Fever and Seizure or Suspected Acute CNS Infection ( not NICU ) - Guideline for the Initial Management of a Child with

Publication: 10/10/2011  --
Last review: 31/10/2017  
Next review: 31/10/2020  
Clinical Guideline
CURRENT 
ID: 2575 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the initial management of a child with fever and seizure or suspected acute CNS infection (not NICU)

Summary
Fever and Seizure or Suspected Acute CNS Infection ( not NICU )

Pathway document

Overview of descriminators for each pathway

 

 

 

 

Definite neck stiffness or Kernigs sign
Multiple seizures same illness
Seizure with focal features
Prolonged seizure > 15 minutes
Does not wake or if roused does not stay awake 30 minutes after seizure (infant)
Conscious level depressed (GCS<15), V or less (AVPU) 30min after seizure (1-16 years)
Non-blanching rash

 

More than 3 days illness
Vomiting at home
Age under 18 months
Possible Neck stiffness
Antibiotics for this illness

 

Seizure must have been an epileptic seizure i.e. clonic or tonic-clonic
Duration short i.e. less than 5 minutes
Child must be between 6 months and 5 years
Conscious level must have returned to normal within 30 minutes of the end of the seizure, unless benzodiazepines have already been given in which case recovery of consciousness may be delayed considerably - up to several hours. In this context the child should be in the RED PATHWAY until clinical improvement occurs
No focal neurological signs after the seizure has ended
(If a child has had a short febrile seizure that nonetheless had some focal features -eg. eye deviation or a unilateral clonic seizure AND they have no other risk factors as listed in the RED PATHWAY, then it may be reasonable to put them in the Yellow pathway. This is of course dependent on regular clinical review i.e. they should not be discharged at this point)
No other obvious diagnosis e.g. meningococcal rash

1. Presentation

Seizure / altered conscious state AND temperature >37.8, OR examination evidence of febrile illness;
OR,
Suspected CNS infection.

  • Record weight
  • Record observations/ PAWS
  • Provide antipyretics as appropriate
  • Then enter pathway corresponding to History & Examination

WARNING - infants and children with an open fontanelle are unlikely to have classic symptoms and signs of meningitis

Overview of pathways


RED

1.1 Does this patient need immediate resuscitation?
(If in status epilepticus - read in conjunction with LHP guideline Seizure in status epilepticus (acute) in infant and children. Pay particular attention to airway security & adequacy of breathing
Remember children with an open fontanelle usually don't display signs of meningism nor can young children articulate them so their absence does not exclude possible CNS infection.
Discuss with senior if any uncertainty
No
Yes Call Paediatric CRASH call 2222.
Provide high flow Oxygen, assess Airway and Breathing. Keep NBM

1.2 IV access
Cannulate (consider urgency vs use of topical anaesthesia).
If unable to secure access discuss with senior/ consultant.

1.3 Assess for
Signs of shock/ dehydration (Resuscitation of Children with suspected infection 2577).
(Treat as directed in this guideline, only restrict fluids if there is evidence of raised intracranial pressure or increased anti-diuretic hormone secretion)
raised intracranial pressure, if present discuss with Consultant & PICU
suspect raised ICP if any :-
*V or less on AVPU consciousness rating
*Abnormal tone or tonic posturing
*Abnormal pupil reaction & size
*Papilloedema

2. Investigations (LP is key investigation- when stable)

2.1 Blood sampling:


BM

__________

 

Venous gas:-

pH

______

 

 

 

 

pCO2

______

 

 

 

 

HCO3

______

 

 

 

 

BXS

______

BM/ gas satisfactory

If not Action_________________________

CRP

Blood Culture

FBC

Urine (consider catheter)

U&E

LFT

Glucose

Bone profile (Ca2+, PO4, Mg2+

PCR (meningo & pneumococcal)

Mycoplasma IgM (If encephalitis suspected)

 

Clotting

 

 

 

WARNING - a normal CRP and or FBC does not exclude bacterial meningitis. A negative blood PCR does not exclude N meningitis
2.2 Neuroimaging: (do not delay administration of antimicrobials) Request urgent CT
2.3 Lumbar Puncture (do not delay administration of antimicrobials either because LP is contraindicated, CSF is not available or uninterpretable) CSF results should be available within 4 hours
Discuss with consultant if signs see Lumbar puncture section for contraindications
collect (refer to table)

