Suspected Meningococcal Disease - Pre-admission management of suspected bacterial meningitis - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  --
Last review: 09/02/2016  
Next review: 01/02/2019  
Clinical Guideline
CURRENT 
ID: 2233 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2016  

 

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.

Guidance for the management of meningococcal disease in primary care

Pre-admission management of suspected bacterial meningitis.

See also Chemoprophylaxis and antibiotic choice for contacts when appropriate

Recommendation: Pre-admission management

Without non-blanching rash - Rapid admission to hospital is highest priority. If urgent transfer to hospital is not possible antibiotics should be administered to children and young people, see below.

Evidence grade C

With non-blanching rash or meningitis septicaemia - Immediate dose of iv/im Benzyl penicillin electronic Medicines Compendium information on Benzyl penicillin should be given at the earliest opportunity, either in primary or secondary care, but urgent transfer to hospital should not be delayed in order to give the parenteral antibiotics.

IV / IM Benzyl penicillin electronic Medicines Compendium information on Benzyl penicillindosages
Adults and children aged 10 years or over 1.2 g
Children aged 1 to 9 years 600 mg
Children aged under 1 year 300 mg

What are the clinical features of bacterial meningitis or meningococcal disease?
It is not possible to rule in or rule out a diagnosis of bacterial meningitis or meningococcal disease on the basis of the presence or absence of any single clinical feature or combination of clinical features. Clinical judgement is required, taking into account how quickly the illness is progressing, the overall severity of the illness, and the level of concern on the part of the patient, parent, or carer (particularly compared with previous illness in the child or young person or their family).

Non-specific features

Common

  • Fever — not always present, especially in neonates.
  • Vomiting/nausea.
  • Lethargy.
  • Irritable or unsettled mood.
  • Ill appearance.
  • Refusal of food and drink.
  • Headache.
  • Muscle ache or joint pain.
  • Respiratory symptoms and signs, or difficulty breathing.

Less common

  • Chills or shivering
  • Diarrhoea, abdominal pain or distention.
  • Sore throat or coryza, or other ear, nose and throat symptoms or signs.

More specific features:

  • Stiff neck.
  • Altered mental state — includes confusion, delirium and drowsiness, and impaired consciousness.
  • Non-blanching rash — be aware that the rash may be less visible in people with darker skin tones — check soles of feet, palms of hands, and conjunctivae. For further information, see Features of meningococcal rash.
  • Shock (see Features of shock for further information).
  • Back rigidity.
  • Bulging fontanelle — in children younger than 2 years of age.
  • Photophobia.
  • Kernig's sign — when the thigh is flexed onto the abdomen, check whether the leg can be passively extended when the knee is flexed. Meningeal inflammation will cause the person to resist leg extension (positive Kernig's sign).
  • Brudzinski's sign — when passive flexion of the neck is performed, meningeal irritation will result in flexion of the hips and knees (positive Brudzinski's sign).
  • Unconsciousness.
  • Toxic or moribund state.
  • Paresis.
  • Focal neurological deficit, including cranial nerve involvement and abnormal pupils.
  • Seizures.

In a person presenting only with meningococcal septicaemia, Kernig's sign, Brudzinski's sign, paresis, focal neurological deficit, and seizures are not present. CKS

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Provenance

Record: 2233
Objective:
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:

Suspected Meningococcal Disease

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

Evidence base

  1. NICE. Bacterial meningitis and meningococcal septicaemia. National Collaborating Centre for Women’s and Children’s health 2009. http://guidance.nice.org.uk/CG102/Guidance Accessed 23.09.14.
  2. Saeed, K., 2011. ‘One for all’ concerns regarding NICE antibiotic guidelines on suspected bacterial meningitis! [letter] Brit J Gen Pract 2011;61:606. RATIONALE: Expert opinion is that in children or young people with suspected bacterial meningitis or meningococcal septicaemia, transfer to hospital is the priority, and that intravenous benzylpenicillin should be given at the earliest opportunity if a non-blanching rash is present, either in primary or secondary care. The NICE guideline development group recommended benzylpenicillin because they are aiming to cover only meningococcal septicaemia, which causes highest mortality, and it is the most frequently used antibiotic in primary care and they found no evidence to recommend an alternative antibiotic. Following prompt admission evaluation a more definitive choice of antimicrobials can be made. Although the scope of the NICE guideline is for children, it seems reasonable to extrapolate the advice to older age groups.
  3. SIGN. Management of invasive meningococcal disease in children and young people. Scottish Intercollegiate Guidelines Network. 2008
    RATIONALE: Expert opinion is that parenteral antibiotics (either benzylpenicillin or cefotaxime) should be administered in children as soon as invasive meningococcal disease is suspected, and not delayed pending investigations/

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Document history

LHP version 1.0

Related information

Not supplied