Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Recommendations on bacterial meningitis also cover meningococcal meningitis without meningococcal sepsis. Recommendations on meningococcal disease cover meningococcal sepsis with or without meningococcal meningitis.

For recommendations on treating bacterial meningitis in newborn babies in hospital, see the NICE guideline on neonatal infection.

For more guidance on recognising, diagnosing and managing sepsis (including for newborn babies), see the NICE guideline on suspected sepsis.

1.1 Recognising bacterial meningitis and meningococcal disease

1.1.1

When considering a diagnosis of bacterial meningitis or meningococcal disease, be aware that:

1.1.3

For people with reduced consciousness or communication difficulties, ask family members or carers about recent changes in symptoms.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on recognising bacterial meningitis and meningococcal disease.

Full details of the evidence and the committee's discussion are in evidence review A1: symptoms and signs associated with bacterial meningitis and evidence review A3: symptoms and signs associated with meningococcal disease.

When to suspect bacterial meningitis

1.1.4

Strongly suspect bacterial meningitis in people with all the symptoms in the red flag combination:

  • fever

  • headache

  • neck stiffness

  • altered level of consciousness or cognition (including confusion or delirium).

1.1.5

Bacterial meningitis can still be strongly suspected based on clinical assessment, even in people who do not have all the symptoms in the red flag combination.

1.1.6

Suspect bacterial meningitis based on assessment of the symptoms and signs in table 1 (for babies, children and young people) or table 2 (for adults), and the section on risk factors. Take into account that:

  • bacterial meningitis can present with any of these symptoms and signs

  • the more symptoms and signs a person has, the more likely it is that they have bacterial meningitis.

Table 1 Symptoms and signs that may indicate bacterial meningitis in babies, children and young people
Symptoms and signs in babies, children and young people

Red flag combination

–

Fever, headache, neck stiffness, and altered level of consciousness or cognition (including confusion or delirium)

Fever and neck stiffness are less common in babies.

Headache and neck stiffness are harder to identify in babies and young children.

See recommendations 1.1.4 to 1.1.6 on when to strongly suspect or suspect bacterial meningitis.

Appearance

–

Bulging fontanelle

In babies and young children with an open fontanelle.

Fever

Fever, headache, neck stiffness and altered level of consciousness or cognition are the red flag combination for bacterial meningitis.

Fever is less common in babies.

Ask the child or young person (or their family members or carers) if they have taken antipyretics, because this may make fever harder to identify.

For other possible causes of fever in under 5s, see table 3 in the NICE guideline on fever in under 5s.

For children under 6 months, see recommendation 1.2.11 in the NICE guideline on fever in under 5s.

Ill appearance

Ask the child or young person (or their family members or carers) if they have taken antipyretics, because this may make ill appearance harder to identify.

Non-blanching petechial or purpuric rash

Mainly in meningococcal disease (with or without meningococcal meningitis). See table 3 on symptoms and signs that may indicate meningococcal disease.

Check all over the body and look for petechiae in the conjunctivae.

May be difficult to see on brown, black or tanned skin.

Pale, mottled skin or cyanosis

May be difficult to see on brown, black or tanned skin.

Behaviour

–

Irritability

Common in babies and young children.

Lethargy

Common in babies and young children.

Reduced feeding

In babies.

Unusual behaviour

For example, the person may be agitated, aggressive or subdued.

Ask family members or carers about changes in the child or young person's behaviour.

For more guidance on identifying changes in babies, children and young people who do not communicate verbally, see recommendation 1.2.14 in the NICE guideline on babies, children and young people's experience of care.

Weak, high-pitched or continuous cry

In babies.

Cardiovascular

–

Early signs of sepsis

Signs of shock

See table 3 on symptoms and signs that may indicate meningococcal disease.

For more guidance on assessing for sepsis, see the sections on evaluating risk in the NICE guideline on suspected sepsis.

Neurological

–

Altered level of consciousness or altered cognition (including confusion or delirium)

Fever, headache, neck stiffness and altered level of consciousness or cognition are the red flag combination for bacterial meningitis.

Focal neurological deficits

–

Headache

Fever, headache, neck stiffness and altered level of consciousness or cognition are the red flag combination for bacterial meningitis.

Babies and children and young people with cognitive impairment or communication difficulties may not be able to report headache.

Neck stiffness, including more subtle discomfort or reluctance to move the neck

Fever, headache, neck stiffness and altered level of consciousness or cognition are the red flag combination for bacterial meningitis.

Neck stiffness is less likely and harder to identify in babies.

Neck stiffness is harder to identify in children and young people with cognitive impairment or communication difficulties.

Photophobia

Harder to identify in babies.

Seizures

–

Respiratory

–

Tachypnoea, apnoea, and grunting

Non-specific signs of illness, including sepsis and meningitis in babies.

Other

–

Unexplained body pain, including limb, back or abdominal pain

–

Vomiting

–
Table 2 Symptoms and signs that may indicate bacterial meningitis in adults
Symptoms and signs in adults Notes

Red flag combination

–

Fever, headache, neck stiffness, and altered level of consciousness or cognition (including confusion or delirium)

Fever is less common in older adults.

Headache and neck stiffness are harder to identify in adults with cognitive impairment.

Neck stiffness is harder to identify in adults with dementia or arthritis.

Altered level of consciousness or cognition may be missed in young adults and older adults.

See recommendations 1.1.4 to 1.1.6 on when to strongly suspect or suspect bacterial meningitis.

Appearance

–

Fever

Fever, headache, neck stiffness and altered level of consciousness or cognition are the red flag combination for bacterial meningitis.

Ask the person (or their family members or carers) if they have taken antipyretics, because this may make fever harder to identify.

Fever is less common in older adults.

Ill appearance

Ask the person (or their family members or carers) if they have taken antipyretics, because this may make ill appearance harder to identify.