  • CSF into 4 universal tubes & 1 glucose tube
  • paired blood glucose

Interpretation of results- refer to table

3. Non-antimicrobial Treatment

3.1 Corticosteroids
OVER 3 months of age give:
IV Dexamethasone base (0.15mg/kg -maximum 10mg, every 6 hours for 4 days) when strong suspicion of meningitis but LP likely to be delayed OR LP result consistent with meningitis (purulent CSF, or CSF WCC >1000/ x106/ l, protein >1g/L, bacteria seen on Gram).
UNDER 3 months of age:
DO NOT GIVE CORTICOSTEROIDS IN CHILDREN UNDER 3 MONTHS WITH SUSPECTED OR CONFIRMED BACTERIAL MENINGITIS.
DO NOT GIVE CORTICOSTEROIDS GREATER THAN 12 HOURS AFTER ANTIBIOTICS HAVE BEEN STARTED
Any age:
Do NOT give steroids to infants or children with clinical evidence of meningococcal septicaemia (i.e. typical non blanching purpuric rash) unless catecholamine resistant shock is present or to children with possible TB meningitis.
NB If corticosteroids have been started, they can be stopped if diagnosis is not meningitis (on clinical or CSF examination findings)
3.2 Fluid management

  • administer fluid as directed in shock guideline
  • note the absence of evidence to restrict fluids in children without obvious raised intracranial pressure

3.3 Management of raised intracranial pressure -

  • airway stabilisation,
  • urgent discussion with Consultant on call
  • Mannitol infusion Child <11 years 0.25-1.5g/Kg, Child 12-17 years 0.25-2g/Kg IV infusion, following discussion with Consultant.
  • Intensive care management

3.4 Be aware of systemic imbalances such as hypoglycaemia, metabolic acidosis, hypokalaemia, hypocalcaemia, hypomagnesaemia, coagulopathy and anaemia. These should be highlighted to the Consultant oncall and managed appropriately

4. Antimicrobial Treatment (NB dose adjustment may be required in renal impairment)

4.1 OVER 3 months of age:
Ceftriaxone Description: electronic Medicines Compendium information on Ceftriaxone IV 80-100mg/kg over 30 minutes (first dose may be used given as a bolus in emergency) once daily
[maximum dose 4g daily]
OR, If true penicillin/ cephalosporin allergy:
IV chloramphenicol 25 mg/kg every 6 hours (reduce dose as soon as is clinically indicated)
Monitor chloramphenicol concentrations (all < 4 years of age, and if doubling dose)

4.2 1-3 months of age (& not on NICU)
IV cefotaxime 50mg/ kg every 6 hourly
If true penicillin/ cephalosporin allergy
IV chloramphenicol (12.5 mg/kg) every 6 hours (may double dose in this age group)
Check dose carefully overdosage can be fatal
Monitor chloramphenicol concentrations

4.3 Neonate (& not on NICU)
IV amoxicillin 50mg/kg every 8 hours
AND
IV gentamicin(see Gentamicin Prescribing Guideline for Neonates)

4.4 If focal seizures, focal neurological signs, status epilepticus, altered conscious level (V or less on AVPU) >30 minutes after a seizure OR known exposure to HSV infection (e.g. maternal infection).
aciclovir IV infusion
Neonate 20mg/kg 8 hourly
Child 1-3 months 20mg/kg 8 hourly
Child 3 months - 12 years 500mg/ m2 8 hourly (use body surface area nomogram at back of BNFc)
Child 12-16 years 10mg/kg every 8 hours
PLUS
clarithromycin
Neonate up to 28 days: PO 7.5mg/kg every 12 hours
Bodyweight under 8kg: PO 7.5mg/kg every 12 hours
Bodyweight 8-11kg: PO 62.5mg every 12 hours
Bodyweight 12 - 19kg: PO 125mg every 12 hours
Bodyweight 20-29kg: PO 187.5mg every 12 hours
Bodyweight 30-40kg: PO 250mg every 12 hours
Child 12-18 years: PO 250mg every 12 hours, increased in severe infections to 500mg every 12 hours
OR if unable to tolerate oral
clarithromycin IV infusion into large proximal vein
Child 1 month - 12 years 7.5mg/kg IV infusion every 12 hours (max dose 500mg)
Child 12 - 18 years 500mg IV infusion every 12 hours
Discuss with senior if any uncertainty

    • Are there concerns of multi-resistant pneumococcal infection history of recent (<6 months) travel to France, Spain, Portugal-
      If so continue current therapy & commence

IV vancomycinsee relevant neonatal/paediatric vancomycin guideline

4.6 Prophylaxis
in the acute admission, prophylaxis should only be given if there is strong concerns of meningococcal disease as likely pathogen - refer to table.
Contact Public health:
Tel: (0113) 3059798 (within hours) (0113) 2063283 (out of hours)
When agent is identified, refer to table
Do other specialties need to be made aware of this patient?
No
Discussed with ____________ (grade) ________________(specialty) At ___________(time)
Arrange admission - admit in source isolation (cubicle), follow trust guidelines regarding
Complete Ward Drug Chart

5. Diagnosis
“When a working diagnosis is established for: Meningitis, Encephalitis OR Brain abscess, discuss antimicrobial therapy and duration with microbiology as required"


