Introduction

Meningitis is a life-threatening illness caused by infection and inflammation of the meninges. The infection can be caused by bacteria, virus, fungus or other rare organisms such as parasites and amoeba. Viral meningitis is more common, but it is less serious than bacterial meningitis.

Aim

The aim of this guideline is to outline the nursing care of an infant, child or young person with suspected or confirmed meningitis. This guideline has been staged, from initial assessment and management, which will occur most frequently in the emergency department, to ongoing assessments and management on the ward, as well as in the paediatric and neonatal intensive care areas. This guideline should be read in conjunction with the Meningitis-encephalitis statewide clinical practice guideline that provides a detailed outline of the medical treatment required

Definition of Terms 

• Encephalitis: Inflammation of the brain
• Fontanel: Soft gap between cranial bones in infants. Posterior fontanel usually close at 2-3months after birth. The Anterior fontanel usually closes at 18months after birth.
• Meninges: The membrane covering the brain and spinal cord. Made up of the dura mater, arachnoid mater, and pia mater.
• Modified GCS: Glasgow Coma Scale modified for the use in children.
• Petechiae: Pinpoint non-blanching spots.
• Photophobia: Intolerance to light.
• Phonophobia: Intolerance to loud noises.
• Purpuric Rash: Purpura are larger non-blanching spots ( <2mm)

Initial Assessment and Management

Features on History

• Infants with meningitis frequently present with non-specific symptoms such as fever, irritability, lethargy, poor feeding, vomiting and diarrhoea.
  
• Older children may complain of headache or photophobia.
  
• Seizures may occur.
  

Features on Examination

• In infants, the anterior fontanel will usually be full and may be bulging.
  
• Neck stiffness may or may not be present (not a reliable sign in young children).
  
• A purpuric rash is suggestive of meningococcal septicaemia.
  
• Kernig's sign: hip flexion with an extended knee causes pain in the back and legs.
  
• CSF shunts, spinal and cranial abnormalities (eg dermal sinuses) which may have predisposed a child to meningitis.
  
• Signs of encephalitis: altered conscious state, focal neurological signs.
  
• Infants may have a high pitched cry.
  

Assessment

Please refer to Nursing Assessment.

• Admission Assessment: Assess and record baseline vital signs: heart rate, blood pressure, respiratory rate, oxygen saturation, temperature, pain.
  
• Neurological assessment: Assess and record: level of consciousness using AVPU and/or modified GCS, seizure activity.
  
• Assess fontanel for fullness or bulging.
  
• Renal Assessment: Assess and record hydration status.
  
• Skin Assessment: Inspect skin for rash. A non-blanching, petechial/pupuric rash is indicative of acute meningococcal disease.
  

Nursing Assessment and Management

Initial Assessment 

• Vital signs and neurological observations including blood pressure must be done at 15-minute intervals for the first two hours, then at minimum of 4hrly when the child is stable.

• In infants, fontanel assessment and head circumference should be completed.

• Strict fluid balance including daily weight.

• Skin assessment to be done at least TDS and included into bedside handover, with any new or increasing rash identified.

• Monitor LP site for signs of infection or swelling at least once per shift (See Lumbar Puncture).

Ongoing Management

Treat seizures in the setting of meningitis immediately.

• See Seizure acute management CPG.

Administer antibiotics +/- Steroids as per MAR.

• Antibiotics must not be delayed for more than 30 minutes once the decision to treat has been made. 
• Delay to LP should not delay antibiotic administration, a delay to antibiotics is associated with poorer outcomes.
• If steroids are ordered, administer 15 minutes prior to parenteral antibiotics or, if this is not possible, within one hour of receiving their first dose of IV antibiotics. 
• Steroids are not recommended in neonates due to concern regarding effects on neurodevelopment.

In infants, head circumference should be measured daily.

• Increased head circumference indicates increased intra-cranial pressure.
  

Blood sampling

• Should continue 6-12hrly, until serum Na+ level is within normal ranges and stable (and/or the child is no longer on IV therapy)

Fluid management

• Intravenous fluid as ordered.
• Enteral feeds should be started when the child is stable.
• Enteral feeds should be withheld in children with a reduced level of consciousness, vomiting or having frequent convulsions.
• Children who are tolerating adequate oral hydration may only require fluid to keep the intravenous line patent.

Ensure adequate analgesia

• Pain can be related to meningeal irritation, LP wound or if subsequent fever from infection.

Low stimulus environment

• Reduce tactile handling of the child by clustering clinical care.
• A quiet, dimly lit room can reduce agitation, especially in children and young people experiencing photophobia and/or phonophobia.

Positioning

• Where possible, raise the head of the bed greater than 30 degrees and maintain a neutral alignment.

Intravenous access

• Maintain peripheral intravenous (IV) access and escalate loss of IV access to medical staff immediately. See Peripheral intravenous (IV) device management.
• Some infants, children and young people may have a central venous access device (CVAD) inserted. See Central venous access device management. Consider early intervention and advocation for Anaesthesia Vascular Access Service (AVAS) referral if the patient requires long term anti-biotics.  

More information about the assessment and management of children with Meningitis can be found in the Meningitis-encephalitis statewide clinical practice guideline.

Discharge Planning

• All patients treated for bacterial meningitis will have a formal audiology assessment 6-8 weeks after discharge, or earlier if there are concerns regarding hearing.
• Neurodevelopmental progress will be monitored in outpatients.
• Depending on the duration of treatment and stability of the child, the child may be eligible to be transferred to the Wallaby Ward for ongoing treatment requirements.
  

Special Considerations

Meningitis is a medical emergency. Nursing staff need to prioritise antibiotic treatment, as delays are associated with poorer outcomes. 

Bacterial Meningitis (excluding meningococcal meningitis) does not require isolation. Staff should don appropriate PPE when performing procedures such as blood sampling.

If Meningococcal Meningitis is suspected patients should be isolated and droplet precautions continued for 24 hours after administration of appropriate antibiotics. Order isolation status in Epic.

Testing the urine specific gravity to assess fluid status can be useful, especially in infants and children with a labile fluid status, and those on full maintenance intravenous fluids. This can be ordered in Epic and performed at the clinician’s discretion.

Companion Documents

• Parent information: Kids Health Info Fact Sheet: Meningitis  
  
• Parent information: Kids Health Info Fact Sheet: Lumbar Puncture
  
• Meningitis Statewide Guideline: Meningitis – Encephalitis 
  
• Nursing Assessment Guideline: Nursing Assessment
  
• Lumbar Puncture CPG: Lumbar Puncture 

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Brittany Hallpike, RN, Sugar Glider, and approved by the Nursing Clinical Effectiveness Committee. Updated March 2025.