Bacterial Meningitis and Meningococcal Septicaemia in Under 16s Diagnosis of Bacterial Meningitis and Meningococcal Septicaemia in Secondary Care

Diagnosis of bacterial meningitis and
meningococcal septicaemia in secondary care
NICE Pathways bring together everything NICE says on a topic in an interactive

flowchart. NICE Pathways are interactive and designed to be used online.
They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:
http://pathways.nice.org.uk/pathways/bacterial-meningitis-and-meningococcal-
septicaemia-in-under-16s
NICE Pathway last updated: 29 November 2021
This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.
Bacterial meningitis and meningococcal septicaemia in under 16s Page 1 of 16

© NICE 2022. All rights reserved. Subject to Notice of rights.
Diagnosis of bacterial meningitis and meningococcal septicaemia in secondary NICE Pathways
care

care
1 Child under 16 with suspected bacterial meningitis or meningococcal

septicaemia
No additional information
2 Specific investigations and immediate treatment when petechial rash

is present
Perform a very careful examination for signs of meningitis or septicaemia in children and young
people presenting with petechial rashes (see table 1 symptoms and signs of bacterial meningitis
and meningococcal septicaemia [See page 9]).
When to give intravenous ceftriaxone
Give intravenous ceftriaxone immediately to children and young people with a petechial rash if
any of the following occur at any point during the assessment (these children are at high risk of
having meningococcal disease):
petechiae start to spread

the rash becomes purpuric
there are signs of bacterial meningitis
there are signs of meningococcal septicaemia
the child or young person appears ill to a healthcare professional.
See management in secondary care.
Child with rash and fever
If a child or young person has an unexplained petechial rash and fever (or history of fever) carry
out the following investigations:
full blood count

CRP
coagulation screen
blood culture
whole-blood PCR for N meningitidis

care
blood glucose
blood gas.
Child with rash and fever but no high-risk clinical manifestations
In a child or young person with an unexplained petechial rash and fever (or history of fever) but
none of the high-risk clinical manifestations:
Treat with intravenous ceftriaxone immediately if the CRP and/or WBC count (especially
neutrophil count) is raised, as this indicates an increased risk of having meningococcal
disease.
Be aware that while a normal CRP and normal WBC count mean meningococcal disease is
less likely, they do not rule it out. The CRP may be normal and the WBC normal or low even
in severe meningococcal disease.
Assess clinical progress by monitoring vital signs (respiratory rate, heart rate, blood
pressure, conscious level (Glasgow Coma Scale and/or APVU), temperature), capillary refill
time, and oxygen saturations. Carry out observations at least hourly over the next 4–6
hours.
If doubt remains, treat with antibiotics and admit to hospital.
If the child or young person is assessed as being at low risk of meningococcal disease and is
discharged after initial observation, advise parents or carers to return to hospital if the child or
young person appears ill to them.
Child with non-spreading rash without fever who does not appear ill
Be aware that in children and young people who present with a non-spreading petechial rash
without fever (or history of fever) who do not appear ill to a healthcare professional,
meningococcal disease is unlikely, especially if the rash has been present for more than 24
hours. In such cases consider:
other possible diagnoses

performing a full blood count and coagulation screen.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
3. Management of petechial rash

care
3 Blood tests for bacterial meningitis and meningococcal disease
C-reactive protein test and white blood cell count for suspected bacterial meningitis
In children and young people with suspected bacterial meningitis, perform a CRP and WBC
count:
If the CRP and/or white blood cell count is raised and there is a non-specifically abnormal
CSF (for example consistent with viral meningitis), treat as bacterial meningitis.
Be aware that a normal CRP and WBC count does not rule out bacterial meningitis.
Regardless of the CRP and WBC count, if no CSF is available for examination or if the CSF
findings are uninterpretable, manage as if the diagnosis of meningitis is confirmed.
Polymerase chain reaction test for bacterial meningitis and meningococcal disease
Perform whole blood real-time PCR testing (EDTA sample) for N meningitidis to confirm a
diagnosis of meningococcal disease.
The PCR blood sample should be taken as soon as possible because early samples are more
likely to be positive.
Use PCR testing of blood samples from other hospital laboratories if available, to avoid
repeating the test.
Be aware that a negative blood PCR test result for N meningitidis does not rule out
meningococcal disease.
Submit CSF to the laboratory to hold for PCR testing for N meningitidis and S pneumoniae, but
only perform the PCR testing if the CSF culture is negative.
Be aware that CSF samples taken up to 96 hours after admission to hospital may give useful
results.
Quality standards
7. Blood tests