YELLOW

1. Presentation:

Does this child need immediate resuscitation?
No Description: http://nww.lhp.leedsth.nhs.uk/images/box.JPG    (Discuss with senior if any uncertainty)
Conscious decision is now made to:
Admit: re-enter RED, Circle pathway
OR
Observe & investigate (off antimicrobial therapy): Review with observations & results in 2 hours.
Consultant/ Registrar aware

2. Investigations:

CRP            FBC           Blood Culture Urine (consider catheter)
 PCR (meningo & pneumo-coccus)                 Gas           BM       Bone profile (Ca,PO4), Mg                     

Consider neuroimaging (discuss with senior if any uncertainty)

3. Observations

Time(mins)

0

20

40

60

80

100

120

AVPU rating

 

 

 

 

 

 

 

Resp Rate

 

 

 

 

 

 

 

Pulse

 

 

 

 

 

 

 

BP

 

 

 

 

 

 

 

SaO2

 

 

 

 

 

 

 

Temperature

 

XXXXXXXXXXXXXXXXXXXXXXXXXX

 

If any deterioration in PAWS score, inform Dr immediately
case discussed with Dr______________________________

4. Review

Are observations & results satisfactory? (Discuss with senior if any uncertainty)
If yes, discharge - enter final common pathway Description: http://nww.lhp.leedsth.nhs.uk/images/box.JPG
If no, Admit: re-enter RED, Circle pathway
complete investigations in line with RED, Circle pathway
commence treatment in line with RED, Circle pathway
consider need for further investigations

5. Diagnosis

“When a working diagnosis is established for: Meningitis, Encephalitis OR Brain abscess, discuss antimicrobial therapy and duration with microbiology as required"


GREEN

1. Presentation

If Simple seizure with fever and no features of yellow- triangle/ red- circle then a diagnosis of "simple febrile convulsion" can be considered:
The diagnosis of "simple febrile convulsion" is a diagnosis of exclusion:

  1. the seizure must have been an epileptic seizure ie. clonic or tonic-clonic
  2. duration short i.e. less than 5 minutes.
  3. the child must be between 6 months and 5 years
  4. the conscious level must have returned to normal within 30 minutes of the end of the seizure, unless benzodiazepines have already been given in which case recovery of consciousness may be delayed considerably - up to several hours. In this context the child should be in the RED PATHWAY until clinical improvement occurs (see Allen et al 2008)
  5. there must be no focal neurological signs after the seizure has ended (see note 1 below)
  6. there is no other obvious diagnosis e.g. meningococcal rash
  7. a past history of a febrile seizure is weakly supportive but must not lead to the assumption the current episode cannot be a CNS infection

Note 1. If a child has had a short febrile seizure that nonetheless had some focal features -e.g. eye deviation or a unilateral clonic seizure AND they have no other risk factors as listed in the RED PATHWAY, then it may be reasonable to put them in the Yellow pathway. This is of course dependent on regular clinical review i.e. they should not be discharged at this point.
If all criteria above are not met then re-enter YELLOW, Triangle pathway or RED circle pathway as appropriate.

2. Investigations

All GREEN pathway children: ensure urine sample obtained (ideally clean catch, alternative; catheter sample or SPA ) for M C & S. Consider other investigations (discuss with senior if any uncertainty)

3. Observation:

Review with observations in 2 hours.

Time(mins)

0

60

120

AVPU rating

 

 

 

Resp Rate

 

 

 

Pulse

 

 

 

BP

 

 

 

SaO2

 

 

 

Temperature

 

 

 

If any deterioration in PAWS score, inform Dr immediately
case discussed with Dr______________________________

4. Review

If observations satisfactory (Discuss with senior if any uncertainty)
Discharge- enter final common pathway
If evidence for Urinary Tract Infection - see LTHT guidelines
If neither applicable- urgent discussion with senior/ consultant

Final Common Pathway

  1. Repeat set of observations satisfactory Description: http://nww.lhp.leedsth.nhs.uk/images/box.JPG
  2. Patient advice leaflet given to parents and information for self help groups Description: http://nww.lhp.leedsth.nhs.uk/images/box.JPG
  3. Discharge letter:
    • given to parents Description: http://nww.lhp.leedsth.nhs.uk/images/box.JPG
    • faxed to GP Description: http://nww.lhp.leedsth.nhs.uk/images/box.JPG
  4. Contact number to CAT given Description: http://nww.lhp.leedsth.nhs.uk/images/box.JPG Explain parents to use this over next 48hrs
  5. Follow-up. All Children with proven or suspected bacterial meningitis should have a hearing check within 4 weeks arranged and follow-up with the results with Children’s Medicine. Consider additional follow-up with appropriate specialities based on co-morbidities. HV and or school nurse should be informed.
  6. Children with a second episode of meningitis, meningococcal non group-B serotypes, or who have a history of recurrent bacterial infection should be considered by the consultant for immune testing. In addition those with meningococcal disease with a FH of meningococcal disease or complement deficiency

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Background

Infants and children with CNS infection may present acutely with a variety of symptoms and signs of CNS disease. There may be overlap in the presenting features of meningitis, acute infectious encephalitis and brain abscesses and it may not be possible to distinguish the cause of infection, or non infective causes on clinical grounds. Headache is the most frequent symptom in children with brain abscesses, followed by fever and seizures. Importantly, the classical triad of fever, headache and neurological deficit are insensitive for the diagnosis of brain abscesses.
Meningitis
The infectious causes of meningitis may be bacterial, viral or fungal. The most common causes of viral meningitis include non polio enterovirus, lymphocytic choriomeningitis virus, mumps virus and polio virus.
Table 1 illustrates the common causes of bacterial meningitis, which vary with age.

