Meningitis	Encephalitis
History Fever Immunisation history Recent antibiotic exposure Infant:  minimal or non-specific symptoms irritability lethargy or drowsiness poor feeding hyper or hypotonia vomiting and diarrhoea temperature instability Child, any of the above and/or: headache photophobia nausea altered conscious state   Preceding URTI may be present Seizures Medical condition that may predispose child to meningitis (eg CNS anatomical abnormality or shunt, immunosuppression, immunodeficiency)	History Fever Features of altered mental state can be subtle and depend on the affected region of the brain: unusual behaviour confusion personality change emotional lability Seizures (common) Headache Nausea and vomiting Consider other causes of encephalopathy eg ADEM, toxins or metabolic
Examination Full fontanelle High-pitched cry  Fever or hypothermia Apnoea Neck stiffness (may be absent in infants) Focal neurological signs  Purpuric rash is a late sign suggestive of meningococcal sepsis Pain and involuntary effort to reduce meningeal “stretch” eg Kernig and Brudzinski signs (see Additional notes below)	Examination Focal neurological signs

• Lumbar puncture (LP)
  • Defer if there are focal neurological signs, markedly reduced GCS, cardiovascular compromise or coagulopathy
  • Urgent CSF microscopy and biochemistry (preferably with simultaneous blood glucose)
  • Based on clinical presentation and initial CSF results consider further investigations eg multiplex or specific PCR testing for enterovirus, parechovirus, Neisseria meningitidis, Streptococcus pneumoniae or Herpes simplex virus (HSV)

• FBE (may be normal), Glucose, Serum sodium, Blood cultures
• Consider venous gas, coagulation studies if shock or coagulopathy suspected
• Consider LFTs, metabolic and toxicology testing if non-infective cause of encephalopathy is suspected
• Neuroimaging
  • Indications include:
    • encephalitis
    • focal neurological signs
    • signs of raised intracranial pressure (ICP)
    • diagnostic uncertainty (eg to look for a mass)
    • Is not routine in meningitis but is used to look for complications eg abscess, thrombosis
    • Normal head CT does not exclude raised ICP and should not influence the decision to perform an LP
    • MRI will provide more detailed information to guide diagnosis, but may require general anaesthetic
• EEG may be helpful in suspected encephalitis

Treatment

Antibiotics must not be delayed for more than 30 minutes after the decision to treat is made
Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines
Suggested antibiotic regimen, if local guidelines not available:

Age group	Common organisms	Empiric antibiotic	Dexamethasone
Meningitis
0–2 months	Group B streptococci (GBS), Escherichia coli, Listeria monocytogenes (rare)	Benzylpenicillin 60 mg/kg IV 12H (week 1 of life) 6–8H (week 2–4 of life) 4H (>week 4 of life) and cefotaxime 50 mg/kg (max 2 g) IV 12H (week 1 of life), 6–8H (week 2–4 of life), 6H (>week 4 of life)	Not advised
≥2 months	N meningitidis, HiB, S pneumoniae	Ceftriaxone 50 mg/kg (max 2 g) IV 12H or cefotaxime 50 mg/kg (max 2 g) IV 6H Add Vancomycin if Gram-positive cocci on Gram stain	0.15 mg/kg (max 10 mg) IV 6H for 4 days
Encephalitis
	HSV     Mycoplasma pneumoniae Other viruses: EBV, CMV, HHV6, Influenza Arboviruses	Aciclovir 20 mg/kg IV 12H (<30 weeks gestation), 8H (>30 weeks gestation to <3 months corrected age) 500 mg/m2  or 20 mg/kg IV 8H (3 months–12 years) 10 mg/kg IV 8H (>12 years) Consider adding azithromycin	Not advised

Steroids

• Current evidence for steroids in bacterial meningitis in children is mixed, but does suggest that steroids may reduce the risk of hearing loss
• Steroids are not recommended in neonates due to possible effects on neurodevelopment
• Give the first dose of IV dexamethasone just before or with the first dose of antibiotics. If giving the first dose of IV dexamethasone after initial antibiotic administration, this should ideally be done within 4 hours and not more than 12 hours after starting antibiotics.

Ongoing management

• All seizures in the setting of meningitis or encephalitis should be treated immediately
• Consult the fluid management in meningitis/encephalitis guideline to assist with fluid balance (restriction is often required)
• Monitor
  • Weight
  • Head circumference <2 yo
  • Vital signs including HR and BP
  • Electrolytes, urea, creatinine and blood glucose
  • Isolation: droplet precautions in first 24 hours of admission
  • Chemoprophylaxis for contacts

Directed treatment*
Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines
Suggested antibiotic regimen, if local guidelines not available:

Organism	Antibiotics	Duration (days)
N meningitidis	Benzylpenicillin	7
S pneumoniae (penicillin sensitive)	Benzylpenicillin	10
S pneumoniae (penicillin resistant)	Vancomycin	10
HiB	Ceftriaxone/cefotaxime	10
Gram-negative	Ceftriaxone/cefotaxime	21
Organism not isolated	Ceftriaxone/cefotaxime	7 minimum
GBS, Listeria	Benzylpenicillin	14–21
HSV	Aciclovir	21 minimum

* consider Infectious Diseases consultation for those with organisms resistant to first line therapy or with immediate hypersensitivity to penicillins/cephalosporins

Notification

• All cases of presumed or confirmed N meningitidis and HiB should be notified to the Health Department immediately
• Confirmed S pneumoniae is notifiable within 5 days
• Follow state guidelines

Complications

• Persistent fever after 4–6 days of treatment consider:
• nosocomial infection
• subdural effusion or empyema
• cerebral abscess or parameningeal foci of ongoing infection
• inadequate treatment
• Hearing impairment
• Neurodevelopmental impairment
• Multi-organ involvement due to primary pathogen or secondary to septic shock (eg hepatic or cardiac)
• Venous sinus thrombosis
• Seizures, subsequent epilepsy
• Permanent focal neurological deficit
• Hydrocephalus

Follow-up

• All children with encephalitis or bacterial meningitis should have a formal audiology assessment 6–8 weeks after discharge (earlier if concerns)
• Neurodevelopmental progress should be monitored in outpatients
• Consider investigating for complement deficiency if the child has had >1 episode of meningococcal disease

Consider consultation with local paediatric team 

• All children with suspected encephalitis or bacterial meningitis
• All children with concern for non-infectious encephalopathy

Consider transfer when

• Haemodynamic or respiratory instability
• Altered conscious state or focal neurological signs
• Child requiring care above the level of comfort of the local hospital
• Complications of meningitis or encephalitis or poor response to treatment

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when 

Children can complete IV treatment through HITH services if available once haemodynamically stable, afebrile and decision made regarding directed treatment

Parent information sheet

Lumbar Puncture
Meningitis
Meningococcal infection