Note: This guideline is currently under review. 

Introduction

Aim

Definition of Terms

Initial Assessment and Management

Ongoing Assessment and Management

Discharge Planning 

Special Considerations 

Companion Documents 

Evidence Table

References

Introduction

Meningitis is a life threatening illness caused by infection and inflammation of the meninges. The infection can be caused by bacteria, a virus, fungus or other rare organisms such as parasites and amoeba. 
Children with bacterial meningitis can become seriously ill very quickly. One in five children infected is left with permanent disabilities, such as deafness or cerebral palsy and in a small number of cases, meningitis can cause death. 
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.

Definition of Terms 

• AVPU – Scale to determine whether the child is Alert, or responds to Voice (Verbal), Pain or is Unresponsive. 
  
• CSF – Cerebral Spinal Fluid
  
• CVAD – Central Venous Access Device 
  
• Encephalitis – Inflammation of the brain
  
• Fontanel – Soft gap between cranial bones in infants. Posterior fontanel usually closes at 2-3 months after birth. The Anterior fontanel usually closes at 18 months after birth.
  
• GCS – Glasgow Coma Scale. A tool to measure level of consciousness.
• LP – Lumbar Puncture
  
• Meninges – The membranes 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 be present. 
  

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.  
  

Management

• Treat seizures in the setting of meningitis immediately.   
  • See Afebrile Seizures or Seizure Management in NICU.
    
• Fluid resuscitation may be required. 
  
  • See Fluid Management in Meningitis. 
    
• Administer antibiotics.
  
  • Antibiotics must not be delayed for more than 30 minutes once the decision to treat has been made. 
  • A delay to antibiotics is associated with poorer outcomes.
    
• Blood tests.
  
  • Blood cultures.
  • Full blood count.
    
  • Glucose, urea and electrolytes.
    
• Bare weight – place order in Epic.
  
• Lumbar Puncture.
  
  • Delay to LP should not delay antibiotic administration.
  • LP may be delayed due to the severity of the child’s condition.
    
  • See Lumbar Puncture.
    
  • Monitor site for swelling and signs of infection ½ hourly for 4 hours.
    
• 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 may be ordered and given at the time of lumbar puncture if the clinical suspicion of meningitis is high.
  • Current evidence suggests that steroids may reduce the risk of hearing loss in bacterial meningitis.
  • Steroids are not recommended in neonates due to concern regarding effects on neurodevelopment.
    
• Measure head circumference of infants – place order in Epic.
  
• If encephalitis is suspected, IV acyclovir will be ordered.
  
• 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.
  

Ongoing Assessment and Management

Ongoing Assessment

• Vital signs and neurological observations including blood pressure must be done at 15 minute intervals for the first two hours, then at intervals determined by the child’s conscious state, or at a minimum of 4hrly when the child is stable. 
  
  • Order observation frequency in Epic. 
    
  • Low threshold for medical review.
• In infants, fontanel assessment to be documented at least once per shift. 
  
• Strict fluid balance monitoring to be maintained. 
  
• Skin assessment to be done at least once per shift, 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

• In infants, head circumference should be measured daily.
  
  • Increased head circumference indicates increased intra-cranial pressure.
    
  • Order in Epic.
    
• Bare weight must be done daily. 
  
  • Older children and adolescents may be weighed with light clothing.
    
  • Place order for daily weight in Epic.
    
• 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 drinking well should have intravenous fluids run slowly to keep cannula patent.
    
• Ensure adequate analgesia.
  
  • Pain can be related to meningeal irritation.
    
• Low stimulus environment 
  
  • Reduce tactile handling of the child
    
  • 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.
    

Discharge Planning

• Ensure medical team have disclosed to parents about the risk of hearing loss. 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 Hospital In The Home for ongoing intravenous antibiotic administration via a CVAD.
  

Special Considerations

• Meningitis can be fatal. Nursing staff need to prioritise antibiotic treatment, as delays are associated with poorer outcomes. 
  
• 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 
  

Evidence Table

The evidence table for this guideline can be found here: Nursing Management of Meningitis Evidence Table 2019

References

• The Royal Children’s Hospital Clinical Practice Guideline: Meningitis – Encephalitis (state-wide). Accessed 20/7/2018 from https://www.rch.org.au/clinicalguide/guideline_index/Meningitis_Guideline/
  
• The Royal Children’s Hospital Clinical Practice Guideline: Fluid Management in Meningitis. Accessed 20/7/2018 from https://www.rch.org.au/clinicalguide/guideline_index/Fluid_Management_in_Meningitis/
  
• The Royal Children’s Hospital Kids Health Info Fact Sheet: Meningitis. Accessed 20/7/208 from https://www.rch.org.au/kidsinfo/fact_sheets/Meningitis/
  
• National Institute for Health and Care Institute. (2018) Bacterial meningitis and meningococcal septicaemia in under 16s: recognition, diagnosis and management. Retrieved from: https://www.nice.org.uk/guidance/cg102.
  
• Swanson, D. (2015) Meningitis. Pediatrics in Review, 35(12), 514-524. doi: 10.1542/pir.36-12-514
  
• Ramasamy R, et al. (2018) Management of suspected paediatric meningitis: A multicentre prospective cohort study. Archives of Disease in Childhood, 103, 1114-1118. doi:10.1136/archdischild-2017-313913
  
• Fenton-Jones, M., Cannon, A., & Paul, S. (2017) Recognition and nursing management of sepsis in early infancy. Emergency Nurse. 25(6), 23-28. doi: 10.7748/en.2017.e1704
  
• Hickey, J. (2014) Clinical Practice of Neurological & Neurosurgical Nursing (7th ed.). Wolters Kluwer Health; Philadelphia, PA.
  
• Maconochie, I., & Bhaumik, S. (2016) Fluid therapy for acute bacterial meningitis. Cochrane Database of Systematic Reviews, 11. doi: 10.1002/14651858.CD004786.pub5.
  
• Ogunlesi, T., Odigwe, C., & Oladapo, O. (2015) Adjuvant corticosteroids for reducing death in neonatal bacterial meningitis. Cochrane Database of Systematic Reviews, 11. doi: 10.1002/14651858.CD010435.pub2.
  
• Brouwer, M., McIntyre, P., Prasad, K., & van de Beek, D. (2015) Corticosteroids for acute bacterial meningitis. Cochrane Database of Systematic Reviews, 9. doi: 10.1002/14651858.CD004405.pub5.
  

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Catherine Wood, CNS, Sugar Glider, and approved by the Nursing Clinical Effectiveness Committee. Updated November 2019.