Table 1: Organisms causing bacterial meningitis according to age

Age

Bacteria

Neonatal

Group B Streptococcus
E.coli and other coliforms
Listeria monocytogenes

1-3 months

Group B Streptococcus
E.coli and other coliforms
Streptococcus pneumoniae
Haemophilus influenzae

3 month-2 years

Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae

>2 years

Neisseria meningitidis
Streptococcus pneumoniae

Encephalitis
Viruses cause the majority of acute infectious encephalitis episodes and Enteroviruses and Herpes simplex virus being the most common aetiological agents. Bacteria can occasionally cause encephalitis, Mycoplasma pneumoniae, for example and some bacteria can cause a mixed clinical picture sometimes referred to as meningoencephalitis (e.g. Listeria monocytogenes).

Herpes simplex encephalitis (HSE) is acute focal necrotizing encephalitis with inflammation and swelling of brain tissue. It represents about 10% of all severe viral CNS infections. 31% of cases occur in patients below 20 years of age and 12% in those between 6 months and 10 years 1, 2. The mortality is 50% in neonates treated with disseminated disease. In children and adults the mortality in untreated HSE is 70%, 19% in treated HSE but greater than 50% of survivors have neurological sequelae3.

Brain abscesses
Brain abscess is a focal, intracerebral infection, which usually begins as an area of cerebritis and develops into a collection of pus surrounded by a well-vascularised capsule. A brain abscess is initiated when microorganisms are introduced into the brain tissue following trauma, contiguous pericranial infection (e.g. ear or sinus infection), and meningitis or haematogenous dissemination from a distant infective focus (e.g. endocarditis). A wide variety of pathogens can cause brain abscesses (LTHT children’s brain abscess guidelines) and there may be overlap in terms of clinical presentation, with other causes of CNS infection.

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Clinical Diagnosis

Recommendation: Because the signs and symptoms of CNS infection may be subtle and are often not classical in infants and young children careful clinical assessment and often a period of observation is required to establish a diagnosis.
[Evidence level D]

Recommendation: Red flag (or alert) symptoms and signs in suspected CNS infection should include:

  • Definite neck stiffness or Kernigs sign
  • Multiple seizures same illness
  • Seizure with focal features
  • Prolonged seizure > 15 minutes
  • Does not wake or if roused does not stay awake 30 minutes after seizure (infant)
  • Conscious level depressed (GCS<15), V or less (AVPU) 30min after seizure (1-16 years)
  • Non-blanching rash
  • new onset of focal neurological signs
  • irritability
  • high pitched cry

[Evidence level C/B]

Recommendation: Other elements in the history or examination that should alert one to the possibility of CNS infection include: vomiting, poor feeding, headache, ill appearance
[Evidence level C]#

Recommendation: Over 1 year of age, if there are no red flag symptoms, then directed investigation and observation are important to allow a diagnosis to be made.
[Evidence level C]

In older children, more classical features are often seen:

  • neck stiffness
  • headache
  • photophobia

Specific signs of Kernig and Brudzinski are not reliable in children.
The diagnosis of "simple febrile convulsion" is a diagnosis of exclusion:

  1. the seizure must have been an epileptic seizure ie. clonic or tonic-clonic
  2. duration short i.e. less than 5 minutes.
  3. the child must be between 6 months and 5 years
  4. the conscious level must have returned to normal within 30 minutes of the end of the seizure, unless benzodiazepines have already been given in which case recovery of consciousness may be delayed considerably - up to several hours. In this context the child should be in the RED PATHWAY until clinical improvement occurs (see Allen et al 2008)
  5. there must be no focal neurological signs after the seizure has ended (see note 1 below)
  6. there is no other obvious diagnosis e.g. meningococcal rash
  7. a past history of a febrile seizure is weakly supportive but must not lead to the assumption the current episode cannot be a CNS infection

Note 1. If a child has had a short febrile seizure that nonetheless had some focal features -e.g. eye deviation or a unilateral clonic seizure AND they have no other risk factors as listed in the RED PATHWAY, then it may be reasonable to put them in the Yellow pathway. This is of course dependent on regular clinical review i.e. they should not be discharged at this point.

