Bacterial meningitis and meningococcal sepsis in adults - Suspected community acquired

Publication: 30/07/2009  --
Last review: 22/09/2021  
Next review: 22/09/2024  
Clinical Guideline
CURRENT 
ID: 1440 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

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

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.

All patients

 

FBC, clotting, U+E, LFTs, Glucose, CRP, Lactate, Procalcitonin.
Blood cultures (within 1 hour of arrival and ideally prior to administration of antibiotics). Antibiotics should only be given prior to blood cultures if blood culture taking will cause a significant delay in antibiotic administration.
EDTA blood for meningococcal and pneumococcal PCR HIV test.
Lumbar puncture2 (providing no contraindication) ideally within 1 hour of suspicion of meningitis and prior to administration of antibiotics. Do not wait for clotting results (unless a coagulopathy is clinically suspected). Best practice is to perform the LP within 1 hour and ideally within 4 hours. Under exceptional circumstances the LP may have to be delayed but should be done within 8 hours.
Complete sepsis screening tool on PPM+ if features of sepsis

If the lumbar puncture cannot be performed within one hour antibiotics should be given after blood cultures have been taken.
Measure opening pressure and take CSF for the following:

  • Microscopy, Gram stain, and culture (send 3 sterile universal containers to microbiology), protein and glucose analysis (1 sterile universal and 1 fluoride oxalate tube to biochemistry)
  • A synchronous blood glucose level should be taken
  • CSF lactate (if prior antibiotics not given)
  • Meningococcal and pneumococcal PCR
  • Take an extra sample for virology (PCR for herpes simplex virus, varicella zoster and enterovirus) to be tested if the CSF is consistent with viral meningitis

Patients with either a history of trauma or recent neurosurgery, or evidence of rhinorrhoea or otorrhoea

Neuroimaging looking for evidence of a CSF leak.

Patient with focal neurological signs, papilloedema, continuous or uncontrolled seizures, GCS </= 12

CT brain prior to lumbar puncture

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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.)

Empirical options for Bacterial Meningitis

Please see British infection association algorithm for early management of suspected meningitis and meningococcal sepsis: http://www.britishinfection.org/files/5414/5674/3289/algorithm.pdf

Duration of treatment: see directed therapy

 

Recommended (1st line) treatment

Severe beta-lactam allergy (confirmed anaphylaxis, angio-oedema or Stevens-Johnson syndrome)

Notes

Bacterial Meningitis

Cefotaxime electronic Medicines Compendium information on Cefotaxime IV 2g 6 hourly

Chloramphenicol electronic Medicines Compendium information on Chloramphenicol IV 25mg/kg 6 hourly (maximum dose of 2g QDS)

 

 

Dexamethasone IV 9.9mg before or at the same time as initial antibiotic therapy should be given. Dexamethasone can be initiated up to 12 hours after the first dose of antibiotics Continue 6 hourly for 4 days only if pneumococcal meningitis confirmed or likely.

If penicillin resistant Streptococcus pneumoniae meningitis is suspected (e.g. travel within the last 6 months to an area of widespread penicillin resistance- please discuss with an infection specialist7 if unsure)

Cefotaxime electronic Medicines Compendium information on Cefotaxime IV 2g 6 hourly 
AND
Vancomycin electronic Medicines Compendium information on Vancomycin IV see dosing guidelines

Chloramphenicol electronic Medicines Compendium information on Chloramphenicol IV 25mg/kg 6 hourly (maximum dose of 2g QDS)
AND
Vancomycin electronic Medicines Compendium information on Vancomycin IV see dosing guidelines

If Listeria meningitis is suspected (≥60 years old OR immunocompromised (including alcohol dependency, diabetes, malignancy)

Cefotaxime electronic Medicines Compendium information on Cefotaxime IV 2g 6 hourly
AND
Amoxicillin electronic Medicines Compendium information on Amoxicillin IV 2g 4 hourly

Chloramphenicol electronic Medicines Compendium information on ChloramphenicolIV 25mg/kg 6 hourly (maximum dose of 2g QDS)
AND
Co-trimoxazole electronic Medicines Compendium information on ChloramphenicolIV 10-20mg/kg (of the trimethoprim component) in four divided doses3

Meningococcal sepsis

Cefotaxime electronic Medicines Compendium information on Cefotaxime IV 2g 6 hourly

Chloramphenicol electronic Medicines Compendium information on Chloramphenicol IV 25mg/kg 6 hourly (maximum dose of 2g QDS)

Dexamethasone should not be used

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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

Organism

No known penicillin allergy

Penicillin allergy

Duration

Neisseria meningitidis

Cefotaxime electronic Medicines Compendium information on Cefotaxime IV 2g 6-hourly

If penicillin susceptible, Benzyl penicillin electronic Medicines Compendium information on Benzyl penicillin2.4 g 4 hourly

Discuss with an Infection specialist*4,5,7

5 days sufficient if the patient has recovered

Streptococcus pneumoniae

Cefotaxime electronic Medicines Compendium information on Cefotaxime2g IV 6-hourly

If penicillin susceptible, Benzyl penicillin electronic Medicines Compendium information on Benzyl penicillin2.4 g 4 hourly

Discuss with  an Infection Specialist7

10-14 days (Stop at day 10 if uncomplicated and good recovery)

Listeria monocytogenes

Amoxicillin electronic Medicines Compendium information on Amoxicillin2g IV 4hourly. Consider adding in gentamicin (only to be done in discussion with an infection specialist7)

Discuss with an Infection Specialist7

21 days (longer treatment will be required for patients with rhomboencephalitis or brain abscess)

No pathogen identified

Cefotaxime electronic Medicines Compendium information on Cefotaxime2g IV 6-hourly

Discuss with an Infection Specialist7

10 days sufficient if the patient has clinically recovered

Any other pathogen

Discuss with an Infection Specialist7

Discuss with an Infection Specialist7

Discuss with an Infection Specialist7

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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

Provenance

Record: 1440
Objective:
Clinical condition:

Community acquired bacterial meningitis and meningococcal septicaemia

Target patient group: All
Target professional group(s): Secondary Care Doctors
Pharmacists
Primary Care Doctors
Adapted from:

Evidence base

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.0

Related information

Not supplied

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