Non-blanching petechial or purpuric rash

Mainly in meningococcal meningitis and meningococcal disease (with or without meningococcal meningitis). See table 3 on symptoms and signs that may indicate meningococcal disease.

Check all over the body and look for petechiae in the conjunctivae.

May be difficult to see on brown, black or tanned skin.

Pale, mottled skin or cyanosis

May be difficult to see on brown, black or tanned skin.

Behaviour

–

Irritability

–

Lethargy

Common in older adults.

Unusual behaviour

For example, the person may be agitated, aggressive or subdued.

Bacterial meningitis may be missed in older adults with delirium or altered consciousness.

In young people and young adults, altered behaviour may be incorrectly assumed to be caused by alcohol or substance misuse, and bacterial meningitis can be missed as a result.

Cardiovascular

–

Early signs of sepsis

Signs of shock

See table 3 on symptoms and signs that may indicate meningococcal disease.

For more guidance on assessing for sepsis, see the sections on evaluating risk in the NICE guideline on suspected sepsis.

Neurological

–

Altered level of consciousness or altered cognition (including confusion or delirium)

Fever, headache, neck stiffness and altered level of consciousness or cognition are the red flag combination for bacterial meningitis.

Bacterial meningitis may be missed in older adults with delirium or altered consciousness.

In young people and young adults, altered level of consciousness may be incorrectly assumed to be caused by alcohol or substance misuse, and bacterial meningitis can be missed as a result.

Focal neurological deficits

–

Headache

Fever, headache, neck stiffness and altered level of consciousness or cognition are the red flag combination for bacterial meningitis.

Adults with cognitive impairment or communication difficulties may not be able to report headache.

Neck stiffness, including more subtle discomfort or reluctance to move the neck

Fever, headache, neck stiffness and altered level of consciousness or cognition are the red flag combination for bacterial meningitis.

Neck stiffness is less likely and harder to identify in older adults.

Neck stiffness is harder to identify in adults with cognitive impairment, communication difficulties, dementia or arthritis.

Photophobia

–

Seizures

–

Other

–

Unexplained body pain, including limb, back or abdominal pain

–

Vomiting

–
Risk factors
1.1.8

Be on heightened alert to the possibility of bacterial meningitis (including meningococcal meningitis) in people with any of these risk factors:

  • missed relevant immunisations, such as meningococcal, Haemophilus influenzae type b (Hib) or pneumococcal vaccines

  • reduced or absent spleen function

  • congenital complement deficiency or acquired inhibition

  • they are a student in further or higher education, particularly if they are in large shared accommodation (such as halls of residence)

  • a family history of meningococcal disease

  • they have been in contact with someone with Hib disease or meningococcal disease, or have been in an area with an outbreak of meningococcal disease

  • a previous episode of bacterial meningitis or meningococcal disease

  • a cerebrospinal fluid leak

  • a cochlear implant.

For newborn babies, see the risk factors for neonatal infection (not specific to meningitis) in the NICE guideline on neonatal infection:

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on when to suspect bacterial meningitis.

Full details of the evidence and the committee's discussion are in evidence review A1: symptoms and signs associated with bacterial meningitis and evidence review A2: risk factors associated with bacterial meningitis.

When to suspect meningococcal disease

1.1.9

Strongly suspect meningococcal disease in people with any of these red flag symptoms:

  • haemorrhagic, non-blanching rash with lesions larger than 2 mm (purpura)

  • rapidly progressive and/or spreading non-blanching petechial or purpuric rash

  • any symptoms and signs of bacterial meningitis (see tables 1 and 2), when combined with a non-blanching petechial or purpuric rash.

1.1.10

Do not rule out meningococcal disease just because a person does not have a rash.

1.1.11

Suspect meningococcal disease based on assessment of the symptoms and signs in table 3, and the section on risk factors. Take into account that meningococcal disease can present with any combination of the non-specific symptoms and signs of severe illness in table 3.

1.1.12

When looking for a rash:

  • check all over the body (including nappy areas), and check for petechiae in the conjunctivae

  • note that rashes can be hard to detect on brown, black or tanned skin (look for petechiae in the conjunctiva)

  • tell the person and their family members or carers to look out for any changes in the rash, because it can change from blanching to non-blanching.

Table 3 Symptoms and signs that may indicate meningococcal disease for babies, children, young people and adults
Symptom or sign Notes

Red flags

–

Haemorrhagic, non-blanching rash with lesions larger than 2 mm (purpura)

Rapidly progressive and/or spreading non-blanching petechial or purpuric rash

Any symptoms and signs of bacterial meningitis (see tables 1 and 2), when combined with a non-blanching petechial or purpuric rash

Check all over the body and look for petechiae in the conjunctivae.

Rashes may be difficult to see on brown, black or tanned skin.

Non-specific symptom or sign

–

Appearance

–

Ill appearance

Ask the person (or their family members or carers) if they have taken antipyretics, because this may make ill appearance harder to identify.

Pale, mottled skin or cyanosis

May be difficult to see on brown, black or tanned skin.

Parent or carer concern

–

Behaviour

–

Lethargy, does not wake or if roused does not stay awake

Common in babies, young children and older adults.

Unusual behaviour

For example, the person may be agitated, aggressive or subdued.

Meningococcal disease may be missed in older adults with delirium or altered consciousness.

In young people and young adults, altered behaviour may be incorrectly assumed to be caused by alcohol or substance misuse, and meningococcal disease can be missed as a result.

Weak, high-pitched or continuous cry

In babies.

Cardiovascular

–

Cold hands and feet

–

Heart rate less than 60 beats per minute

In babies and children under 12 years.

High age-specific heart rate

For age-specific heart rates, see the sections on evaluating risk in the NICE guideline on suspected sepsis.

Low age-specific blood pressure

For age-specific blood pressures, see the sections on evaluating risk in the NICE guideline on suspected sepsis.

