Bacterial meningitis and meningococcal septicaemia in adults - Suspected community acquired

Publication: 30/07/2009  --
Last review: 30/09/2017  
Next review: 30/09/2020  
Clinical Guideline
CURRENT 
ID: 1440 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

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 and prophylaxis of suspected community acquired bacterial meningitis and meningococcal septicaemia in adults

Summary
Bacterial meningitis and meningococcal septicaemia in adults

Diagnosis: consider meningitis in patients with any two symptoms of; fever, neck stiffness, headache, or change in mental status.
Consider the diagnosis of encephalitis in patients with fever, altered behaviour, new onset seizures or new focal neurological deficits. See - http://www.theabn.org/media/docs/ABN%20publications/Management_of_Suspected_Viral_Encephalitis_in_Adults.pdf

Investigations:

  • FBC, clotting, U+E, LFTs, Glucose, CRP, Lactate
  • Blood cultures
  • EDTA blood for meningococcal and pneumococcal PCR
  • Lumbar puncture (LP): Should be done urgently, ideally within 1 hour but not more than 4 hours after admission if there is no contra indication. Do not wait for clotting results unless a coagulopathy is clinically suspected.) - See Box 1
  • CT brain scan normally not indicated- See Box 2.
  • All patients with meningitis should have a HIV test

Non-antimicrobial treatment

  • Stabilisation of the patient’s airway, breathing and circulation should be an immediate priority - See sepsis guidelines
  • The patient should be reviewed by a ST3 or more senior doctor
  • Dexamethasone IV 9.9mg before or at the same time as initial antibiotic therapy should be given if bacterial meningitis is strongly suspected. Continue 6hourly for 4 days only if pneumococcal meningitis confirmed.

Empirical antibiotic treatment

Bacterial meningitis: Give antibiotics immediately after the LP. If LP cannot be done within the first hour, antibiotics must be given immediately after blood cultures have been taken
IV Cefotaxime electronic Medicines Compendium information on Cefotaxime 2g 6 hourly.
If penicillin resistant Streptococcus pneumoniae is suspected (e.g. if patient has recent travel to an area of widespread penicillin resistance) add Vancomycin electronic Medicines Compendium information on Vancomycin see dosing guidelines. (Discuss with ID or microbiology)

≥60 years old OR immunocompromised (including alcohol dependency and diabetes) cover for Listeria meningitis Cefotaxime electronic Medicines Compendium information on Cefotaxime 2g IV 6 hourly PLUS Amoxicillin electronic Medicines Compendium information on Amoxicillin 2g IV 4 hourly

Meningococcal septicaemia: LP is not indicated. Antibiotics should be given immediately after blood cultures have been taken.

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

Beta-lactam allergy - See antibiotic allergy guideline on trust intranet
Non severe allergy; i.e. non-severe skin rash - treat as above.

Severe allergy; i.e. confirmed anaphylaxis, angio-oedema or Stevens-Johnson syndrome:

Chloramphenicol electronic Medicines Compendium information on Chloramphenicol IV 25mg/kg 6 hourly

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

Duration and directed antimicrobial therapy

Outpatient IV antibiotic therapy (OPAT/CIVAS)

This can be considered in selected patients

Referral criteria
Patients with bacterial meningitis or meningococcal septicaemia 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

Notification
Meningitis and meningococcal septicaemia are notifiable diseases.
Patients with proven or suspected meningococcal meningitis or septicaemia should be notified urgently by telephone to the consultant in communicable disease control (available via switch) so that antibiotic prophylaxis may be provided to contacts.