care
4 Cranial CT examination for suspected bacterial meningitis
Use clinical assessment and not cranial CT, to decide whether it is safe to perform a lumbar
puncture. CT is unreliable for identifying raised intracranial pressure.
If a CT scan has been performed, do not perform a lumbar puncture if the CT scan shows
radiological evidence of raised intracranial pressure.
In children and young people with a reduced or fluctuating level of consciousness (Glasgow
Coma Scale score less than 9 or a drop of 3 or more) or with focal neurological signs, perform a
CT scan to detect alternative intracranial pathology.
Do not delay treatment to undertake a CT scan.
Clinically stabilise children and young people before CT scanning.
If performing a CT scan consult an anaesthetist, paediatrician or intensivist.
5 Lumbar puncture and CSF examination for suspected bacterial

meningitis
Perform a lumbar puncture as a primary investigation unless this is contraindicated.
Do not allow lumbar puncture to delay the administration of parenteral antibiotics.
CSF examination should include WBC count and examination, total protein and glucose
concentrations, Gram stain and microbiological culture. A corresponding laboratory-determined
blood glucose concentration should be measured.
In children and young people with suspected meningitis or suspected meningococcal disease,
perform a lumbar puncture unless any of the following contraindications are present:
signs suggesting raised intracranial pressure

shock (see table 2 signs of shock [See page 12])
extensive or spreading purpura
after convulsions until stabilised
coagulation abnormalities

care
local superficial infection at the lumbar puncture site

respiratory insufficiency (lumbar puncture is considered to have a high risk
of precipitating respiratory failure in the presence of respiratory
insufficiency).
In children and young people with suspected bacterial meningitis, if contraindications to lumbar
puncture exist at presentation consider delaying lumbar puncture until there are no longer
contraindications. Delayed lumbar puncture is especially worthwhile if there is diagnostic
uncertainty or unsatisfactory clinical progress.
CSF WBC counts, total protein and glucose concentrations should be made available within 4
hours to support the decision regarding adjunctive steroid therapy.
Start antibiotic treatment for bacterial meningitis if the CSF WBC count is abnormal:
in neonates at least 20 cells/microlitre (be aware that even if fewer than 20 cells/microlitre,
bacterial meningitis should still be considered if other symptoms and signs are present (see
table 1 symptoms and signs of bacterial meningitis and meningococcal septicaemia [See
page 9])
in older children and young people more than 5 cells/microlitre or more than 1 neutrophil/
microlitre, regardless of other CSF variables.
See treatment with antibiotics.
In children and young people with suspected bacterial meningitis, consider alternative
diagnoses if the child or young person is significantly ill and has CSF variables within the
accepted normal ranges.
Consider herpes simplex encephalitis as an alternative diagnosis.
If CSF white cell count is increased and there is a history suggesting a risk of tuberculous
meningitis, evaluate for the diagnosis of tuberculous meningitis in line with the NICE Pathway
on assessing for active tuberculosis.
Perform a repeat lumbar puncture in neonates with:
persistent or re-emergent fever

deterioration in clinical condition
new clinical findings (especially neurological findings) or
persistently abnormal inflammatory markers.

care
Do not perform a repeat lumbar puncture in neonates:
who are receiving the antibiotic treatment appropriate to the causative organism and are
making a good clinical recovery
before stopping antibiotic therapy if they are clinically well.
Quality standards
5. Lumbar puncture for suspected bacterial meningitis
6. CSF microscopy for suspected bacterial meningitis
6 Skin samples
Do not use any of the following techniques when investigating for possible meningococcal
disease: skin scrapings, skin biopsies, petechial or purpuric lesion aspirates (obtained with a
needle and syringe).
7 Management in secondary care
See Bacterial meningitis and meningococcal septicaemia in under 16s / Management of

bacterial meningitis and meningococcal septicaemia in secondary care
8 Non-meningococcal septicaemia
See the NICE Pathway on sepsis.

care
Table 1 Symptoms and signs of bacterial meningitis and meningococcal

septicaemia
Common non-specific symptoms / signs
Meningococcal
Bacterial meningitis
disease
(meningococcal
(meningococcal Meningococcal
Symptom / sign meningitis and
meningitis and/or septicaemia
meningitis caused by
meningococcal
other bacteria)
septicaemia)
Fevera Y Y Y
Vomiting / nausea Y Y Y
Lethargy Y Y Y
Irritable / unsettled Y Y Y
Ill appearance Y Y Y
Refusing food / drink Y Y Y
Headache Y Y Y
Muscle ache / joint

