About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Commonest bacterial causes beyond neonatal period: N. meningitidis (meningococcal) and S. pneumoniae (pneumococcal)
- Non-blanching petechial/purpuric rash + fever = meningococcal disease until proven otherwise — give IM/IV benzylpenicillin or ceftriaxone IMMEDIATELY
- Classic signs: fever, headache, neck stiffness, photophobia, positive Kernig/Brudzinski. In infants: bulging fontanelle, poor feeding, irritability, high-pitched cry
- Empirical antibiotics per NICE NG240: IV ceftriaxone (children >3 months). Add amoxicillin if <3 months (Listeria cover)
- IV dexamethasone 150 micrograms/kg QDS for 4 days if LP shows turbid CSF or Gram-positive cocci (pneumococcal meningitis) — reduces hearing loss
- Close contacts require chemoprophylaxis: ciprofloxacin (single dose) or rifampicin (2 days) for meningococcal disease
Overview
Bacterial meningitis in children is a medical emergency requiring immediate recognition and treatment. Beyond the neonatal period, the most common causative organisms are Neisseria meningitidis (serogroups B and W most common in the UK) and Streptococcus pneumoniae. The UK vaccination programme (MenB, MenACWY, PCV13, Hib) has significantly reduced incidence but cases still occur. Meningococcal disease can present as meningitis, septicaemia, or both. Septicaemia without meningitis carries the highest mortality. The non-blanching petechial rash of meningococcal septicaemia is a clinical emergency requiring immediate parenteral antibiotics.
Epidemiology
The incidence of bacterial meningitis in the UK has fallen significantly since the introduction of Hib, PCV, and MenB/MenACWY vaccines. Peak incidence is in children under 5, particularly infants. Meningococcal disease has a bimodal age distribution: under 5 years and 15–19 years. Case fatality rate for meningococcal disease is approximately 5–10%. Pneumococcal meningitis has higher mortality (~20%) and morbidity than meningococcal meningitis. Risk factors include immunodeficiency, asplenia, cochlear implants, CSF leak, and complement deficiency.
Clinical Features
Symptoms
Fever — may be the only early symptom
Headache — severe and diffuse
Photophobia
Neck stiffness (older children)
Vomiting (often projectile)
Non-blanching petechial or purpuric rash (meningococcal septicaemia)
Altered consciousness, confusion, drowsiness
Seizures
In infants: irritability, poor feeding, high-pitched cry, bulging fontanelle, hypotonia
Signs
Positive Kernig sign (pain on knee extension with hip flexed)
Positive Brudzinski sign (hip flexion on passive neck flexion)
Bulging fontanelle in infants
Purpura fulminans (widespread purpura with DIC — meningococcal)
Signs of shock: tachycardia, hypotension, poor CRT, cold peripheries
Opisthotonus (severe meningeal irritation)
Investigations
First-line
Blood cultureBefore antibiotics if possible — but do NOT delay treatment
FBC, CRP, coagulation, glucose, lactate, blood gasAssess severity. Look for DIC (low platelets, prolonged clotting), raised lactate (shock)
Lumbar punctureWhen safe to perform — CSF for MC&S, protein, glucose (with paired blood glucose), PCR. Bacterial: turbid, raised WCC (neutrophils), raised protein, low glucose (<50% blood glucose)
Second-line
Blood PCR for N. meningitidisMeningococcal PCR — useful if blood cultures negative (especially if antibiotics given before cultures)
Throat swabFor meningococcal carriage — useful for public health and contact tracing
CT headBefore LP only if: focal neurological signs, papilloedema, GCS <12, signs of raised ICP, immunocompromised. Otherwise LP should not be delayed for CT
Specialist
LP contraindications (perform CT first or defer LP)Signs of raised ICP, focal neurology, GCS <9, cardiorespiratory instability, coagulopathy, overlying skin infection. Start antibiotics without LP
1
Pre-hospital (GP or paramedic)
- If suspected meningococcal disease (non-blanching rash + fever): give IM/IV benzylpenicillin immediately
- Doses: <1 year 300 mg, 1–9 years 600 mg, 10+ years 1200 mg
- Transfer to hospital urgently — do NOT wait for ambulance if critical
- If penicillin allergic: give ceftriaxone or transfer immediately without antibiotics
2
Hospital empirical antibiotics
- IV ceftriaxone 80 mg/kg/day (max 4 g) — covers meningococcal and pneumococcal
- If <3 months: IV cefotaxime + IV amoxicillin (Listeria cover)
- Start antibiotics WITHIN 1 HOUR of arrival if meningitis/septicaemia suspected
- If LP done: adjust antibiotics based on CSF results and sensitivities
3
Adjunctive treatment
- IV dexamethasone 150 micrograms/kg QDS for 4 days — give with or just before first dose of antibiotics
- Dexamethasone indicated if LP shows turbid CSF or Gram-positive diplococci (pneumococcal) — reduces hearing loss and neurological sequelae
- Do NOT give dexamethasone in meningococcal meningitis (no proven benefit) or if immunocompromised
- Fluid management: avoid overhydration (risk of cerebral oedema) but treat shock with fluid boluses
4
Contact management and public health
- Notify public health immediately (meningococcal disease is notifiable)
- Chemoprophylaxis for close contacts of meningococcal disease: ciprofloxacin single dose (adults 500 mg, child 1–11 years 250 mg) or rifampicin for 2 days
- Chemoprophylaxis NOT needed for pneumococcal meningitis contacts
- Follow-up: hearing assessment (audiometry) within 4 weeks for all children after bacterial meningitis
Complications
- Sensorineural hearing loss: Most common long-term complication — especially after pneumococcal meningitis. Audiometry within 4 weeks
- Seizures: Acute and long-term epilepsy
- Cerebral oedema and raised ICP: Can be fatal
- Subdural empyema or effusion: Especially pneumococcal
- Hydrocephalus: Communicating — from impaired CSF absorption
- Cerebral infarction: From vasculitis
- Waterhouse-Friderichsen syndrome: Bilateral adrenal haemorrhage in fulminant meningococcal septicaemia
- Limb ischaemia and amputation: From purpura fulminans and DIC
UKMLA Exam Tips
- 1Non-blanching rash + fever = give parenteral antibiotics IMMEDIATELY — do not wait for investigations
- 2Meningism is UNRELIABLE in infants — look for bulging fontanelle, poor feeding, irritability, high-pitched cry
- 3Empirical antibiotic: IV ceftriaxone (>3 months). Add amoxicillin if <3 months (Listeria)
- 4IV dexamethasone for pneumococcal meningitis (turbid CSF, Gram-positive diplococci) — reduces hearing loss
- 5CT before LP only if: focal neurology, GCS <12, signs of raised ICP, immunocompromised
- 6Chemoprophylaxis for meningococcal contacts: ciprofloxacin single dose
- 7The glass test: a non-blanching rash does not fade when pressed with a glass tumbler
practicetest your knowledge on meningitis and sepsis in childrenApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — paediatrics and beyond.
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