Chemoprophylaxis: Close contacts of patients with meningococcal disease should be given antibiotic prophylaxis to eliminate pharyngeal carriage

Patients with meningococcal disease who have not received a dose of Ceftriaxone electronic Medicines Compendium information on Ceftriaxone should receive a single dose of Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin to eliminate pharyngeal carriage

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Background

Bacterial meningitis and meningococcal septicaemia are important preventable causes of mortality and morbidity. A recent study in England and Wales showed an increase in the incidence of meningitis in adults between 2004 and 2011,with an in crease of 3% per year in patients over 65 years of age [1] The mortality rate is high, approximately 20% for all cases and this increase with age. [2]The number of cases of meningococcal meningitis and septicaemia has declined over the last decade following the introduction of the group C vaccine. Amongst adults, the incidence of meningococcal disease is highest in younger adults, between the ages of 16-25. [1,3]

Neisseria meningitidis is carried by approximately 10% of the UK population in the nasopharynx without causing problems. It is transmitted from person to person by inhaling respiratory secretions from the mouth and throat or by direct contact. There are at least 13 serotypes of Neisseria meningitidis that cause invasive disease, of which the main serotypes are A, B, C, W, and Y.

Streptococcus pneumoniae is the commonest cause of community acquired pneumonia. It can cause bacterial meningitis by reaching the meninges either via the bloodstream or via the Ear, Nose or Throat. It is more common in immunocompromised patients, and in those patients who may have a direct communication between the meninges and the nasopharynx / ears, such as in patients with a skull vault defect or recent neurosurgery. The mortality rate is approximately 30% [2]

Listeria monocytogenes is a gram positive cocco-bacillus that resides in the environment including soil and decaying vegetation but grows well at refrigeration temperatures and can be found in certain types of food, particularly deli produce such as cold meat. [4] It is a well recognised cause of gastroenteritis, but it can also cause severe systemic illness including bacteraemia, meningitis, chorioamnionitis and miscarriage. Severe illness is unusual unless an individual is pregnant, has significant immunosuppression, malignancy, or is at an extreme of age.[5] Over one third of cases of Listeriosis between 1999 and 2009 occurred in patients with malignancy
Risk factors for L. monocytogenes meningitis are, pregnancy (particularly 3rd trimester, malignancy (solid organ / haematological), steroid use / immunosuppression, alcohol dependence and extremes of age
Other bacteria that cause meningitis in adults include Haemophilus influenza,Streptococcus pyogenes, Enterococcus species, Group B streptococcus, and other gram negative bacteria such as Klebsiella, Pseudomonas and Enterobacter. Mycobacterium tuberculosis should also be considered in those with appropriate risk factors, even in patients with an acute presentation. [6]

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Clinical Diagnosis

The early recognition of meningitis and institution of antimicrobial and adjunctive treatment is crucial to patient outcome. In the early stages the clinical features of meningitis and meningococcal septicaemia are often non-specific and require a high index of suspicion. An analysis of 696 cases of bacterial meningitis showed the classic triad of fever, neck stiffness and change in mental status in only 44% but if headache is added then at least 2 features were present in 95% of cases. [2] Kernig’s sign (inability to allow full knee extension when the hip is flexed to 90 degrees) and Brudzinski’s sign (spontaneous flexion of the hips during passive neck flexion) have poor sensitivity and specificity for detecting meningitis. [7] Patients with pneumococcal meningitis are more likely to have focal neurological symptoms, seizures and a reduced consciousness level. Meningitis is the commonest presentation of meningococcal disease occurring in about 60% of patients. 10-20% may have fulminant sepsis without meningitis and 30% fever and a rash but no evidence of shock or meningitis [8]

Recommendation: consider meningitis in patients with any 2 symptoms of fever, neck stiffness, headache and change in mental status. Evidence level B

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Investigation
  • FBC, clotting, U+E, LFTs, Glucose, CRP, Lactate
  • Blood cultures
  • EDTA blood for meningococcal and pneumococcal PCR
  • Lumbar puncture (LP): LP is undertaken to obtain a sample of cerebrospinal fluid (CSF). Provided there is no contraindication a LP should be performed urgently in patients with suspected bacterial meningitis.
  • All patients with meningitis should have a HIV test

Blood cultures are a highly sensitive and specific investigation for the diagnosis of bacterial meningitis and should be taken in all patients in whom bacterial meningitis is suspected, prior to the administration of antibiotics where the yield can be as high as 74%. Blood cultures should still be taken if pre-hospital antibiotics have been administered [9] PCR increases the laboratory confirmation rate in meningococcal disease [10] and whilst there is less data on blood PCR in pneumococcal meningitis [11] it can be useful addition for diagnosis the aetiological cause.

