Prehospital management of suspected meningitis

Arrange urgent transfer of patients with suspected bacterial meningitis to hospital. For in-hospital management, see Immediate and early hospital management of meningitis.

Note: Arrange urgent transfer of patients with suspected bacterial meningitis to hospital.

Prompt treatment of bacterial meningitis reduces morbidity and mortality. If there are signs of meningococcaemia, administer an immediate (prehospital) dose of antibiotics, because meningococcal sepsis can be rapidly fatal.

Antibiotic choice for prehospital management of suspected meningococcaemia is contentious. Benzylpenicillin is recommended on the basis of retrospective studies that showed prehospital administration reduced mortality – it is also widely available in primary care. While there is clinical experience with prehospital administration of ceftriaxone for this indication, clinical evidence to support its use is lacking. Ceftriaxone offers the additional benefit of providing activity against other common causes of meningitis (eg Streptococcus pneumoniae with reduced susceptibility or resistance to penicillins, Haemophilus influenzae)Australian Commission on Safety and Quality in Health Care (ACSQHC) 2021. Given this, ceftriaxone is preferred in these guidelines.

Note: If meningococcaemia is suspected in the community, administer an immediate dose of ceftriaxone or benzylpenicillin.

If meningococcaemia is suspected on clinical grounds (eg fever plus purpuric rash, sepsis plus meningeal symptoms, unexplained septic shock in young adults) in the community, administer an immediate dose of ceftriaxone or benzylpenicillin.

If possible, before administering antibiotics, collect blood samples for culture, and swabs or aspirates of punctured skin lesions. Send all samples with the patient to hospital.

If meningococcaemia is suspected in the community, use:

ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously or intramuscularly¹. For advice on reconstitution and administration, see Preparation of ceftriaxone for intravenous administration for suspected meningitis for intravenous doses and Preparation of ceftriaxone for intramuscular administration for suspected meningitis for intramuscular doses. ceftriaxone ceftriaxone ceftriaxone

If ceftriaxone is not available, benzylpenicillin can be given. Use:

benzylpenicillin 2.4 g (child: 60 mg/kg up to 2.4 g) intravenously or intramuscularly. For dosage adjustment in adults with kidney impairment, see benzylpenicillin dosage adjustment. For advice on reconstitution and administration, see Preparation of benzylpenicillin for intravenous administration for suspected meningitis for intravenous doses and Preparation of benzylpenicillin for intramuscular administration for suspected meningitis for intramuscular doses. benzylpenicillin benzylpenicillin benzylpenicillin

For patients treated with benzylpenicillin who have not arrived at a hospital within 4 hours, administer another dose of benzylpenicillin. Continue to administer doses every 4 hours until arrival at hospital.

Ceftriaxone can be used in patients who have had a severe immediate² or nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, but not in those who have had a severe delayed³ hypersensitivity reaction to a penicillin.

For patients who have had a severe delayed³ hypersensitivity reaction to a penicillin, use:

moxifloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, daily⁴. For dosage adjustment in adults with kidney impairment, see moxifloxacin dosage adjustment. moxifloxacin moxifloxacin moxifloxacin

If moxifloxacin is not available, or if the patient does not receive a prehospital dose of antibiotics for another reason, transfer to hospital should be expedited.

Note: If the patient does not receive a prehospital antibiotic, transfer to hospital should be expedited.

Table 1. Preparation of ceftriaxone for intravenous administration for suspected meningitisThe Royal Children's Hospital Melbourne (RCH) 2021 The Society of Hospital Pharmacists of Australia (SHPA) 2024
Reconstitute the vial Reconstitute the vial (Ceftriaxone AFT [NB1]) to achieve an initial ceftriaxone concentration of 100 mg/mL 500 mg vial: add 4.7 mL WFI 1 g vial: add 9.4 mL WFI 2 g vial: add 18.9 mL WFI Prepare a dilute solution Further dilute the reconstituted solution to achieve a final concentration of 40 mg/mL 500 mg vial: add 7.5 mL of sodium chloride 0.9% 1 g vial: add 15 mL of sodium chloride 0.9% 2 g vial: add 30 mL of sodium chloride 0.9% Determine the volume to administer Determine the final volume to be administered according to the recommendations below.
Age	Dose	Administration instructions
child 1 month or older weighing less than 40 kg	50 mg/kg up to 2 g	Calculate the dose eg for a 20 kg child: 50 mg/kg × 20 kg = 1000 mg Calculate the volume of dilute solution eg for a 20 kg child: 1000 mg ÷ 40 mg/mL = 25 mL Administer: doses 1 g or less over 5 minutes doses more than 1 g over at least 30 minutes [NB2]
adult or child weighing 40 kg or more	2 g	Administer the dose (50 mL of diluted solution) over 30 minutes [NB2]
Note: WFI = water for injection NB1: Ceftriaxone powder volumes vary depending on the brand used. The advice in this table is specific to the Ceftriaxone AFT brand. NB2: Some centres administer doses more than 1 g over 5 to 15 minutes.