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Investigation

1. Lumbar puncture:

Recommendation: Cerebrospinal fluid (CSF) analysis and culture remain the gold standard for diagnosing meningitis(3,4) and lumbar puncture (LP) should be performed as soon as possible, unless there are clinical reasons to defer (see below).
[Evidence level A]

Recommendation: Because clinical assessment of acute CNS infection in younger infants is unreliable, CSF examination is considered mandatory in all children <1 year of age with no other focus to account for any of the above.
[Evidence level C]

Recommendation: Antibiotic administration should NOT be delayed if LP is deferred.
[Evidence level C]

Recommendation: LP should always be deferred and discussed with a consultant paediatrician in the presence of :

  • shock
  • suspicion of meningococcal bloodstream infection/disease (e.g. purpura or petechial rash in this context)
  • raised intracranial pressure (ICP) (see non-antimicrobial management)
  • Glasgow Coma Score <13 or deteriorating level of consciousness (eg a drop in GCS from 15 to 13); if GCS <13 but stable
  • Other signs of raised intracranial pressure - altered pupillary responses, absent Doll's eye reflexes, decerebrate or decorticate posturing, abnormal respiratory pattern, papilloedema, hypertension, bradycardia.
  • Within 30 minutes of a convulsive seizure (after 30 minutes, take GCS into consideration before LP).
  • Focal seizures (may potentially indicate a structural abnormality including a tumour or an abscess).
  • Tonic seizures BEWARE extensor posturing (syn. decerebrate posturing) is a sign of brain herniation until proved otherwise.
  • New focal neurological signs - hemi/monoparesis, extensor plantar responses, ocular palsies.
  • Local infection over the LP site.
  • Coagulation disorder/patients treated with anticoagulants/low platelets.

suspect raised ICP if any :-
*V or less on AVPU consciousness rating
*Abnormal pupil reaction & size

Depth of LP needle insertion (correlates to height of child: 0.03 x height cm)

Age (height) of child

insertion depth (22G or 25G in older children)

Pre-term neonates (<50cm)

2cm

Under 2 years (50-80cm)

3cm

2 - 5 years (80-120cm

4 cm

5 - 12 years (120-150cm)

5cm

Over 12 years (150-180cm)

6cm

CSF should be collected, and investigations arranged in table 2. below

CSF collection

Tube

Destination; test

CSF 1 (10 drops)

Microbiology; M, C & S, PCR

CSF 2 (10 drops)

Biochemistry; Protein

CSF 3 (10 drops)

Virology; PCR- Enteroviruses, HSV, VZV

CSF 4 (10 drops)

Microbiology; M, C & S

CSF Glucose

Biochemistry; Glucose

Venous glucose (paired- taken at same time)

Biochemistry; Glucose

Table 2. Schedule for laboratory testing of CSF samples.
* Please remember to print and send ALL ICE order forms and stickers for CSF samples. Virology, Bacteriology and Biochemistry forms are ALL separate.
For CSF interpretation refer to table 3 below

Interpretation

Result

Neutrophils (x106/ l)

Lymphocytes (x106/ l)

Protein
(g/l)

Glucose
(CSF:Blood ratio)

Normal (over 1 month of age)

0

≤ 5

< 0.4

≥ 0.6
(or ≥ 2.5 mmol/l)

Normal term neonate

0

< 20

< 1.0

≥ 0.6
(or ≥ 2.5 mmol/l)

Bacterial Meningitis

100-10,000
(but may be normal)

< 100
(Usually)

> 1.0
(but may be normal)

< 0.4
(but may be normal)

Viral Meningitis

< 100
usually

10-1000
(but may be normal)

0.4 - 1.0
(but may be normal)

Usually normal

TB meningitis

< 100
usually

50-1000
(but may be normal)

1.0 - 5.0
(but may be normal)

< 0.3
(but may be normal)

Table 3. Interpretation of CSF analysis results.

Lumbar puncture (LP) is an important diagnostic tool and is generally a safe procedure. However, in the presence of raised intracranial pressure it can be associated with herniation of the brain structures.

Clinical or LP findings in keeping with TB should be discussed with the Consultant or Infectious Disease specialist.

Repeat LP is sometimes indicated and should be discussed with the Consultant

2. Neuroimaging - Cranial computed tomography (CT).
Recommendation: CT should be undertaken in all children on RED pathway or when the clinical diagnosis is uncertain or space occupying lesion (e.g. cerebral abscess) is suspected.
[Evidence level D]

Recommendation: CT must not delay antibiotic treatment to children on red pathway.
[Evidence level D]

Recommendation: CT cannot be relied upon to exclude raised intracranial pressure.
[Evidence level B]

3. Other Investigations: [Evidence level D]
Recommendation: The following investigations should be carried out in all children on red or yellow pathway:

  • Blood culture
  • FBC
  • C reactive protein (can be normal in the early stages of disease)
  • Urea & electrolytes
  • Glucose (bedside estimation- BM stix & formal laboratory glucose)
  • Blood gases (venous)
  • Throat swab
  • Blood sample for Mycoplasma IgM (if encephalitis suspected)
  • EDTA specimen for PCR studies (Neisseria meningitidis and Streptococcus pneumoniae)
  • Clotting