CSF PCR can rapidly identify the causative organism in meningitis and is especially useful if antibiotics have been given prior to LP. PCR has a sensitivity of 87-100% and specificity of 98-100% [13]. If an organism cannot be identified by pathogen specific PCR, then PCR for 16S ribosomal RNA, which is present in almost all bacteria may be used, although it has lower specificity.

Ideally LP should be performed before starting antibiotics to allow the best chance of establishing a definite diagnosis. The 2016 UK meningitis guidelines recommend LP within 1 hour of arrival in hospital meaning that LP may need to be done in A+E or the patient fast tracked to the acute medical unit. Even if treatment has been started it is a priority to perform the LP as soon as possible, ideally within 4 hours of admission, since there is evidence that after that time it can be more difficult to establish a diagnosis [12]. If there is any reason to delay the LP initially this decision should be reviewed regularly and consideration given to performing the procedure later if the diagnosis has not been confirmed by other means.

Typical CSF findings in bacterial meningitis

  • Opening pressure elevated (>25 cmH2O)
  • WBC 1,000-3000/mm3
  • Percentage of neutrophils >80%.
  • Protein 1–5 g/L.
  • CSF/blood Glucose ratio ≤ 1/3

* Please remember to print and send ALL order forms and stickers for CSF samples. Virology, Bacteriology and Biochemistry forms are separate.

Evidence level B

Box 1: Lumbar puncture [6]

CSF examination is necessary for the diagnosis of meningitis. It provides vital information regarding aetiology, antibiotic sensitivity and prognostic information.

Timing of Lumbar puncture
A lumbar puncture should be performed within 1 hour of arriving in hospital if it is safe to do so (C)
Do the LP without waiting for clotting results unless a clotting defect is suspected

Antibiotic treatment should be commenced immediately after the LP and within the first hour.
If the LP cannot be performed immediately antibiotics should be given after blood cultures have been taken and provided there is no contra indication the LP should not be delayed by more than 4 hours

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. These may be especially useful when antibiotics have been administered prior to LP and gram stain and culture are negative
  • If the CSF is consistent with viral meningitis PCR for herpes simplex virus, varicella zoster and enterovirus should be requested following the initial results.

LP should be delayed/avoided in the following situations

  • Respiratory, cardiac compromise or continued seizures
  • Suspected meningococcal septicemia
  • Infection at the site of the LP
  • Neuroimaging reveals significant brain shift
  • Clinically suspected coagulopathy or INR>1.5
  • Patients on anticoagulants or clopidogrel - expert advice should be sought from the coagulation team
  • Platelet count <40 x109/L

Performing a CT scan before the LP is associated with delays in antibiotics, which in turn can lead to an increase in mortality [15]. A CT scan should only be performed if there are clinical signs suggestive of a shift of brain compartments. A normal CT head scan cannot exclude raised intra cranial pressure. The exact level of GCS at which a CT scan is indicated is debated and the 2016 UK meningitis guidelines recommend a LP can be performed if the GCS is >12.
Evidence level C

Box 2: Neuroimaging [6]
Patients should not have a CT brain before LP unless there is a clinical indication suggestive of brain shift.
Indications for CT scan before LP

  • Focal neurological signs
  • Papilloedema (inability to see the fundus is not a contra indication to LP)
  • Continuous or uncontrolled seizures
  • GCS </= 12

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Treatment
Non-Antimicrobial Treatment

Immediate action
The priority for patients admitted with suspected meningitis is to stabilise their airway, breathing and circulation, begin appropriate investigations, and instigate prompt treatment. A decision regarding the need for senior review and/or intensive care admission should be made within the first hour

Stabilisation of the patient’s airway, breathing and circulation should be an immediate priority - Link to sepsis pathway