Hydration

–

Capillary refill time of 3 seconds or longer

–

Reduced urine output

–

Neurological

–

Altered level of consciousness or altered cognition (including confusion or delirium)

Meningococcal disease may be missed in older adults with delirium or altered consciousness.

In young people and young adults, altered level of consciousness may be incorrectly assumed to be caused by alcohol or substance misuse, and meningococcal disease can be missed as a result.

Respiratory

–

Grunting

In babies and children.

High age-specific respiratory rate

For age-specific respiratory rates, see the sections on evaluating risk in the NICE guideline on suspected sepsis.

Temperature

–

Fever

Ask the person (or their family members or carers) if they have taken antipyretics, because this may make fever harder to identify.

Fever is a particular concern for babies at the levels specified in the NICE guideline on suspected sepsis:

  • 39°C or higher in children aged 3 to 6 months

  • 38°C or higher in children younger than 3 months.

Temperature less than 36°C

–

Other

–

Abdominal pain

–

Diarrhoea

–

Leg pain

–
Risk factors
1.1.14

Be on heightened alert to the possibility of meningococcal disease in people with any of these risk factors:

  • missed meningococcal vaccinations

  • reduced or absent spleen function

  • complement deficiency or inhibition

  • they are a student in further or higher education, particularly if they are in large shared accommodation (such as halls of residence)

  • a family history of meningococcal disease

  • they have been in contact with someone with meningococcal disease, or have been in an area with an outbreak

  • a previous episode of meningococcal disease.

For newborn babies, see the risk factors for neonatal infection (not specific to meningococcal disease) in the NICE guideline on neonatal infection:

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on when to suspect meningococcal disease.

Full details of the evidence and the committee's discussion are in evidence review A3: symptoms and signs associated with meningococcal disease and evidence review A4: risk factors associated with meningococcal disease.

Safety netting

1.1.16

If you send a person home after clinical assessment for bacterial meningitis and meningococcal disease:

  • give safety netting advice (see recommendation 1.3.2)

  • ask them to return for further assessment if they develop new symptoms, if a rash changes from blanching to non-blanching, or if existing symptoms get worse.

Alternative causes

1.1.17

Be aware that many of the symptoms and signs of bacterial meningitis and meningococcal disease are also indicators of many other serious conditions in babies, children, young people and adults (for example, other forms of sepsis, non-bacterial meningitis, intracranial bleed or ischaemia, and pneumonia).

For guidance on assessing for sepsis, see the NICE guideline on suspected sepsis.

For guidance on assessing fever in children under 5, see the section on clinical assessment of children with fever in the NICE guideline on fever in under 5s.

For guidance on diagnosing and managing stroke and transient ischaemic attack in over 16s, see the NICE guideline on stroke.

For guidance on diagnosing and managing pneumonia in adults, see the NICE guideline on pneumonia.

For guidance on initial assessment and management of suspected acute respiratory infection in over 16s, see the NICE guideline on acute respiratory infection.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on safety netting and alternative causes.

Full details of the evidence and the committee's discussion are in evidence review A1: symptoms and signs associated with bacterial meningitis and evidence review A3: symptoms and signs associated with meningococcal disease.

1.2 Transfer to hospital and antibiotics before arrival at hospital

1.2.1

Transfer people with suspected bacterial meningitis or meningococcal disease to hospital as an emergency.

1.2.2

Tell the hospital that a person with suspected bacterial meningitis or meningococcal disease is being transferred and that they will need assessment by a senior clinical decision maker.

1.2.3

Do not delay transfer to hospital to give antibiotics to people with suspected or strongly suspected bacterial meningitis or meningococcal disease.

1.2.4

If there is likely to be a clinically significant delay in transfer to hospital for people with strongly suspected bacterial meningitis, give intravenous or intramuscular ceftriaxone or benzylpenicillin outside of hospital.

1.2.5

For people with strongly suspected meningococcal disease, give intravenous or intramuscular ceftriaxone or benzylpenicillin as soon as possible outside of hospital, unless this will delay transfer to hospital.

1.2.6

Do not give antibiotics outside of hospital if the person has severe antibiotic allergy to either ceftriaxone or benzylpenicillin.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on transfer to hospital and antibiotics before arrival at hospital.

Full details of the evidence and the committee's discussion are in:

1.3 Information and support for people with suspected bacterial meningitis or meningococcal disease

1.3.1

Discuss the following with people who are in hospital with suspected bacterial meningitis or meningococcal disease and their family members and carers:

  • the reasons for their suspected diagnosis, and any uncertainty about this

  • when they can expect to know more

  • the need for investigations (including lumbar puncture for bacterial meningitis)

  • the timing of investigations and antibiotics.

1.3.2

For people who are unlikely to have bacterial meningitis or meningococcal disease, but who are sent home from hospital with an unconfirmed diagnosis:

  • explain which symptoms and signs to look out for, and what changes should prompt them to return to hospital

  • direct them to sources of online information.

For more guidance on providing information to adults, see the NICE guideline on patient experience in adult NHS services. In particular, see the sections on:

For more guidance on providing information to babies, children and young people, see the NICE guideline on babies, children and young people's experience of healthcare. In particular, see the sections on:

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on information and support for people with suspected bacterial meningitis or meningococcal disease.

Full details of the evidence and the committee's discussion are in evidence review K1: information for suspected bacterial meningitis or meningococcal disease and evidence review K2: support for suspected bacterial meningitis or meningococcal disease.

1.4 Investigating suspected bacterial meningitis in hospital

Timing of investigations and antibiotics

1.4.1

A senior clinical decision maker should perform an initial assessment and ensure that:

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on timing of investigations and antibiotics for bacterial meningitis.

