• Consider TB meningitis:  if raised CSF WCC and risk factors for TB. If TB meningitis in differential diagnosis, refer to NICE (2019) TB NG33 for appropriate antibiotic treatment. 
• Consider herpes simplex meningoencephalitis: If HSV in differential diagnosis give Aciclovir.

Administer steroids if 12h or less from first antibiotics and LP shows:

•  frankly purulent CSF
• CSF WCC over 1000/μl
• raised CSF WCC and protein above 1 g/L
• bacteria on gram stain.
• Steroids should not be used in developing countries. 
• If TB meningitis in the differential diagnosis, refer to NICE (2019) TB NG33 before administering steroids.

Steroid dosage: dexamethasone 0.15 mg/kg to a max dose of 10 mg, qds x 4 days for children 3 months or older.

Note: Indications for tracheal intubation and mechanical ventilation:

• Threatened or actual loss of airway patency (e.g. GCS <9, response to pain only).
• Need for any form of assisted ventilation e.g. bag–mask ventilation.
• Clinical observation of increased work of breathing
• Hypoventilation or apnoea
• Features of respiratory failure, including
  • irregular respiration (e.g. Cheyne–Stokes breathing)
  • hypoxia (saturation below 94% in air, PaO₂ below 13 kPa or 97.5mmHg), hypercapnoea (PaCO2 over 6 kPa or 45 mmHg).
• Continuing shock following 40ml/kg of resuscitation fluid
• Signs of raised intracranial pressure
• Impaired mental status
  • GCS drop of more than 3, or score below 9, or fluctuation in conscious level
  • moribund state
• Control of intractable seizures
• Need for Stabilisation for brain imaging or for transfer to PICU.

Should be undertaken by a health professional with expertise in paediatric airway management, consult PICU/. (See note MD4)

Does the patient have any of the following indications requiring CT scan?

Note: CT scan cannot reliably detect raised intracranial pressure. This should be assessed clinically.