Corticosteroids have potential anti inflammatory effects in bacterial meningitis including decreasing the amount of cytokine released and inhibition of prostaglandins and platelet activating factor [16]. Experimental animal models of infection have shown that subarachnoid inflammatory space inflammation, caused by bacterial products is a major contributory factor to morbidity and mortality [17] The evidence that dexamethasone has a beneficial effect is based largely on the result of a large multi centre trial in Europe. [18] A total of 301 adults were randomized to receive dexamethasone (10 mg q6h for 4 days) or placebo, the first dose being administered 15–20 min prior to the first antimicrobial dose. At 8 weeks after enrolment, the percentage of patients with an unfavourable outcome was significantly lower in the dexamethasone group. Among the subgroup of patients with pneumococcal meningitis, benefit was evident in those who received adjunctive dexamethasone, with a lower percentage of unfavourable outcomes and deaths. Benefits were not seen in meningitis caused by other meningeal pathogens, although patient numbers in those groups were small. In all groups, dexamethasone appeared to be the most beneficial in patients with moderate to severe disease on the Glasgow outcome scale. Randomised control trials in Malawi and Vietnam did not show any benefit [19,20]. The most recent Cochrane review concluded there was a small reduction in mortality in patients with pneumococcal meningitis with corticosteroids but not other causes [21]. This review did not show any difference in outcome when comparing whether corticosteroids were given before or after antibiotics.
Given that there is little evidence of harm with steroids the recommendation is that dexamethasone should be given before (or up to 12 hours after antibiotics) in suspected bacterial meningitis. Steroids should be stopped if a cause other than Streptococcus pneumoniae is identified.

Recommendation

  • 9.9 mg IV dexamethasone (this is expressed as base and is equivalent to a 10mg dose) (6 hourly) should be given before or with the first dose of antibiotics if bacterial meningitis is strongly suspected. This can be initiated up to 12 hours after the first dose of antibiotics
  • Dexamethasone should not be used if the presentation is predominantly that of meningococcal sepsis
  • Continue dexamethasone 6-hourly for 4 days only if pneumococcal meningitis confirmed.
  • If pneumococal meningitis is not identified or not thought to be highly probable then the dexamethasone should be discontinued.

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Empirical Antimicrobial Treatment

Antimicrobial Management

Empirical treatment [6]

There is no prospective clinical data on the timing of antibiotic therapy in relation to outcome in patients with bacterial meningitis. The logical approach is to administer antibiotic therapy as soon as the diagnosis is suspected.

Patients with predominantly sepsis or a rapidly evolving rash

  • Antibiotics should be given immediately after blood cultures have been taken
  • Fluid resuscitation should be commenced immediately
  • The Surviving sepsis guidelines should be followed
  • LP should not be performed at this time

Bacterial meningitis

  • Cefotaxime electronic Medicines Compendium information on Cefotaxime IV 2g 6hourly
  • If penicillin resistant Streptococcus pneumoniae is suspected (e.g. travel to a country within the last 6 months where penicillin resistant pneumocci are prevalent such as Greece, Spain, Italy, Canada, USA) add Vancomycin see dosing guidelines. Rifampicin electronic Medicines Compendium information on Rifampicin is an alternative in patients with renal failure. Please discuss patients where this may be suspected, i.e. travel within the last 6 months, with infectious diseases or microbiology.
  • Listeria meningitis occurs in people who are elderly, immunocompromised or have chronic illness such as alcohol dependence, diabetes or malignancy. It responds poor to cephalosporins and Amoxicillin electronic Medicines Compendium information on Amoxicillin should be added. Alternative antibiotics should only be used if there is a clear history of a severe allergy such as anaphylaxis.
  • Patients over 60 years give IV Amoxicillin electronic Medicines Compendium information on Amoxicillin 2g 4 hourly in addition to Cefotaxime electronic Medicines Compendium information on Cefotaxime
  • Immunocompromised patients including diabetics and those with severe alcohol misuse give IV Amoxicillin electronic Medicines Compendium information on Amoxicillin 2g 4 hourly in addition to Cefotaxime electronic Medicines Compendium information on Cefotaxime

Meningococcal septicaemia

Beta-lactam allergy
It is essential to ascertain the nature of the allergy.

Non severe allergy - treat as above

Severe allergy ; i.e. confirmed anaphylaxis, angio-oedema or Stevens-Johnson syndrome

Bacterial meningitis

Meningococcal septicaemia

Continued treatment
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 the results of the Gram stain. A negative Gram stain does not exclude bacterial meningitis and the yield is significantly lower in patients who received antibiotics prior to LP. Treatment should be modified when the results of culture and antibiotic sensitivity are available.
Evidence level C

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Directed Antimicrobial Treatment (when microbiology results are known)

Treatment should be adjusted according to subsequent culture and sensitivity results.