Table 2. Preparation of ceftriaxone for intramuscular administration for suspected meningitisThe Royal Children's Hospital Melbourne (RCH) 2021 The Society of Hospital Pharmacists of Australia (SHPA) 2024
Reconstitute the vial Reconstitute the vial (Ceftriaxone AFT [NB1]) to achieve a ceftriaxone concentration of 250 mg/mL [NB2] [NB3]. 500 mg vial: add 1.7 mL WFI or lidocaine 1% 1 g vial: add 3.4 mL WFI or lidocaine 1% 2 g vial: add 6.9 mL WFI or lidocaine 1% Determine the volume to administer Determine the final volume to be administered according to the recommendations below.
Age	Dose	Administration instructions
child 1 month or older weighing less than 40 kg	50 mg/kg up to 2 g	Calculate the dose eg for a 20 kg child: 50 mg/kg × 20 kg = 1000 mg Calculate the volume eg for a 20 kg child: 1000 mg ÷ 250 mg/mL = 4 mL Administer the dose by deep intramuscular injection into a large muscle Consider dividing the dose among multiple injection sites to minimise pain
adult or child weighing 40 kg or more	2 g	Administer the dose (8 mL) by deep intramuscular injection into a large muscle Consider dividing the dose among multiple injection sites to minimise pain
Note: WFI = water for injection NB1: Ceftriaxone powder volumes vary depending on the brand used. The advice in this table is specific to the Ceftriaxone AFT brand. NB2: Some centres use ceftriaxone concentrations of up to 350 mg/mL in children.The Royal Children's Hospital Melbourne (RCH) 2021 NB3: Lidocaine 1% can be used when the dose will be given intramuscularly; it must not be used if the dose is to be given intravenously.

Table 3. Preparation of benzylpenicillin for intravenous administration for suspected meningitis[NB1]The Royal Children's Hospital Melbourne (RCH) 2021 The Society of Hospital Pharmacists of Australia (SHPA) 2024
Reconstitute the vial Reconstitute the vial to achieve an initial benzylpenicillin concentration of 300 mg/mL 600 mg vial: add 1.6 mL WFI 1.2 g vial: add 3.2 mL WFI 3 g vial: add 8 mL WFI Prepare a dilute solution Further dilute the reconstituted solution to achieve a final concentration of 60 mg/mL 600 mg vial: add 8 mL of sodium chloride 0.9% 1.2 g vial: add 16 mL of sodium chloride 0.9% 3 g vial: add 40 mL of sodium chloride 0.9% Determine the volume to administer Determine the final volume to be administered according to the recommendations below.
Age	Dose	Administration instructions
child weighing less than 40 kg	60 mg/kg up to 2.4 g	Calculate the dose [NB2] eg for a 20 kg child: 60 mg/kg × 20 kg = 1200 mg Calculate the volume eg for a 20 kg child: 1200 mg ÷ 60 mg/mL = 20 mL Administer the dose over at least 30 minutes
adult or child weighing 40 kg or more	2.4 g	Administer the dose (40 mL of diluted solution) over at least 30 minutes
Note: WFI = water for injection NB1: Do not confuse benzylpenicillin (also known as Penicillin G) with benzathine benzylpenicillin, which is long acting and achieves much lower serum concentrations. NB2: Because the concentration of dilute solution (mg/mL) is the same as the benzylpenicillin dose (mg/kg), the volume (in mL) of dilute solution is the same as the child’s weight (in kg). For example, a 14 kg child will receive 14 mL of dilute benzylpenicillin solution.

Table 4. Preparation of benzylpenicillin for intramuscular administration for suspected meningitis[NB1]The Royal Children's Hospital Melbourne (RCH) 2021 The Society of Hospital Pharmacists of Australia (SHPA) 2024
Reconstitute the vial Reconstitute the vial to achieve a benzylpenicillin concentration of 300 mg/mL 600 mg vial: add 1.6 mL WFI 1.2 g vial: add 3.2 mL WFI 3 g vial: add 8 mL WFI Determine the volume to administer Determine the final volume to be administered according to the recommendations below.
Age	Dose	Administration instructions
child weighing less than 40 kg	60 mg/kg up to 2.4 g	Calculate the dose eg for a 20 kg child: 60 mg/kg × 20 kg = 1200 mg Calculate the volume eg for a 20 kg child: 1200 mg ÷ 300 mg/mL = 4 mL Administer the dose by deep intramuscular injection into a large muscle Consider dividing the dose among multiple injection sites to minimise pain
adult or child weighing 40 kg or more	2.4 g	Administer the dose (8 mL) by deep intramuscular injection into a large muscle Consider dividing the dose among multiple injection sites to minimise pain
Note: WFI = water for injection NB1: Do not confuse benzylpenicillin (also known as Penicillin G) with benzathine benzylpenicillin, which is long acting and achieves much lower serum concentrations.

¹ Intramuscular injection of ceftriaxone is painful; consider reconstituting with lidocaine 1%. Split large intramuscular doses into 2 injections.Return

² Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

³ Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return

⁴ Moxifloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, clinical trial data suggest that adverse musculoskeletal events are usually mild and short term, similar to those observed in adults. Moxifloxacin can be used in children when it is the drug of choice.Return