Full details of the evidence and the committee's discussion are in evidence review B1: investigating and diagnosing suspected bacterial meningitis with blood and urine investigations and evidence review C1: timing of antibiotics for bacterial meningitis.

Making a diagnosis

1.4.2

Confirm a diagnosis of bacterial meningitis based on:

  • clinical features and

  • blood test results and

  • lumbar puncture results.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on lumbar puncture.

Full details of the evidence and the committee's discussion are in evidence review B3: investigating and diagnosing suspected bacterial meningitis with cerebrospinal fluid parameters and evidence review C1: timing of antibiotics for bacterial meningitis.

Bacterial throat swab

1.4.3

For people with suspected bacterial meningitis, perform a bacterial throat swab for meningococcal culture, preferably before starting antibiotics. Indicate on the request form that this is specifically for meningococcal culture.

Blood tests

1.4.4

Perform the following blood tests for people with suspected bacterial meningitis:

  • blood culture

  • white blood cell count (including neutrophils)

  • blood C-reactive protein (CRP), or procalcitonin (PCT) if CRP is not available

  • blood glucose

  • whole-blood diagnostic polymerase chain reaction (PCR), including meningococcal and pneumococcal

  • HIV test (in line with recommendations 1.10.1 and 1.10.2).

1.4.5

Do not rule out bacterial meningitis based only on a normal CRP, PCT, or white blood cell count.

For guidance on blood tests for sepsis, see the sections on managing suspected sepsis in the NICE guideline on suspected sepsis.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on bacterial throat swabs and blood tests for bacterial meningitis.

Full details of the evidence and the committee's discussion are in evidence review B1: investigating and diagnosing suspected bacterial meningitis with blood and urine investigations and evidence review C1: timing of antibiotics for bacterial meningitis.

Neuroimaging

1.4.6

Do not routinely perform neuroimaging before lumbar puncture.

1.4.7

Perform imaging if the person has:

  • risk factors for an evolving space-occupying lesion or

  • any of these symptoms or signs, which might indicate raised intracranial pressure:

    • new focal neurological features (including seizures or posturing)

    • abnormal pupillary reactions

    • a Glasgow Coma Scale (GCS) score of 9 or less, or a progressive and sustained or rapid fall in level of consciousness.

      Do not perform a lumbar puncture until these factors have been resolved.

1.4.8

Take bloods, give antibiotics and stabilise the person before imaging.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on neuroimaging.

Full details of the evidence and the committee's discussion are in evidence review B4: factors associated with brain herniation and evidence review B5: role of neuroimaging prior to lumbar puncture.

Lumbar puncture

1.4.9

Perform the lumbar puncture before starting antibiotics, unless it is not safe to do so or it will cause a clinically significant delay to starting antibiotics.

1.4.10

If the person has started on antibiotics before having a lumbar puncture, perform a lumbar puncture as soon as possible (if it is safe to perform).

1.4.11

Treat and stabilise any of the following before performing a lumbar puncture:

  • unprotected airway

  • respiratory compromise

  • shock

  • uncontrolled seizures

  • bleeding risk.

1.4.12

Do not perform lumbar puncture if there is:

  • extensive or rapidly spreading purpura

  • infection at the lumbar puncture site

  • risk factors for an evolving space-occupying lesion (follow recommendation 1.4.7 on imaging)

  • any of these symptoms or signs, which might indicate raised intracranial pressure (follow recommendation 1.4.7 on imaging):

    • new focal neurological features (including seizures or posturing)

    • abnormal pupillary reactions

    • a Glasgow Coma Scale (GCS) score of 9 or less, or a progressive and sustained or rapid fall in level of consciousness.

1.4.13

Measure blood glucose in people immediately before lumbar puncture, so that the cerebrospinal fluid to blood glucose ratio can be calculated.

For information about investigations and when to perform a lumbar puncture in newborn babies with suspected meningitis, see the NICE guideline on neonatal infection:

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on lumbar puncture.

Full details of the evidence and the committee's discussion are in evidence review B3: investigating and diagnosing suspected bacterial meningitis with cerebrospinal fluid parameters and evidence review C1: timing of antibiotics for bacterial meningitis.

Cerebrospinal fluid investigations

1.4.14

Perform the following cerebrospinal fluid investigations in people with suspected bacterial meningitis:

  • red and white cell count and cell type (including differential white cell count)

  • total protein

  • glucose concentration (to calculate cerebrospinal fluid to blood glucose ratio)

  • microscopy for bacteria (using gram stain)

  • microbiological culture and sensitivities

  • PCR for relevant pathogens.

1.4.15

Store the remaining cerebrospinal fluid in case more tests are needed.

1.4.16

Ensure that cerebrospinal fluid, cell counts, total protein and glucose concentrations are available within 4 hours of lumbar puncture.

1.4.17

When interpreting the results of cerebrospinal fluid investigations, take into account:

  • red cells in the sample, which may suggest blood contamination or a different diagnosis

  • whether earlier antibiotics may have reduced the diagnostic reliability of these investigations

  • that the normal thresholds for white cell count and protein may be higher in babies under 3 months.

1.4.18

Interpret cerebrospinal fluid results using standard age-appropriate threshold values (taking into account factors such as earlier antibiotic use or suspected immunodeficiency).

1.4.19

If cerebrospinal fluid results are abnormal, consider alternative viral, mycobacterial, fungal or non-infectious causes as well as bacterial meningitis.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on cerebrospinal fluid investigations.

Full details of the evidence and the committee's discussion are in evidence review B3: investigating and diagnosing suspected bacterial meningitis with cerebrospinal fluid parameters.

1.5 Investigating suspected meningococcal disease in hospital

Timing of investigations and antibiotics

Bacterial throat swab

1.5.2

For people with suspected meningococcal disease, perform a bacterial throat swab for meningococcal culture, preferably before starting antibiotics. Indicate on the request form that this is specifically for meningococcal culture.