WARNING - a normal CRP and or FBC does not exclude bacterial meningitis. A negative blood PCR does not exclude N meningitidis

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Treatment
Non-Antimicrobial Treatment

General
Recommendation: Manage all children with suspected CNS infection in line with APLS guidelines/protocols, pay particular attention to:

  • Airway security & adequacy of ventilation
  • Fluid resuscitation & need for ionotropic support
  • Seizure management (LHP guideline)
  • Hypoglycaemia, recognition and management
  • Electrolyte disturbance, recognition and management

[Evidence level A]
Liaise with PICU/ Consultant if any doubt

Fluid Management
Recommendation: There is no evidence to restrict fluid in children without obvious signs of raised intracranial pressure. Recommended maintenance fluid is 5% Glucose & 0.9% sodium chloride. See Guidelines for Fluid Management in Infants and Children on PICU.
[Evidence level A]

Failure to administer sufficient fluids in children with meningococcal disease and septic shock is associated with a higher risk of mortality (NICE).

Dexamethasone
Children OVER 3 months of age.
Recommendation: give IV Dexamethasone base (0.15mg/kg -maximum 10mg, every 6 hours for 4 days) should be administered when there is a strong suspicion of meningitis (consultant decision) and LP result is likely to be delayed (>4 hours) OR if LP confirms diagnosis of meningitis (purulent CSF, or CSF WCC.1000/ x106/ l, protein >1g/L, bacteria seen on Gram).
[Evidence level A]

UNDER 3 months of age:
Recommendation: DO NOT GIVE CORTICOSTEROIDS IN CHILDREN UNDER 3 MONTHS WITH SUSPECTED OR CONFIRMED BACTERIAL MENINGITIS.
[Evidence level A]

Any age.
Recommendation: Do not give steroids to Infants or children with clinical evidence of meningococcal septicaemia (i.e. typical non blanching purpuric rash) unless catecholamine resistant shock is present or in children with possible TB meningitis.
[Evidence level C]

Recommendation: If corticosteroids have been started, they can be stopped if the diagnosis turns out not to be meningitis (on clinical or CSF examination findings)
[Evidence level D]

Evidence from a systematic review suggests that corticosteroids significantly reduce mortality in acute bacterial meningitis but the effect was not seen in a the subgroup of children (Van de Beek, D, 2007). Hearing loss was reduced in children with meningitis, mostly caused by H. influenzae type B (Van de Beek, D, 2007). Corticosteroids are not recommended for children under three months (NICE CG 102). NICE CG 102 recommends starting steroids early with the first dose of antibiotics, based on LP findings. If steroid administration is delayed NICE advise starting within 4 hours of commencing antimicrobial therapy, therefore, if a LP procedure (or result) is likely to be delayed more than 4 hours and there is a strong clinical suspicion of acute bacterial meningitis then we advise empirical steroid administration.

DO NOT GIVE CORTICOSTEROIDS GREATER THAN 12 HOURS FTER ANTIBIOTICS HAVE BEEN STARTED.

Management of raised intracranial pressure

  • airway stabilisation,
  • urgent discussion with Consultant on call
  • Mannitol infusion Child <11 years 0.25-1.5g/Kg, Child 12-17 years 0.25-2g/Kg IV infusion, following discussion with Consultant.
  • Intensive care management

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Empirical Antimicrobial Treatment

Recommendation: Commence empirical antimicrobial therapy in all children on red pathway as indicated below:

OVER 3 months of age

Ceftriaxone Description: electronic Medicines Compendium information on Ceftriaxone 80-100mg/kg once daily IV infusion over 30 minutes (first dose can be given as a bolus in emergency) [maximum dose 4g daily]
OR, If true penicillin/ cephalosporin allergy
chloramphenicol 25 mg/kg) IV every 6 hours (reduce dose as soon as is clinically indicated)
Monitor chloramphenicol concentrations (all < 4 years of age and if doubling dose)

1- 3 months of age (& not on NICU)

IV cefotaxime Description: electronic Medicines Compendium information on Cefotaxime
Child 1-3 months- 50mg/kg every 6 hours

OR, If true penicillin/ cephalosporin allergy
IV chloramphenicol 12.5 mg/kg every 6 hours (may double dose)
Check dose carefully overdosage can be fatal
Monitor chloramphenicol concentrations

Neonate (not on NICU)

IV amoxicillin Description: electronic Medicines Compendium information on Amoxicillin 50mg/kg every 8 hours
AND
IV gentamicin (see Gentamicin Prescribing Guideline for Neonates)