Table. Recommendations for directed antimicrobial therapy [6]

Aetiology Antimicrobial regimen
Neisseria meningitidis infection

Benzyl penicillin electronic Medicines Compendium information on Benzyl penicillin 2.4g IV 4hourly.
Non-severe beta-lactam allergy: Cefotaxime electronic Medicines Compendium information on Cefotaxime 2g IV 6hourly.
Severe beta-lactam allergy*: Discuss with Microbiology or Infectious Diseases
Duration: 5-7 days

Streptococcus pneumoniae

Cefotaxime electronic Medicines Compendium information on Cefotaxime 2g IV 6-hourly
If penicillin sensitive (MIC <0.06 mg/L)Benzyl penicillin electronic Medicines Compendium information on Benzyl penicillin 2.4 g 4 hourly is an alternative option
Severe beta-lactam allergy: Discuss with Microbiology or Infectious Diseases
Duration: 10-14 days (Stop at day 10 days if uncomplicated and good recovery)

Listeria monocytogenes

Amoxicillin electronic Medicines Compendium information on Amoxicillin 2g IV 4hourly
penicillin allergy: Discuss with Microbiology or infectious diseases
Duration: 21 days.
Longer treatment will be required for patients with rhomboencephalitis or brain abscess

*Severe beta-lactam allergy includes anaphylaxis, angio-oedema and Stevens-Johnson syndrome
Evidence level C

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Duration of Treatment
See table 1. If not specified contact Microbiology or infectious diseases
There is little evidence to guide the duration of treatment in adults. The 2016 UK meningitis guidelines recommend that treatment can be stopped after 5 days for meningococcal disease and 10 days in pneumococcal disease if the patient has recovered. If no pathogen has been found antibiotics can be stopped after 10 days if the patient has clinically recovered.

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Switch to oral agent(s)

Switch to oral antimicrobials is not recommended

Outpatient IV antibiotic therapy (OPAT/ CIVAS)

This can be considered in patients who are afebrile, clinically stable and have received at least 5 days of in-patient treatment [6] Animal studies have shown that once daily Ceftriaxone electronic Medicines Compendium information on Ceftriaxone achieves similar CSF sterilisation rates as twice daily after the first 24 hours [22]

Antibiotic choice: Ceftriaxone electronic Medicines Compendium information on Ceftriaxone IV 4g once daily

Recommendation: Refer suitable patients to the Leeds Community IV Antibiotic Service for consideration of OPAT

Predisposing factors:
  • Patients with two or more episodes of meningococcal or pneumococcal meningitis should have appropriate immunological investigations. Contact immunology to discuss
  • Patients who have a family history of more than one episode of meningococcal disease should be discussed with immunology
  • Patients with either a history of trauma or recent neurosurgery or evidence of rhinorrhea or otorrhoea should have investigations for a CSF leak
Infection Prevention:
Patients with suspected bacterial meningitis should be nursed in source isolation until meningococcal disease is excluded. Patients with confirmed meningococcal disease should remain source isolated until they have 24 hours of treatment with Ceftriaxone electronic Medicines Compendium information on Ceftriaxone or a single dose of Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin .
Evidence level C
Meningitis chemoprophylaxis

Meningococcal disease
Close contacts of patients should be given antibiotic prophylaxis to eliminate pharyngeal carriage. These include those living in the same household, those sharing a living space e.g. students in a hall of residence sharing a kitchen, or those with droplet/kissing contact.

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. Patients with meningococcal disease who have not received a dose of Ceftriaxone electronic Medicines Compendium information on Ceftriaxone should receive one of the antibiotic regimes below to eliminate pharyngeal carriage

Recommendation: Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin is the first choice antimicrobial for chemoprophylaxis in all age groups and in pregnancy unless there is a contraindication such as hypersensitivity or risk of interactions with other drugs [Evidence Level B].

