Suspected Meningococcal Disease - Pre-admission management of suspected bacterial meningitis

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

Publication: 30/09/2010

Next review: 01/05/2023

Clinical Guideline

CURRENT

ID: 2233

Approved By:

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.

Suspected Meningococcal Disease - Pre-admission management of suspected bacterial meningitis - Management of Infection Guidance in Primary Care
See also Chemoprophylaxis and antibiotic choice for contacts when appropriate. 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. Irritability/unsettled behaviour. Ill appearance. Refusing food/drink. Headache. Muscle ache/joint pain. Respiratory symptoms/signs or breathing difficulty. 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 and hypotension (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). See NICE Full Guidance (2010) page 208 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). See NICE Full Guidance (2010) page 211 Unconsciousness. Toxic or moribund state. Paresis. Focal neurological deficit, including cranial nerve involvement and abnormal pupils. Seizures. Capillary refill time of more than 2 seconds, cold hands and feet. Unusual skin colour. Leg pain.
Action
Transfer all patients to hospital by ambulance immediately.^1D If time before hospital admission,^2D,3A+ if suspected meningococcal septicaemia or non-blanching rash,2D,4D give IV Benzyl penicillin ^1D,2D,4D as soon as possible.^2D Urgent transfer to hospital should not be delayed in order to give the parenteral antibiotics. Do not give IV or IM antibiotics if there is a definite history of anaphylaxis;^1D rash is not a contraindication.^1D	IV / IM Benzyl penicillin ^1D,2D Stat dose;^1D give IM, if vein cannot be accessed ^1D Child <1 year: 300mg^5D Child 1 to 9 years: 600mg^5D Adult/child 10+ years: 1.2g^5D
PHE CKS

General Principles for Treating Infections
This summary table is based on the best available evidence, but use professional judgement and involve patients in management decisions.

This summary table should not be used in isolation; it should be supported with patient information about safety netting, back-up antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials are available on the RCGP TARGET website.
Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate.
If person is systemically unwell with symptoms or signs of serious illness, or is at high risk of complications: give immediate antibiotic. Always consider possibility of sepsis, and refer to hospital if severe systemic infection
Use a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens, and seek advice.
In severe infection, or immunocompromised, it is important to initiate antibiotics as soon as possible, particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information about symptom monitoring, and how to access medical care if they are concerned.
Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 07825 906030, 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)
Limit prescribing over the telephone to exceptional cases.
Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (for example coamoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs.
Avoid widespread use of topical antibiotics, especially in those agents also available systemically (for example fusidic acid); in most cases, topical use should be limited.
Always check for antibiotic allergies. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight, renal function, or if immunocompromised. In severe or recurrent cases, consider a larger dose or longer course.
Avoid use of quinolones unless benefits outweigh the risk as new 2018 evidence indicates that they may be rarely associated with long lasting disabling neuro-muscular and skeletal side effects.
Refer to the BNF for further dosing and interaction information (for example the interaction between macrolides and statins), and check for hypersensitivity.

Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = expert opinion

Provenance

Record:	2233
Objective:
Clinical condition:	Suspected Meningococcal Disease
Target patient group:
Target professional group(s):	Primary Care Doctors Pharmacists
Adapted from:	Management of Infection guidance for primary care for consultation and local adaptation

Evidence base

Evidence base

Grading of guidance recommendations

The strength of each recommendation is qualified by a letter in parenthesis.

Study design	Recommendation grade
Good recent systematic review and meta-analysis of studies	A+
One or more rigorous studies; randomised controlled trials	A-
One or more prospective studies	B+
One or more retrospective studies	B-
Non-analytic studies, eg case reports or case series	C
Formal combination of expert opinion	D

1. National Institute for Health and Care Excellence (NICE). Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management. 2010 Jun. Available from: www.nice.org.uk/guidance/CG102 .

RATIONALE: NICE recommends that children and young people with suspected bacte-rial meningitis without non-blanching rash should be transferred directly to secondary care without giving parenteral antibiotics. This guideline recommends that, if urgent transfer to hospital is not possible, for example, in remote locations or adverse weather conditions, parenteral antibiotics should be administered immediately (either intrave-nous or intramuscular benzylpenicillin). For suspected meningococcal disease (menin-gitis with non-blanching rash or meningococcal septicaemia) parenteral antibiotics (in-tramuscular or intravenous benzylpenicillin) should be given at the earliest opportunity, either in primary or secondary care, but urgent transfer to hospital should not be de-layed in order to give the parenteral antibiotics. Intramuscular administration can pro-vide a satisfactory clinical outcome in patients with limited intravenous access. This guideline also recommends that benzylpenicillin should only be withheld in children and young people who have a clear history of anaphylaxis; a history of a rash following pen-icillin is not a contraindication.