Recommendation: In children with focal seizures, focal neurological signs, status epilepticus or altered conscious level (V or less on AVPU) >30 minutes after a seizure add antimicrobial agents to cover encephalitis, pending further investigation.
[Evidence level D]

aciclovir Description: electronic Medicines Compendium information on Aciclovir IV infusion
Neonate: 20mg/kg every 8 hours
Child 1-3 months: 20mg/kg every 8hours
Child 3 months- 12 years: 500mg/m2 (use body surface area nomogram at back of BNFc)
Child 12-16years: 10mg/kg every 8 hours
PLUS
clarithromycin Description: electronic Medicines Compendium information on Clarithromycin
Neonate up to 28 days: PO 7.5mg/kg every 12 hours
Bodyweight under 8kg: PO 7.5mg/kg every 12 hours
Bodyweight 8-11kg: PO 62.5mg every 12hours
Bodyweight 12 - 19kg: PO 125mg every 12 hours
Bodyweight 20-29kg: PO 187.5mg every 12 hours
Bodyweight 30-40kg: PO 250mg every 12 hours
Child 12-18 years: PO 250mg every 12 hours, increased in severe infections to 500mg every 12 hours
OR if unable to tolerate oral
clarithromycinDescription: electronic Medicines Compendium information on Clarithromycin IV infusion into large proximal vein
Child 1 month- 12years 7.5mg/kg IV infusion every 12 hours (max dose 500mg)
Child 12 -18 years 500mg IV infusion every 12 hours

N.B. The practise of adding a macrolide is controversial. The incidence of Mycoplasma encephalitis and the effectiveness of macrolide therapy are unknown. This practise will be reviewed and a further risk benefit analysis undertaken.

Are there concerns of multi-resistant pneumococcal infection
history of recent (<6month) travel to France, Spain, Portugal
if so use additional
IV vancomycinDescription: electronic Medicines Compendium information on Vancomycin see relevant neonatal/paediatric vancomycin guideline

Chloramphenicol Monitoring
Monitor FBC daily on chloramphenicol.
Check PRE-DOSE (“trough”) level before the 3rd dose and should not exceed 15mg/ litre
Check PEAK (1hour after 3rd IV infusion) 15-25mg/litre
NB levels are sent away so monitor daily FBC result.
Reduce high doses immediately. Overdosage can be fatal

Vancomycin Description: electronic Medicines Compendium information on Vancomycin Monitoring
PRE-DOSE (“trough”) concentration should be 10-20mg/litre

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Directed Antimicrobial Treatment (when microbiology results are known)

Recommendation: Choice of antimicrobial therapy should be reviewed following confirmation of the clinical diagnosis, microbiology results and investigations. The relevant LTHT children's infection guidelines should be followed for subsequent management.
[Evidence level C]

Recommendation: Antimicrobial therapy should be “de-escalated” to the agent with the narrowest effective spectrum of activity, e.g. benzylpenicillin should be used in preference to cephalosporins for treatment of susceptible isolates.
[Evidence level C]

Ambulatory Management
Recommendation: If considered appropriate, following discussion with the consultant, a child may be discharged home to complete their treatment course through once daily administration of ceftriaxoneDescription: electronic Medicines Compendium information on Ceftriaxone.
[Evidence level B]

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Duration of Treatment

Recommendation: Duration of therapy should be determined by the final clinical diagnosis and results of microbiology.
[Evidence level C]

Current treatment guidelines recommend a 7 day course of antibiotic therapy for Neisseria meningitidis and 7-14 days for either H. influenzae or S. pneumoniaei. A recent meta-analysis has shown no significant difference in terms of clinical effectiveness and safety of shortened (7 days or less) duration of treatment for community acquired bacterial meningitisii.

Longer duration of antibiotics (21 days) considered for Gram negative / Listeria meningitis

Over 3 months with an unconfirmed but clinically suspected bacterial meningitis treat with IV Ceftriaxone Description: electronic Medicines Compendium information on Ceftriaxone for at least 10 days, depending on symptoms, signs and course of the illness. This should be under guidance of the Consultant +/- microbiology

Under 3 months with an unconfirmed but clinically suspected bacterial meningitis treat with cefotaxime plus amoxicillin for at least 14 days depending on symptoms, signs and course of the illness. This should be under guidance of the Consultant +/- microbiology and Consultant for infectious diseases.

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Switch to oral agent(s)
See relevant LTHT guidelines for recommendations.

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Treatment Failure

If the child is not responding to therapy as expected then obtain:

  • Urgent review by Consultant.
  • Neuroimaging to exclude effusion/ abscess.
  • Discuss with Microbiology as appropriate.