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin (single dose)
Adults and children > 12 years: 500mg
Children 5-12 years: 250mg
Children under 5 years 30mg/kg up to a maximum of 125 mg stat

Recommendation: Rifampicin electronic Medicines Compendium information on Rifampicin is an alternative for chemoprophylaxis in all age groups where there is hypersensitivity/contraindication to Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin [Evidence Level B].

Rifampicin electronic Medicines Compendium information on Rifampicin (48 hour course)
Adults and children > 12 years: 600mg BD
Children 1-12 years: 10mg/kg BD
Children <12 months: 5mg/kg BD

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin is now recommended for use in all age groups and in pregnancy. Evidence grade B
The use of single dose Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin is recommended by a Cochrane review16.
The advantages of Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin over rifampicin are:

  • Given as a single dose,
  • Does not interact with oral contraceptives,
  • More readily available in community pharmacies.

It is contraindicated in cases of known Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin hypersensitivity. Healthcare staff should give out information sheets that include the risk of side effects, and be prepared to deal with allergic reactions. The administration of Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin may, however, be followed by anaphylactic reactions.
It can also interact with other drugs but a single dose is unlikely to have a significant effect. It has an unpredictable effect on epilepsy but may be preferable to Rifampicin electronic Medicines Compendium information on Rifampicin if the patient is on treatment with phenytoin.
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin is usually not recommended in children due to induced arthropathy in juvenile animals. However in studies, the risk of arthropathy due to Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin was very low, arthralgia was transient and most were coincidental.

Rifampicin
Rifampicin electronic Medicines Compendium information on Rifampicin was the drug of choice for meningococcal chemoprophylaxis because it has been licensed for chemoprophylaxis for many years. However, the disadvantages of rifampicin are:

  • It is associated with rapid induction of resistance,
  • Inhibits contraceptives,
  • Has a longer regime duration
  • It is usually only available from hospital pharmacies.

It is recommended for use in all age groups. Evidence grade B
Rifampicin is contraindicated in the presence of jaundice or known hypersensitivity to rifampicin. Interactions with other drugs, such as anticoagulants, phenytoin, and hormonal contraceptives should be considered. Side effects should be explained including staining of urine and contact lenses. Written information for patients should be supplied with the prescription. This is the responsibility of the prescriber.

Pregnancy and breast feeding
Either Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin , Ceftriaxone electronic Medicines Compendium information on Ceftriaxone or Azithromycin electronic Medicines Compendium information on Azithromycin can be used as chemoprophylaxis in pregnancy. Evidence grade C
Whilst Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin is contraindicated in its SPC for use in pregnancy, short duration treatment for other indications appears to be safe. A systematic review of antibiotic use in lactation considered Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin and rifampicin as compatible with breastfeeding; other antibiotics were not studied.
As Ceftriaxone electronic Medicines Compendium information on Ceftriaxone can only be given by injection and is painful, its main indication is when preferred for specific reasons, e.g. in pregnancy. Potential side effects include diarrhoea, allergies, hepatic and blood disorders.
A single dose Azithromycin electronic Medicines Compendium information on Azithromycin can be advised for chemoprophylaxis for pregnant women. Evidence grade B

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Treatment Failure
Please contact Infectious diseases or Microbiology if the patient is not responding to the recommended antimicrobial regimens.

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Provenance

Record: 1440
Objective: Objective: To improve the diagnosis and management of suspected community acquired bacterial meningitis and meningococcal septicaemia
Aims: To improve the diagnosis and management of suspected community acquired bacterial meningitis and meningococcal septicaemia in adults
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

