When should I consider referring a patient with suspected meningitis to secondary care?

Refer a patient with suspected meningitis to secondary care immediately as an emergency. This applies particularly if the patient has the red flag combination of symptoms: fever, headache, neck stiffness, and altered level of consciousness or cognition (including confusion or delirium).

Do not delay transfer to hospital to administer antibiotics if bacterial meningitis or meningococcal disease is strongly suspected; transfer should be urgent and the hospital should be informed that the patient requires assessment by a senior clinical decision maker.

If there is likely to be a clinically significant delay in transfer, give intravenous or intramuscular ceftriaxone or benzylpenicillin outside hospital unless the patient has a severe allergy to these antibiotics.

For children under 5, especially those who are shocked, unrousable, or showing signs of meningococcal disease, urgent review by an experienced paediatrician and consideration of referral to paediatric intensive care is recommended.

Safety netting advice should be given if the patient is sent home without admission, including instructions to return if symptoms worsen or new symptoms develop.