meningitis cases, decision making regarding treatment should be conservative. If there are more white cells than the normal range for age, then the safest option is to treat.

Management

Refer to flowchart [PDF 705.5 KB] for a summary of the recommended emergency management and medications for children with suspected meningitis.

Consider seeking senior emergency/paediatric advice as per local practice if meningitis is suspected.

Seek urgent senior emergency/paediatric assistance as per local practice for a child with suspected meningitis who is unstable or toxic. Consider critical care.

Seek urgent paediatric critical care advice (onsite or via Retrieval Services Queensland (RSQ)) for the following children:

• in shock and not responding to initial treatment
• suspected raised ICP
• seizure

The absence of early appropriate senior input (including the absence of consultant supervision) during the first 24 hours in hospital is an independent risk factor for death.²¹

The initial management for a child suspected of having meningitis is the same as for any serious illness. The assessment and management should be performed simultaneously, and the child moved into the resuscitation area for stabilisation of airway, breathing, circulation, and disability (seizures/ hypoglycaemia). This assessment and stabilisation should be prioritised above any illness-specific diagnostic assessment or treatment.

Antibiotic therapy

Early use of appropriate antibiotics IV (and antivirals where HSV meningoencephalitis is considered, especially in neonates) has been shown to improve outcome. Empiric antibiotic therapy regimens are selected to cover the most likely pathogens for the selected age group.

The child should be admitted, and empiric antibiotic therapy continued until culture results are known to be negative or an organism and its sensitivity pattern are identified. Although Streptococcus pneumoniae penicillin resistance remains low in Queensland, in some countries the incidence of multi-resistant Streptococcus pneumoniae is on the rise and many are also resistant to the third-generation cephalosporins.^22,23 In critically ill children with suspected Streptococcus pneumoniae and children with gram positive cocci in CSF (depending on age and illness severity) add Vancomycin to empiric antibiotics. Consider consulting Infectious diseases physician for advice.

Antivirals

Aciclovir is not routinely required in children with meningitis. It is recommended for all children with suspected encephalitis. For Aciclovir dosing recommendations, refer to the relevant antimicrobial guidelines for your site (see above).

Corticosteroids

Corticosteroids should be considered in all suspected bacterial meningitis cases over three months of age, with administration ideally prior to or immediately following the first antibiotic IV dose.

Corticosteroids potentially improve patient outcome in acute bacterial meningitis by modulating the response to inflammatory mediators. The inflammatory response may be initiated in response to lysis of bacterial cell walls after the first antibiotic dose. However, there is no evidence of benefit in viral meningitis, neonatal bacterial meningitis, Gram-negative bacterial meningitis, or in children already on antibiotics (partially-treated meningitis).²⁴

A Cochrane review concluded that corticosteroids (used in conjunction with antibiotic therapy) significantly reduces hearing loss (but not overall mortality) in children with acute bacterial meningitis.²⁵

Fluid management

Initial fluid resuscitation is recommended as clinically indicated. Careful fluid management and electrolyte balance is important. Children with meningitis are at high risk of developing hyponatraemia associated with increased secretion of ADH.³ Fluid restriction is not recommended in the first 48 hours. It has not been shown to reduce the incidence of cerebral oedema in children with bacterial meningitis.¹ Titrate maintenance fluid rate to feeds, fluid deficit if present, and any ongoing losses. Assess hydration status, GCS and serum sodium every 6-12 hours initially.

Infection control measures

Standard precautions and droplet precautions should be observed during the care of a child with suspected or confirmed acute bacterial meningitis. Appropriate personal protective equipment must be worn when undertaking any procedure where there is a risk of exposure to blood or body fluids. All cases of suspected bacterial meningitis should be initially isolated in a single room until cleared or confirmed and ongoing isolation requirements discussed with the local hospital infection control team.

Public health notification

Under the Public Health Act 2005 (Qld) a provisional diagnosis (i.e. prior to laboratory confirmation) of N. meningitidis or Hib meningitis requires urgent notification to your local Public Health Unit to enable timely chemoprophylaxis [PDF 724.18 KB] for identified contacts.

Chemoprophylaxis

Chemoprophylaxis aims to eradicate asymptomatic carriage in contacts so that susceptible members of the group do not acquire the organism from the original carrier and develop an invasive infection. In meningococcal meningitis and Hib cases, chemoprophylaxis is offered to close (usually household) contacts of the primary index case.²⁶ Despite prophylaxis, disease may still occur. Advise contacts of the need for frequent, careful observation and to seek medical attention at the first signs of any unexplained illness.

Prophylaxis for health care workers is not routinely recommended. It is limited to staff in direct contact with the nasopharyngeal secretions of a child with suspected (or proven) meningococcal meningitis (where appropriate PPE was not used e.g. intubation or mouth-to-mouth resuscitation) or those who have had close contact nursing a child for more than six hours.²⁷

Escalation and advice outside of ED

Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Transfer is recommended if the child requires a higher level of care.

Critically unwell or rapidly deteriorating child

Non-critical child

Inter-hospital transfers

Disposition

Admission

Admission is required for:

• children with confirmed meningitis
• children in whom meningitis is suspected and unable to be excluded (due to delay in LP).

Ensure urgent notification to your local Public Health Unit as appropriate.

Children who have meningitis excluded on CSF but had received empiric antibiotic therapy IV will usually require a period of inpatient observation. Always seek senior emergency/paediatric advice on management and disposition of these children.

Consider admission for children with a previous diagnosis of viral meningitis and who represent with symptoms within 24 hours of discharge.

Following the exclusion of meningitis, discharge may be considered providing ALL of the following criteria are met:

• symptoms such as pain and vomiting are controlled
• clear alternative diagnosis which does not require inpatient management
• can be safely managed at home and return in event of deterioration (consider time of day, parent/carers comprehension and compliance, access to transport and distance to local hospital)

Discharge

On discharge:

• advise parent/caregiver to seek medical attention if any concerns prior to scheduled review appointment
• provide parent/caregiver with a Fever factsheet

Follow-up

• with General Practitioner within 24 – 48 hours
• All children with bacterial meningitis or encephalitis should have formal audiology assessment [PDF] within 1 week of diagnosis. Neurodevelopmental progress should be monitored as an outpatient.

Related documents

Guidelines and skill sheets

• Febrile illness
• Sepsis
• Audiology referral, assessment and monitoring of children following meningitis
• Holding for a Lumbar Puncture: Infant (PDF and video)

Factsheet

• Fever in children