Evidence base

  1. Okike IO, Ribeiro S, Ramsay M, Heath PT, Sharland M, 
Ladhani SN. Trends in bacterial, mycobacterial and fungal meningitis in England and Wales 2004-11: an observational study. Lancet Infect Dis 2014;14.
  2. Van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med. 2004;351(18):1849-1859. doi:10.1056/NEJMoa040845.
  3. Bijlsma MW, Bekker V, Brouwer M, Spanjaard L, van de Beek D, van der Ende A. Epidemiology of invasive meningococcal disease in the Netherlands, 1960e2012:an analysis of national surveillance data. Lancet Infect Dis 2014;14:805e12.
  4. Cartwright EJ, Jackson K a., Johnson SD, Graves LM, Silk BJ, Mahon BE. Listeriosis outbreaks and associated food vehicles, United States, 1998-2008. Emerg Infect Dis. 2013;19(1):1-9. doi:10.3201/eid1901.120393.
  5. Mook P, O’Brien SJ, Gillespie I a. Concurrent conditions and human listeriosis, England, 1999-2009. Emerg Infect Dis. 2011;17(1):38-43. doi:10.3201/eid1701.101174.
  6. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults, J Infect (2016), http://dx.doi.org/10.1016/j.jinf.2016.01.007
  7. Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig’s sign, Brudzinski's sign, and nuchal rigidity in adults with suspected meningitis. Clin Infect Dis. 2002;35(1):46-52. doi:10.1086/340979.
  8. Stephens DS, Greenwood B, Brandtzaeg P. Epidemic meningitis, meningococcaemia and Neisseria meningitidis. Lancet 2007;369:2196e210
  9. Fallon RJ, Madeley CR, Mayon-White RT, Urquhart a. M, Welsby PD. Bacterial meningitis: Causes for concern. J Infect. 1995;30(2):89-94. doi:10.1016/S0163-4453(95)80001-8.
  10. Newcombe J, Cartwright K, Palmer WH, McFadden J. PCR of peripheral blood for diagnosis of meningococcal disease. J Clin Microbiol 1996;34(7):1637e40.
  11. Azzari C, Moriondo M, Indolfi G, Massai C, Becciolini L, de Martino M, et al. Molecular detection methods and serotyping performed directly on clinical samples improve diagnostic sensitivity and reveal increased incidence of invasive disease by Streptococcus pneumoniae in Italian children. J Med Microbioly 2008;57(Pt 10):1205e12.
  12. Grindborg O, Naucler P, Sjolin J, Glimaker M. Adult bacterial meningitis-a quality registry study: earlier treatment and favourable outcome if initial management by infectious dis- eases physicians. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis 2015;21(6):560e6.
  13. Richardson DC, Louie L, Louie M, Simor AE. Evaluation of a rapid PCR assay for diagnosis of meningococcal meningitis. J Clin Micro 2003;41(8):3851e3
  14. Srinivasan L, Pisapia R, Shah S, Halpern C, Harris M. Can broad-range 16S ribosomal ribonucleic acid gene polymerase chain reactions improve the diagnosis of bacterial meningitis? a systematic review and meta analysis. Ann Emerg Med 2012; 60:609e20.
  15. Michael B, Sidhu M, Stoeter D, Roberts M, Beeching N, Bonington A, et al. Acute central nervous system infections in adults, a retrospective cohort study in the NHS North West region. QJM 2010;103:10
  16. Kadurugamuwa JL, Hengstler B, Bray MA, Zak O. Inhibition of complement-factor-5a-induced inflammatory reactions by prostaglandin E2 in experimental meningitis. J Infect Dis 1989;160(4):715e9.
  17. Scheld WM, Koedel U, Nathan B, Pfister HW. Pathophysiology of bacterial meningitis: mechanisms of neuronal injury. J Infect Dis 2002; 186:S225–33.
  18. de Gans, van de Beek D. Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002; 347:1549–56.
  19. Mai N, Chau T, Thwaites G, Chuong LV, Sinh D, Nghia H, et al. Dexamethason in Vietnamese adolescents and adults with bacterial meningitis. N Engl J Med 2004;357:2431e40.
  20. Scarborough M, Gordon S, Whitty C, French N, Njalale Y, Chitani A, et al. Corticosteroids for bacterial meningitis in adults in sub Saharan Africa. N Engl J Med 2007;357:2441e50
  21. Brouwer MC, McIntyre P, van de Beek D. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev 2013:6.
  22. Lutsar I, Ahmed A, Friedland IR, Trujillo M, Wubbel L, Olsen K, et al. Pharmacodynamics and bactericidal activity of ceftriax- one therapy in experimental cephalosporin-resistant pneumococcal meningitis. Antimicrob Agents Chemother 1997; 41(11):2414e7.

Evidence levels:
A. Controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

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