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Meningitis prophylaxis

Recommendation: Prophylaxis is not required for the index case if they have been given a third generation cephalosporin.
[Evidence level C]

Recommendation: Prophylaxis may be indicated for close contacts of the index case following discussion with Consultant in Communicable Diseases/ Public Health. Tel (0113) 3059798 (within hours) (0113) 2063283 (out of hours).
[Evidence level B]

Use the Meningococcal Prophylaxis Prescription (depicted below table) for prescribing meningococcal prophylaxis

Organism

Treatment

H. influenza B (HiB)

Rifampicin Description: electronic Medicines Compendium information on Rifampicin
Child 1 - 3 months rifampicin Description: electronic Medicines Compendium information on Rifampicin 10mg/kg PO once daily for 4 days
Child 3 months - 12 years rifampicin Description: electronic Medicines Compendium information on Rifampicin 20mg/kg (max 600mg) PO once daily for 4 days
Child 12 - 18 years rifampicin Description: electronic Medicines Compendium information on Rifampicin 600mg PO once daily for 4 days
If oral route unavailable:
Ceftriaxone Description: electronic Medicines Compendium information on Ceftriaxone
Child 1 month-11years - IV infusion 50mg/kg daily (max. per dose 1g) for 2 days
Child 12-17years - IM/IV 1g daily for 2 days

N. meningitidis (meningococcal)

Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin
Adults and children over 12 years ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin 500mg PO as single dose
Pregnant adult ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin 500mg PO as single dose
Child 5 - 12 years ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin 250mg PO as single dose
Child 1 month- 4 years ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin 30mg/kg (max 125mg) PO as single dose.
Or for patient allergic to ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin
Rifampicin Description: electronic Medicines Compendium information on Rifampicin
Adults and children over 12 years rifampicin Description: electronic Medicines Compendium information on Rifampicin 600mg PO every 12 hours for 2 days
Child 1-12 years rifampicin Description: electronic Medicines Compendium information on Rifampicin 10 mg/kg (max 300mg) PO every 12 hours for 2 days
Children less than 1 year rifampicin Description: electronic Medicines Compendium information on Rifampicin 5mg/kg PO every 12 hours for 2 days

S. pneumoniae
(pneumococcal)

Not indicated

Other types of bacterial meningitis

Not indicated

Vaccinations recommendations for close contacts from the Green Book (September 2016):
Confirmed or probable serogroup C disease, non-immunised, partially immunised & previously immunised (>1 year previously) - MenC conjugate vaccine single dose

Confirmed capsular group A, W or Y infections, non-immunised & previously immunised (>1 year previously) - Men ACWY conjugate vaccine single dose (aged <1 year requires 2 doses, >1 month apart)

Un-immunised individuals - follow routine immunisation schedule


Notification
Inform Public health: Tel (0113) 3059798 (within hours) (0113) 2063283 (out of hours)

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Provenance

Record: 2575
Objective:

Aims
To improve the diagnosis and management of child with fever, seizure and/or suspected acute central nervous system (CNS) infection
Objectives

  • To provide evidence-based recommendations for appropriate diagnosis and investigation of meningitis and suspected CNS infections
  • To provide evidence-based recommendations for appropriate non-antimicrobial management of meningitis and suspected CNS infections
  • To provide evidence-based recommendations for appropriate empirical and directed antimicrobial therapy of meningitis & suspected CNS infections
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set-out criteria for referral to specialists.
Clinical condition:

Suspected acute CNS infection

Target patient group: Children with suspected CNS infection
Target professional group(s): Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

References

NICE clinical guideline 47, Feverish illness in children. 2007

NICE clinical guideline 102, Bacterial meningitis and meningococcal septicaemia in children. 2010

Hviid A, Melbye M. The epidemiology of Viral Meningitis Hospitalization in Childhood. Epidemiology 2007;18:695-701

Lissauer. T, Clayden G. Illustrated textbook of Paediatrics 2nd Edition. Mosby 2001

Riordan FAI, Cant AJ. When do a lumbar puncture. Arch Dis Child 2002;87:235-237

Basher H El, Laundy M, Booy R. Diagnosis and treatment of bacterial meningitis. Arch Dis Child 2003;88:615-620

Bitnun A, Ford-Jones E, Blaser S, Richardson S. Mycoplasma
pneumoniae encephalitis. Semin Pediatr Infect Dis. 2003;14:96 - 107

Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004;39:1267 - 84.

Karageorgopoulos DE, Valkimadi PE, Kapaskelis A, Rafalidis PI, Falagas M E. Short versus long duration of antibiotic therapy for bacterial meningitis: a meta-analysis of Randomized Controlled trials in children:Arch Dis Child 2009;94:607 - 614

Maconochie IK, Baumer JH, Stewart M. Fluid therapy for acute bacterial meningitis.
Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004786. DOI: 10.1002/14651858.CD004786.pub3

Van de Beek D, de Gans J, Mcintyre P, Prasad K. Corticosteroids for acute bacterial meningitis. Cochrane database of systematic reviews 2007, issue 1. Art no.: CD004405

Karageorgopoulos DE, Valkimadi PE, Kapaskelis A, Rafalidis PI, Falagas M E. Short versus long duration of antibiotic therapy for bacterial meningitis: a meta-analysis of Randomized Controlled trials in children:Arch Dis Child 2009;94:607 - 614

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

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