Blood tests

1.5.3

Perform the following blood tests for people with suspected meningococcal disease:

  • blood culture

  • white blood cell count (including neutrophils)

  • blood C-reactive protein (CRP), or procalcitonin (PCT) if CRP is not available

  • lactate

  • whole-blood diagnostic polymerase chain reaction (PCR), including meningococcal and pneumococcal.

1.5.4

Do not rule out meningococcal disease based only on a normal CRP, PCT or white blood cell count.

Making a diagnosis

1.5.5

Confirm a diagnosis of meningococcal disease based on the blood test results and clinical features.

For guidance on blood tests for sepsis, see the sections on managing suspected sepsis in the NICE guideline on suspected sepsis.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on investigating suspected meningococcal disease in hospital.

Full details of the evidence and the committee's discussion are in evidence review B2: investigating and diagnosing suspected meningococcal disease with blood and urine investigations and evidence review C2: timing of antibiotics for meningococcal disease.

1.6 Antibiotics for bacterial meningitis in hospital

March 2024: when using ceftriaxone, follow the Medicines and Healthcare products Regulatory Agency (MHRA) safety advice that ceftriaxone is incompatible with solutions containing calcium.

1.6.3

Give intravenous antibiotics as soon as bacterial meningitis is suspected, within 1 hour of arrival in hospital (after taking blood samples and performing a lumbar puncture).

1.6.4

Get infection specialist advice for all cases of bacterial meningitis. This is particularly important for:

  • people who have recently travelled outside of the UK and may be at risk of antimicrobial resistance

  • people who are colonised with cephalosporin-resistant Enterobacterales (coliforms).

See the recommendation on antibiotic allergy for alternative antibiotics for each causative organism.

For guidance on antibiotics for newborn babies, see:

For guidance on antimicrobial stewardship, see the NICE guideline on antimicrobial stewardship.

Before the causative organism is known, or when it cannot be identified

1.6.5

For suspected bacterial meningitis when the causative organism has not been identified:

  • give ceftriaxone (use the highest doses recommended by the BNF or BNFC or refer to local antimicrobial guidance)

  • if ceftriaxone is contraindicated, consider cefotaxime (see the BNFC for contraindications to ceftriaxone for pre-term babies under 41 weeks corrected gestational age).

1.6.6

Give intravenous amoxicillin in addition to ceftriaxone or cefotaxime for people with risk factors for Listeria monocytogenes.

1.6.7

Do not routinely give intravenous aciclovir unless herpes simplex encephalitis is strongly suspected.

1.6.8

Continue initial antibiotic treatment until the results of blood and cerebrospinal fluid tests suggest an alternative treatment is needed or there is an alternative diagnosis. If test results are normal, but bacterial meningitis is still suspected, get advice from an infection specialist.

1.6.9

If the cerebrospinal fluid results suggest bacterial meningitis, but the blood culture and whole-blood diagnostic polymerase chain reaction are negative:

  • continue antibiotics for 10 days

  • after 10 days, stop antibiotics if the person has recovered, or get advice from an infection specialist if they have not.

See the recommendation on antibiotic allergy for alternative antibiotics.

For guidance on public health management of meningococcal disease, see the Public Health England guidance on meningococcal disease.

For guidance on antivirals for suspected herpes simplex encephalitis in children under 5, see recommendation 1.5.20 in the NICE guideline on fever in under 5s.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on antibiotics for bacterial meningitis in hospital.

Full details of the evidence and the committee's discussion are in the following evidence reviews:

When the causative organism is known

See the recommendation on antibiotic allergy for alternative antibiotics for each causative organism.

Streptococcus pneumoniae
1.6.10

For Streptococcus pneumoniae meningitis:

  • give ceftriaxone (use the highest doses recommended by the BNF or BNFC or refer to local antimicrobial guidance)

  • if ceftriaxone is contraindicated, consider cefotaxime (see the BNFC for contraindications to ceftriaxone for pre-term babies under 41 weeks corrected gestational age)

  • after 10 days, stop antibiotics if the person has recovered, or get advice from an infection specialist if they have not.

Haemophilus influenzae type b
1.6.11

For Haemophilus influenzae type b meningitis:

  • give ceftriaxone (use the highest doses recommended by the BNF or BNFC or refer to local antimicrobial guidance)

  • if ceftriaxone is contraindicated, consider cefotaxime (see the BNFC for contraindications to ceftriaxone for pre-term babies under 41 weeks corrected gestational age)

  • get advice from an infection specialist when starting treatment

  • after 7 days, stop antibiotics if the person has recovered, or continue for a total of 10 days if they have not

  • get further advice from an infection specialist if the person has not recovered after 10 days.

Group B streptococcal meningitis
1.6.12

For group B streptococcal meningitis:

  • give ceftriaxone (use the highest doses recommended by the BNF or BNFC or refer to local antimicrobial guidance)

  • if ceftriaxone is contraindicated, consider cefotaxime (see the BNFC for contraindications to ceftriaxone for pre-term babies under 41 weeks corrected gestational age)

  • get advice from an infection specialist when starting treatment

  • after 14 days, stop antibiotics if the person has recovered, or get further advice from an infection specialist if they have not.

Enterobacterales (coliforms)
1.6.13

For meningitis caused by Enterobacterales (coliforms):

  • give ceftriaxone (use the highest doses recommended by the BNF or BNFC or refer to local antimicrobial guidance)

  • if ceftriaxone is contraindicated, consider cefotaxime (see the BNFC for contraindications to ceftriaxone for pre-term babies under 41 weeks corrected gestational age)

  • get advice from an infection specialist on using meropenem as an alternative to ceftriaxone and cefotaxime, while awaiting antibiotic sensitivities

  • review treatment once antibiotic sensitivities are available

  • after 21 days, stop antibiotics if the person has recovered, or get further advice from an infection specialist if they have not.