2. Theilen U, Wilson L, Wilson G, Beattie JO, Qureshi S, Simpson D. Management of invasive meningococcal disease in children and young people: summary of SIGN guidelines. BMJ. 2008;336(7657):1367-70. Available from: www.bmj.com/content/336/7657/1367

RATIONALE: A summary of the SIGN guidelines suggesting that antibiotics should be administered to reduce the risk of mortality. Parenteral antibiotics (either benzylpenicil-lin or cefotaxime) should be administered, if time, before hospital admission, and a non- blanching rash. Antibiotics should not be delayed pending investigation, but should be administered as soon as invasive meningococcal disease is suspected.

3. Sudarsanam T, Rupali P, Tharyan P, Abraham OC, Thomas K. Pre-admission antibiotics for suspected cases of meningococcal disease (Review). Cochrane Database Syst Rev. 2008 Jan; 23(1):1-40. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005437.pub2/epdf .

RATIONALE: A systematic review of randomised controlled trials aiming to study the effectiveness and safety of pre-admission antibiotics versus no pre-admission antibiot-ics or placebo, and different pre-admission antibiotic regimens in decreasing mortality, clinical failure, and morbidity in people with suspected meningococcal disease. The au-thors state that meningococcal disease can lead to disability or death within hours after onset. Pre- admission antibiotics aim to reduce the risk of serious disease and death by preventing delays in starting therapy before confirmation of the diagnosis. No RCTs were found that compared pre-admission antibiotics versus no pre-admission antibiot-ics or placebo. One open-label, non-inferiority RCT, conducted during an epidemic in Niger, evaluated a single-dose of intramuscular ceftriaxone versus a single-dose of in-tramuscular long-acting chloramphenicol. Ceftriaxone was not inferior to chlorampheni-col in reducing mortality (RR 1.2; 95% CI 0.6 to 2.6; n=503, 308 with confirmed menin-gococcal meningitis and 26 deaths), clinical failures (RR 0.8; 92% effectiveness; 95% CI 0.3 to 2.2; n=477, 18 clinical failures), or neurological sequelae (RR 1.3; 95% CI 0.6 to 2.6; n-477, 29 with sequelae). No adverse effects of treatment were reported, and estimated treatment costs were similar. No data was available on disease burden due to sequelae. The authors conclude that there is no reliable evidence to support or refute the use of pre-admission antibiotics for suspected cases of non-severe meningococcal disease. Evidence of moderate quality from 1 RCT indicated that single intramuscular injections of ceftriaxone and long-acting chloramphenicol were equally effective, safe, and economical in reducing serious outcomes. The choice between these antibiotics should be based on affordability, availability and patterns of antibiotic resistance. Fur-ther RCTs comparing different pre- admission antibiotics, accompanied by intensive supportive measures, are ethically justifiable in participants with severe illness, and are needed to provide reliable evidence in different clinical settings.

4. Saeed K. ‘One for all’ concerns regarding NICE antibiotic guidelines on suspected bacterial meningitis. Br J Gen Pract. 2011 Oct; 61(591):606. Available from: www.ncbi.nlm.nih.gov/pmc/articles/PMC3177115/pdf/bjgp61-606.pdf .

RATIONALE: A review article of NICE antibiotic guidelines stating that, in children or young people with suspected bacterial meningitis or meningococcal septicaemia, trans-fer to hospital is the priority, and intravenous benzylpenicillin should be given at the ear-liest opportunity if a non-blanching rash is present. This article recommends benzylpen-icillin because it covers meningococcal septicaemia, which causes the highest mortal-ity, and it is the most frequently used antibiotic in primary care. However, following prompt admission, evaluation of a more definitive choice of antimicrobials can be made. Although the scope of the NICE guideline is for children, the author states that it seems reasonable to extrapolate the advice to older age groups.

5. Andes DR, Craig WA. Pharmacokinetics and pharmacodynamics of antibiotics in meningitis. Infect Dis Clin North Am. 1999 Sep; 13(3):595-618. Available from: www.ncbi.nlm.nih.gov/pubmed/10470557 .

RATIONALE: A review article, stating that, for the antibiotics administered in bacterial meningitis, it is the duration of time that antibiotic concentrations in the cerebrospinal fluid exceed the minimum bactericidal concentration for that antibiotic that determines the rate of bactericidal activity. Taking this into consideration, the following dosages are recommended for IV or IM administration (if a vein cannot be accessed). For ben-zylpenicillin, a child under 1 year should be given a stat dose of 300mg, a child be-tween 1 and 9 years should be given a stat dose of 600mg, and an adult or child over the age of 10 should be given a stat dose of 1.2g. In true penicillin allergy, cefotaxime should be given at a dose of 50mg/kg for children under 12 years, and a dose of 1g should be given for adults or children over the age of 12.

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