GUIDELINE FOR THE MANAGEMENT OF SUSPECTED COMMUNITY ACQUIRED BACTERIAL MENINGITIS AND MENINGOCOCCAL SEPSIS IN ADULTS

• Referral criteria
• Diagnostics
• Empirical Treatment
• Review by 72
• Directed therapy
• Follow up

REFERRAL CRITERIA

Patients with bacterial meningitis or meningococcal sepsis should be referred to infectious diseases. This is particularly important in complicated cases or when bacterial meningitis is suspected but cultures and PCR are negative

Meningitis and invasive meningococcal disease are notifiable diseases.  Patients with proven or suspected meningococcal meningitis or sepsis should be notified urgently (within 24 hours) by telephone to the local health protection team (phone 0113 386 0300) so that antibiotic prophylaxis may be provided to contacts. This should be followed up by a written notification within 3 days. See: https://www.gov.uk/guidance/notifiable-diseases-and-causative-organisms-how-to-report

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DIAGNOSTICS

Consider meningitis in patients with any two symptoms of: fever, neck stiffness, headache, or change in mental status¹. For patients with a presumed diagnosis of bacterial meningitis or meningococcal sepsis the following diagnostic tests should be taken to confirm diagnosis:

Patients should have an early review by a senior clinician (ST3 or above). Patients can deteriorate very quickly and escalation as per NEWS/clinical concern should be performed. Ensure the consciousness and neurological observations section of the NEWS score is complete and accurate.

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EMPIRICAL TREATMENT

Doses assume normal renal and hepatic function. (Refer to the BNF, SPC and The Renal Drug Handbook for further guidance on dosing in renal and hepatic impairment; refer to the ward pharmacist for further guidance if required.)

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REVIEW BY 72

By 72 hours of antimicrobial treatment, diagnostics should have proven your initial diagnosis or guided to a new diagnosis.

Antibiotics should be discontinued if the CSF is normal or the CSF and clinical presentation is consistent with viral meningitis. Patients with CSF findings consistent with bacterial meningitis should continue antibiotic therapy, if possible guided by any significant positive microbiology results. A negative CSF culture does not exclude bacterial meningitis.

A switch to oral antimicrobials is not recommended.

Outpatient Parenteral Antimicrobial Therapy (OPAT) can be considered in patients who are afebrile and clinically stable. Refer suitable patients for consideration of OPAT via http://lthweb.leedsth.nhs.uk/sites/infectious-diseases/opat-civas

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DIRECTED THERAPY

• When microbiology results are known, review and amend regimen as below following discussion with infection specialist⁷.
• Doses assume normal renal and hepatic function

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FOLLOW UP

Patients with two or more episodes of meningococcal or pneumococcal meningitis or patients who have a family history of more than one episode of meningococcal disease should be discussed with immunology. Patients with rare group e.g. Y/no group/infection after men ACWY vaccine should be tested for splenic function and complement deficiency

Patients with invasive pneumococcal disease (proven pneumococcal meningitis) should be vaccinated with PPV23 (Pneumovax) on discharge if unimmunised and ≥65 years old or in an at risk group according to the Green Book: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/857267/GB_Chapter_25_pneumococcal_January_2020.pdf

All patients should be assessed for potential long-term sequelae, both physical and psychological before discharge from hospital. Patients (including those who have had meningococcal sepsis) should have a hearing test if the clinician, the patient or their family thinks hearing may have been affected, or if the patient no longer has the capacity to report hearing loss. The hearing test should take place before discharge or within 4 weeks of being well enough to test, whichever is sooner. Patients found to have severe to profound deafness should be offered a ‘fast-track’ assessment for cochlear implant.

All patients with confirmed or probable bacterial meningitis should be given a medical follow up appointment within 6 weeks after discharge.
All patients and their families should be provided with the contact details of support organisations such as the Meningitis Research Foundation (www.meningitis.org) or Meningitis Now (www.meningitisnow.org).

FOOTNOTES

1. Patients with suspected bacterial meningitis should be nursed in respiratory source isolation, with droplet precautions including surgical mask if within 3 feet, until meningococcal disease is excluded. Patients with confirmed meningococcal disease should remain source isolated until they have 24 hours of treatment with Cefotaxime or Ceftriaxone or had a single dose of Ciprofloxacin (500mg as a single dose orally).
2. Lumbar puncture should be delayed/avoided in the following situations: respiratory/cardiac compromise, continued seizures, rapidly reducing GCS, suspected meningococcal septicaemia, infection at the site of the lumbar puncture, neuroimaging reveals significant brain shift, clinically suspected coagulopathy or INR>1.5, platelet count <40 x10⁹/L. For patients on anticoagulants or clopidogrel - expert advice should be sought from the coagulation team.  It is safe to do lumbar puncture if patient is taking aspirin/NSAIDS.
3. Co-trimoxazole 480mg consists of sulfamethoxazole 400 mg and trimethoprim 80 mg as an intravenous infusion. When dosing, round to the nearest dose to allow easier administration i.e. patient weighing 50kg x 10mg trimethoprim = 500mg/24hours i.e. 125mg of trimethoprim QDS. To achieve this trimethoprim dose, prescribe co-trimoxazole 960mg QDS IV. Total trimethoprim per dose would be 160mg which is equal to 10-20mg/kg QDS of the trimethoprim component). Discuss with pharmacist if needed.
4. Patients with meningococcal disease who have not received a dose of Cefotaxime or Ceftriaxone should receive a single dose of Ciprofloxacin (500mg as a single dose orally)  to eliminate pharyngeal carriage
5. Under normal circumstances prophylaxis is not required for members of healthcare staff looking after a patient with suspected or confirmed meningococcal infection. This is only likely to be needed for those involved in airway management without wearing a mask prior to patient receiving 24 hours of antibiotics.
6. Infection Specialist: Microbiology/Infectious diseases consultant/registrar