Listeria monocytogenes
1.6.14

For meningitis caused by Listeria monocytogenes:

  • give intravenous amoxicillin or ampicillin for 21 days

  • get advice from an infection specialist on adding intravenous co-trimoxazole for the first 7 days

  • after 21 days, stop antibiotics if the person has recovered, or get advice from an infection specialist if they have not.

    In March 2024, this was an off-label use of co-trimoxazole. See NICE's information on prescribing medicines.

Neisseria meningitidis
1.6.15

For Neisseria meningitidis:

  • give ceftriaxone (use the highest doses recommended by the BNF or BNFC or refer to local antimicrobial guidance)

  • if ceftriaxone is contraindicated, consider cefotaxime (see the BNFC for contraindications to ceftriaxone for pre-term babies under 41 weeks corrected gestational age)

  • after 5 days, stop antibiotics if the person has recovered, or get advice from an infection specialist if they have not.

Antibiotic allergy with bacterial meningitis

1.6.16

In people with an antibiotic allergy:

  • ask about the reaction they get

  • get advice from an infection specialist, in particular for people who are pregnant

  • if their reaction was not severe allergy, consider:

    • ceftriaxone or cefotaxime for suspected meningitis or confirmed meningitis caused by Streptococcus pneumoniae, Haemophilus influenzae type b, group B streptococcus, Enterobacterales (coliforms), or Neisseria meningitidis

    • co-trimoxazole, and either ceftriaxone or cefotaxime for people with risk factors for suspected Listeria monocytogenes

  • if their reaction was severe allergy, consider:

    • co-trimoxazole and chloramphenicol for people with risk factors for Listeria monocytogenes

    • chloramphenicol for suspected meningitis, or confirmed meningitis caused by other causative organisms.

      In March 2024, this was an off-label use of co-trimoxazole. See NICE's information on prescribing medicines.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on antibiotic allergy.

Full details of the evidence and the committee's discussion are in the following evidence reviews:

1.7 Antibiotics for meningococcal disease in hospital

March 2024: when using ceftriaxone, follow the Medicines and Healthcare products Regulatory Agency (MHRA) safety advice that ceftriaxone is incompatible with solutions containing calcium.

1.7.1

Give intravenous ceftriaxone for suspected or confirmed meningococcal disease in hospital.

1.7.2

After 5 days, stop antibiotics if the person has recovered, or get advice from an infection specialist if they have not.

1.7.3

In people with an antibiotic allergy:

  • ask about the reaction they get

  • give ceftriaxone if their reaction was not severe allergy

  • if their reaction was severe allergy, get advice from an infection specialist and consider chloramphenicol.

For guidance on antibiotics for newborn babies, see:

For guidance on antimicrobial stewardship, see the NICE guideline on antimicrobial stewardship.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on antibiotics for meningococcal disease in hospital settings.

Full details of the evidence and the committee's discussion are in evidence review F: antibiotics for meningococcal disease.

1.8 Corticosteroids for bacterial meningitis and meningococcal disease

Bacterial meningitis

In March 2024, all uses of dexamethasone in this section were off-label. See NICE's information on prescribing medicines.

1.8.1

For people over 3 months with strongly suspected or confirmed bacterial meningitis, give intravenous dexamethasone.

1.8.3

When the causative organism is found:

  • continue dexamethasone if it is pneumococcus or Haemophilus influenzae type b

  • stop dexamethasone for all other organisms.

1.8.4

If no causative organism is found, get advice from an infection specialist on whether or not to continue dexamethasone.

1.8.5

For people receiving dexamethasone:

  • give the first dose with or before the first dose of antibiotics if possible

  • however, do not delay antibiotics to wait for dexamethasone to be started

  • if dexamethasone is delayed for less than 12 hours after the start of antibiotics, give dexamethasone as soon as possible

  • if dexamethasone is delayed for more than 12 hours after the start of antibiotics, get advice from an infection specialist and decide whether dexamethasone is still likely to provide benefit.

Meningococcal disease

1.8.6

Do not routinely give corticosteroids to people with meningococcal disease.

1.8.7

Consider low-dose replacement corticosteroids for people with meningococcal septic shock that is not responding to high-dose vasoactive agents.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on corticosteroids.

Full details of the evidence and the committee's discussion are in evidence review G4: corticosteroids for treatment of bacterial meningitis and evidence review H: corticosteroids in meningococcal disease.

1.9 Fluid restriction, osmotic agents and intracranial pressure monitoring for confirmed bacterial meningitis

Fluid restriction

1.9.1

Do not routinely restrict fluid intake to below routine maintenance needs in people with bacterial meningitis.

1.9.2

Give maintenance fluids orally or by enteral tube, if tolerated.

For more guidance on fluid therapy, see the NICE guidelines on intravenous fluid therapy in adults and intravenous fluid therapy in children and young people.

Osmotic agents

1.9.3

Do not use glycerol in the management of bacterial meningitis in babies, children, young people and adults.

1.9.4

Do not routinely use other osmotic agents (such as mannitol or hypertonic sodium chloride) in the management of bacterial meningitis in babies, children, young people and adults.

1.9.5

If there are signs of raised intracranial pressure and concerns about brain herniation:

  • consider osmotic agents (but not glycerol) as a temporary measure to reduce intracranial pressure

  • for adults, get urgent advice from critical care

  • for babies, children and young people, get urgent advice from paediatric critical care services.

Intracranial pressure monitoring

1.9.6

Do not routinely use invasive intracranial pressure monitoring in the management of bacterial meningitis in babies, children, young people and adults.

1.9.7

Get specialist advice on intracranial pressure monitoring if there are features of raised intracranial pressure or hydrocephalus.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on fluid restriction, osmotic agents and intracranial pressure monitoring.