Y Y Y
pain
Respiratory
symptoms / signs or Y Y Y
breathing difficulty

care
Less common non-specific symptoms / signs
Meningococcal
disease
(meningococcal
meningococcal
other bacteria)
septicaemia)
Chills / shivering Y Y Y
Diarrhoea, abdominal
Y Y Not known
pain / distension
Sore throat / coryza

or other ear, nose
Y Y Not known
and throat symptoms
/ signs
More specific symptoms / signs
Meningococcal
disease
(meningococcal
meningococcal
other bacteria)
septicaemia)
Non-blanching rashb Y Y Y
Stiff neck Y Y Not known

care
Altered mental statec Y Y Y
Capillary refill time

Not known Y Y
more than 2 seconds
Unusual skin colour Not known Y Y
Shock Y Y Y
Hypotension Not known Y Y
Leg pain Not known Y Y
Cold hands / feet Not known Y Y
Back rigidity Y Y Not known
Bulging fontanelled Y Y Not known
Photophobia Y Y N
Kernig's sign Y Y N
Brudzinski's sign Y Y N
Unconsciousness Y Y Y
Toxic / moribund
Y Y Y
state

care
Paresis Y Y N
Focal neurological
deficit including
cranial nerve Y Y N
involvement and
abnormal pupils
Seizures Y Y N
Y: symptom or sign present;
N: symptom or sign not present;
Not known: not reported in the evidence.
a
Not always present, especially in neonates;
b
Be aware that a rash may be less visible in darker skin tones – check soles of feet, palms or
hands and conjunctivae;
c
Includes confusion, delirium and drowsiness, and impaired consciousness;
d
Only relevant in children under 2 years.
Table 2 Signs of shock
Signs of shock include:
capillary refill time more than 2 seconds

unusual skin colour
tachycardia and/or hypotension
respiratory symptoms or breathing difficulty

care
leg pain
cold hands/feet
toxic/moribund state
altered mental state/decreased conscious level
poor urine output
Glossary
APVU
Alert, voice, pain, unresponsive.
CRP
C-reactive protein
CSF
Cerebrospinal fluid
CT
Computed tomography
EDTA
ethylenediaminetetraacetic acid
N. meningitidis
Neisseria meningitidis
PCR
polymerase chain reaction

care
_S pneumoniae
Streptococcus pneumoniae
WBC
white blood cell
Sources
Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and
management (2010 updated 2015) NICE guideline CG102
Your responsibility
Guidelines
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

care
Technology appraisals
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures

guidance
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.

care



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Diagnosis of bacterial meningitis and

meningococcal septicaemia in secondary care

NICE Pathways bring together everything NICE says on a topic in an interactive

Bacterial meningitis and meningococcal septicaemia in under 16s Page 1 of 16

Bacterial meningitis and meningococcal septicaemia in under 16s Page 2 of 16

1 Child under 16 with suspected bacterial meningitis or meningococcal

2 Specific investigations and immediate treatment when petechial rash

When to give intravenous ceftriaxone

petechiae start to spread

See management in secondary care.

Child with rash and fever

full blood count

Bacterial meningitis and meningococcal septicaemia in under 16s Page 3 of 16

Child with rash and fever but no high-risk clinical manifestations

other possible diagnoses

3. Management of petechial rash

Bacterial meningitis and meningococcal septicaemia in under 16s Page 4 of 16

3 Blood tests for bacterial meningitis and meningococcal disease

Bacterial meningitis and meningococcal septicaemia in under 16s Page 5 of 16

4 Cranial CT examination for suspected bacterial meningitis

Do not delay treatment to undertake a CT scan.

Clinically stabilise children and young people before CT scanning.

If performing a CT scan consult an anaesthetist, paediatrician or intensivist.

5 Lumbar puncture and CSF examination for suspected bacterial

Perform a lumbar puncture as a primary investigation unless this is contraindicated.

Do not allow lumbar puncture to delay the administration of parenteral antibiotics.

signs suggesting raised intracranial pressure

Bacterial meningitis and meningococcal septicaemia in under 16s Page 6 of 16

local superficial infection at the lumbar puncture site

See treatment with antibiotics.

Consider herpes simplex encephalitis as an alternative diagnosis.

Perform a repeat lumbar puncture in neonates with:

persistent or re-emergent fever

Bacterial meningitis and meningococcal septicaemia in under 16s Page 7 of 16

Do not perform a repeat lumbar puncture in neonates:

5. Lumbar puncture for suspected bacterial meningitis

6. CSF microscopy for suspected bacterial meningitis

7 Management in secondary care

See Bacterial meningitis and meningococcal septicaemia in under 16s / Management of

See the NICE Pathway on sepsis.

Bacterial meningitis and meningococcal septicaemia in under 16s Page 8 of 16

Table 1 Symptoms and signs of bacterial meningitis and meningococcal

Common non-specific symptoms / signs

Refusing food / drink Y Y Y

Muscle ache / joint

Bacterial meningitis and meningococcal septicaemia in under 16s Page 9 of 16

Less common non-specific symptoms / signs

Sore throat / coryza

More specific symptoms / signs

Stiff neck Y Y Not known

Bacterial meningitis and meningococcal septicaemia in under 16s Page 10 of 16

Altered mental statec Y Y Y

Capillary refill time

Unusual skin colour Not known Y Y

Hypotension Not known Y Y

Leg pain Not known Y Y

Cold hands / feet Not known Y Y

Back rigidity Y Y Not known