Full details of the evidence and the committee's discussion are in the following evidence reviews:

1.10 Assessing for immunodeficiency and recurrence risk in people with bacterial meningitis or meningococcal disease

1.10.1

Test for HIV in adults with bacterial meningitis or meningococcal disease.

1.10.2

Consider testing for HIV in babies, children and young people with bacterial meningitis or meningococcal disease, if they have signs of immunodeficiency or risk factors for HIV.

1.10.3

Refer babies, children and young people with pneumococcal meningitis to a paediatric immunology and infectious disease specialist to assess for primary immunodeficiency.

1.10.4

For babies and young children with bacterial meningitis, examine their back and scalp for signs of a sinus tract.

1.10.5

For all people with bacterial meningitis or meningococcal disease, take a history of:

  • head trauma, surgery or cerebrospinal fluid leak

  • immunisations

  • medicines, including drugs that suppress the immune system (such as complement inhibitors).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessing for immunodeficiency and recurrence risk in people with bacterial meningitis or meningococcal disease.

Full details of the evidence and the committee's discussion are in evidence review J1: factors associated with recurrent bacterial meningitis and evidence review J2: factors associated with recurrent meningococcal disease.

1.11 Information and support after diagnosis

1.11.1

Early in the management of confirmed bacterial meningitis or meningococcal disease, discuss the following with people and their family members or carers:

  • what might happen during the course of the disease

  • the uncertainty about their initial prognosis, and when they can expect to know more

  • the risk of passing on the infection

  • whether their close contacts need to take any preventative measures (for example, for meningococcal meningitis, meningococcal disease or Haemophilus influenzae type b)

  • visible effects (such as drips and other invasive devices), swelling (for people receiving fluid resuscitation), and how rashes can spread and turn purple

  • effects of sedative withdrawal, such as agitation or abnormal neurological behaviour

  • the potential short and long-term outcomes, taking account of the severity of their illness and their need for critical care

  • how to access support, including contact details of meningitis charities.

1.11.2

Repeat information over time and check the person understands, as they may be distressed and unable to ask questions when they are first diagnosed.

For more guidance on providing information, see the NICE guidelines on:

1.11.3

Provide emotional and pastoral support for people and their family members and carers during hospitalisation.

1.11.4

Consider referral for psychological interventions, for people with bacterial meningitis or meningococcal disease who need specialist psychological support.

1.11.5

Before discharge from hospital, explain to the person and their family members or carers:

  • how to access support, including contact details of meningitis charities

  • what assessments, aftercare and follow-up they will receive (now and long-term)

  • any uncertainties about what long-term effects they might experience.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on information and support after diagnosis.

Full details of the evidence and the committee's discussion are in evidence review K3: information for confirmed bacterial meningitis or meningococcal disease and evidence review K4: support for confirmed bacterial meningitis or meningococcal disease.

1.12 Preparing for hospital discharge

Identifying and managing complications

1.12.1

Identify follow-up needs for people who have had bacterial meningitis or meningococcal disease, taking into account potential cognitive, neurological, developmental, orthopaedic, skin, hearing, psychosocial, education, and renal complications.

Cognitive, neurological and developmental complications
1.12.2

Refer babies, children and young people for community neurodevelopmental follow-up.

1.12.3

Refer children, young people and adults to psychological services for cognitive and psychological support if follow-up needs have been identified.

1.12.4

For people who are taking anti-epileptic drugs, refer for a medicines review 3 months after hospital discharge, with a clinician with an interest in epilepsy, an epilepsy specialist nurse, or a neurologist.

Orthopaedic and skin complications
1.12.5

For people with acute orthopaedic complications (such as amputation):

  • arrange follow-up with an orthopaedic surgeon after discharge

  • consider referral to psychological services.

1.12.6

For people with orthopaedic and skin complications:

  • coordinate management with tissue viability and community nursing services

  • refer to rehabilitation services for assessment as needed.

Audiological assessment
1.12.7

Offer an audiological assessment within 4 weeks of the person being well enough for testing (and preferably before discharge).

1.12.8

Offer children, young people and adults with severe or profound deafness an urgent assessment for cochlear implants.

For further guidance on cochlear implants, see the NICE technology appraisal guidance on cochlear implants for children and adults with severe to profound deafness.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on identifying and managing complications.

Full details of the evidence and the committee's discussion are in evidence review I1: long-term complications and follow-up for bacterial meningitis and evidence review I2: long-term complications and follow-up for meningococcal disease.

Planning for care after discharge

1.12.9

For people who have had bacterial meningitis or meningococcal disease, tell their GP (and health visitor and school nurse if relevant), and explain any follow-up plans.

1.12.10

Tell the person and their family members or carers who their main point of contact will be after discharge.

1.12.11

Document the follow-up plan for managing complications in the discharge summary.

1.12.12

The hospital team should coordinate with the following professionals for care after discharge:

  • tertiary and primary care and other specialists

  • allied professionals and community teams that will be involved in follow-up (for example audiology, speech and language therapy, and psychology departments).

Providing information

Psychosocial support

1.12.14

Consider referral to psychosocial support for people who have had bacterial meningitis or meningococcal disease and their family members and carers.

Education support

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on planning for care after hospital discharge.

Full details of the evidence and the committee's discussion are in the following evidence reviews:

1.13 Care after hospital discharge

First review

1.13.1

For babies, children and young people who have had bacterial meningitis or meningococcal disease, arrange for a review with a paediatrician at 4 to 6 weeks after discharge from hospital. As part of this review, cover:

  • the results of their audiological assessment, and whether cochlear implants are needed

  • damage to bones and joints

  • skin complications (including scarring from necrosis)

  • psychosocial problems (if relevant, see the NICE guideline on post-traumatic stress disorder)

  • neurological and developmental problems, in liaison with community child development services.

1.13.2

For adults who have had bacterial meningitis or meningococcal disease, arrange for a review with a hospital doctor at 4 to 6 weeks after discharge from hospital. As part of this review, cover:

  • the results of their audiological assessment (if available at this time), and whether cochlear implants are needed

  • damage to bones and joints

  • skin complications (including scarring from necrosis)

  • psychosocial problems (if relevant, see the NICE guideline on post-traumatic stress disorder)

  • neurological problems

  • care needs.

Further reviews for babies, children and young people

1.13.3

For babies under 12 months who have had meningitis or meningococcal disease, arrange a review with a paediatrician for 1 year after discharge. At this review, assess for possible late-onset neurodevelopmental, orthopaedic, sensory and psychosocial complications.

1.13.4

Healthcare professionals (such as school nurses, health visitors and GPs) with responsibility for monitoring the health and wellbeing of babies, children and young people should be alert for late-onset complications of bacterial meningitis or meningococcal disease.

1.13.5

Be aware that late-onset complications may not be apparent until transition points (such as starting nursery or school).

1.13.6

For babies, children and young people, community child development services should follow up and assess the risk of long-term neurodevelopmental complications for at least 2 years after discharge.

1.13.7

If a neurodevelopmental deficit is identified, refer to the appropriate services (for example, neurodisability services) and agree with them who will be responsible for follow-up, to ensure that nobody misses out on care.

1.13.8

Advise family members or carers to get advice from their GP if their child or young person develops possible neurodevelopmental complications more than 2 years after discharge.

1.13.9

Advise family members or carers to discuss the following with their child or young person's school:

  • their child or young person has had meningitis or meningococcal disease

  • this may affect their learning

  • they may need additional reviews of their educational outcomes and learning needs, even when there have been no known complications.

Return to education or work for adults

1.13.10

Advise adults that they may need to arrange a phased return to education or employment.

1.13.11

Refer for assessments of any additional needs or adaptations (including driving) if needed.

For guidance on helping people return to work, see the NICE guideline on workplace health: long-term sickness absence and capability to work.

For guidance on rehabilitation for adults, see the NICE guideline on rehabilitation after critical illness in adults.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on care after hospital discharge.

Full details of the evidence and the committee's discussion are in the following evidence reviews:

1.14 Recurrent bacterial meningitis and meningococcal disease

Risk factors

1.14.1

Risk factors for recurrent bacterial meningitis are:

  • primary or secondary immunodeficiency, including:

    • HIV

    • congenital complement deficiency or acquired inhibition

    • reduced or absent spleen function

    • hypogammaglobulinaemia

  • communication between the cerebrospinal fluid and external surface, for example caused by:

    • prior trauma or surgery

    • a congenital anomaly.

1.14.2

The risk factor for recurrent meningococcal disease is primary or secondary immunodeficiency, including:

  • HIV

  • congenital complement deficiency or acquired inhibition

  • reduced or absent spleen function.

Management

1.14.3

For people who have had a recurrent episode of bacterial meningitis or meningococcal disease:

  • review with a paediatric immunology and infectious disease specialist or an adult infection specialist or immunologist (as appropriate) and

  • agree which tests, investigations, vaccines and other interventions are needed to prevent re-occurrence.

1.14.4

Test for HIV in babies, children, young people and adults with recurrent bacterial meningitis or meningococcal disease.

1.14.5

For babies and young children with recurrent bacterial meningitis, examine their back and scalp for signs of a sinus tract.

1.14.6

For people with recurrent bacterial meningitis, get specialist radiological advice on investigations for a cerebrospinal fluid leak.

1.14.7

For people with recurrent bacterial meningitis or meningococcal disease, take an immunisation and medicine history, including for drugs that suppress the immune system (such as complement inhibitors).

1.14.8

In people with recurrent meningitis with unconfirmed bacterial cause, consider other causes (for example, Mollaret's lymphocytic meningitis) and get advice from an infection specialist.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on recurrent bacterial meningitis and meningococcal disease.

Full details of the evidence and the committee's discussion are in evidence review J1: factors associated with recurrent bacterial meningitis and evidence review J2: factors associated with recurrent meningococcal disease.

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline.

Adults

18 years and over.

Babies

29 days to 1 year (adjusted for gestational age from their due birth date).

Children

1 to 11 years.

Enterobacterales (coliforms)

Enterobacterales (formerly known as Enterobacteriaceae and commonly referred to as 'coliform' bacteria) are a large order of gram-negative bacterial pathogens, including Escherichia coli (E. coli), Klebsiella, Enterobacter, Serratia and others.

Infection specialist

Microbiologist or infectious diseases specialist.

Older adults

Over 65 years.

Senior clinical decision maker

A 'senior clinical decision maker' for people under 18 is a paediatric or emergency care qualified doctor or equivalent with core competencies in the care of acutely ill children (usually grade ST4 or above).

A 'senior clinical decision maker' for people aged 18 years or over should be a clinician with core competencies in the care of acutely ill patients (usually ST3 or above) or equivalent.

Severe antibiotic allergy

A history of allergy to antibiotics with effects that are clearly likely to be allergic in nature, such as anaphylaxis, respiratory distress or angioedema.

Strongly suspected

Bacterial meningitis can be strongly suspected:

  • if the person has the red flag combination of symptoms (see recommendation 1.1.4) or

  • based on clinical assessment of the symptoms and signs and risk factors present, for people who do not have the red flag combination.

Meningococcal disease can be strongly suspected:

  • if the person has any of the red flag symptoms (see recommendation 1.1.9) or

  • based on clinical assessment of the symptoms and signs and risk factors present, for people who do not have any of the red flag symptoms.

Young adults

18 to 25 years.

Young babies

29 days to 3 months (adjusted for gestational age from their due birth date).

Young children

Over 1 year up to 5 years (adjusted for gestational age from their due birth date for children up to 2 years).

Young people

12 to 17 years.