Fever and Seizure or Suspected Acute CNS Infection ( not NICU ) - Guideline for the Initial Management of a Child with |
Publication: 10/10/2011 -- |
Last review: 31/10/2017 |
Next review: 31/10/2020 |
Clinical Guideline |
CURRENT |
ID: 2575 |
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. |
Guideline for the initial management of a child with fever and seizure or suspected acute CNS infection (not NICU)
Summary Fever and Seizure or Suspected Acute CNS Infection ( not NICU ) |
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Pathway document
1. PresentationSeizure / altered conscious state AND temperature >37.8, OR examination evidence of febrile illness;
WARNING - infants and children with an open fontanelle are unlikely to have classic symptoms and signs of meningitis Overview of pathways
Final Common Pathway
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Clinical Diagnosis |
Recommendation: Because the signs and symptoms of CNS infection may be subtle and are often not classical in infants and young children careful clinical assessment and often a period of observation is required to establish a diagnosis. Recommendation: Red flag (or alert) symptoms and signs in suspected CNS infection should include:
[Evidence level C/B] Recommendation: Other elements in the history or examination that should alert one to the possibility of CNS infection include: vomiting, poor feeding, headache, ill appearance Recommendation: Over 1 year of age, if there are no red flag symptoms, then directed investigation and observation are important to allow a diagnosis to be made. In older children, more classical features are often seen:
Specific signs of Kernig and Brudzinski are not reliable in children.
Note 1. If a child has had a short febrile seizure that nonetheless had some focal features -e.g. eye deviation or a unilateral clonic seizure AND they have no other risk factors as listed in the RED PATHWAY, then it may be reasonable to put them in the Yellow pathway. This is of course dependent on regular clinical review i.e. they should not be discharged at this point. |
Investigation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Recommendation: Cerebrospinal fluid (CSF) analysis and culture remain the gold standard for diagnosing meningitis(3,4) and lumbar puncture (LP) should be performed as soon as possible, unless there are clinical reasons to defer (see below). Recommendation: Because clinical assessment of acute CNS infection in younger infants is unreliable, CSF examination is considered mandatory in all children <1 year of age with no other focus to account for any of the above. Recommendation: Antibiotic administration should NOT be delayed if LP is deferred. Recommendation: LP should always be deferred and discussed with a consultant paediatrician in the presence of :
suspect raised ICP if any :-
CSF should be collected, and investigations arranged in table 2. below
Table 2. Schedule for laboratory testing of CSF samples.
Table 3. Interpretation of CSF analysis results. Lumbar puncture (LP) is an important diagnostic tool and is generally a safe procedure. However, in the presence of raised intracranial pressure it can be associated with herniation of the brain structures. Clinical or LP findings in keeping with TB should be discussed with the Consultant or Infectious Disease specialist. Repeat LP is sometimes indicated and should be discussed with the Consultant 2. Neuroimaging - Cranial computed tomography (CT). Recommendation: CT must not delay antibiotic treatment to children on red pathway. Recommendation: CT cannot be relied upon to exclude raised intracranial pressure. 3. Other Investigations: [Evidence level D]
WARNING - a normal CRP and or FBC does not exclude bacterial meningitis. A negative blood PCR does not exclude N meningitidis |
Treatment | |||||||||||
Non-Antimicrobial Treatment | |||||||||||
General
[Evidence level A] Fluid Management Failure to administer sufficient fluids in children with meningococcal disease and septic shock is associated with a higher risk of mortality (NICE). Dexamethasone UNDER 3 months of age: Any age. Recommendation: If corticosteroids have been started, they can be stopped if the diagnosis turns out not to be meningitis (on clinical or CSF examination findings) Evidence from a systematic review suggests that corticosteroids significantly reduce mortality in acute bacterial meningitis but the effect was not seen in a the subgroup of children (Van de Beek, D, 2007). Hearing loss was reduced in children with meningitis, mostly caused by H. influenzae type B (Van de Beek, D, 2007). Corticosteroids are not recommended for children under three months (NICE CG 102). NICE CG 102 recommends starting steroids early with the first dose of antibiotics, based on LP findings. If steroid administration is delayed NICE advise starting within 4 hours of commencing antimicrobial therapy, therefore, if a LP procedure (or result) is likely to be delayed more than 4 hours and there is a strong clinical suspicion of acute bacterial meningitis then we advise empirical steroid administration. DO NOT GIVE CORTICOSTEROIDS GREATER THAN 12 HOURS FTER ANTIBIOTICS HAVE BEEN STARTED. Management of raised intracranial pressure
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Empirical Antimicrobial Treatment | |||||||||||
Recommendation: Commence empirical antimicrobial therapy in all children on red pathway as indicated below: OVER 3 months of age Ceftriaxone 1- 3 months of age (& not on NICU) IV cefotaxime OR, If true penicillin/ cephalosporin allergy Neonate (not on NICU) IV amoxicillin Recommendation: In children with focal seizures, focal neurological signs, status epilepticus or altered conscious level (V or less on AVPU) >30 minutes after a seizure add antimicrobial agents to cover encephalitis, pending further investigation. aciclovir N.B. The practise of adding a macrolide is controversial. The incidence of Mycoplasma encephalitis and the effectiveness of macrolide therapy are unknown. This practise will be reviewed and a further risk benefit analysis undertaken. Are there concerns of multi-resistant pneumococcal infection Chloramphenicol Monitoring Vancomycin |
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Directed Antimicrobial Treatment (when microbiology results are known) | |||||||||||
Recommendation: Choice of antimicrobial therapy should be reviewed following confirmation of the clinical diagnosis, microbiology results and investigations. The relevant LTHT children's infection guidelines should be followed for subsequent management. Recommendation: Antimicrobial therapy should be “de-escalated” to the agent with the narrowest effective spectrum of activity, e.g. benzylpenicillin should be used in preference to cephalosporins for treatment of susceptible isolates. Ambulatory Management |
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Duration of Treatment | |||||||||||
Recommendation: Duration of therapy should be determined by the final clinical diagnosis and results of microbiology. Current treatment guidelines recommend a 7 day course of antibiotic therapy for Neisseria meningitidis and 7-14 days for either H. influenzae or S. pneumoniaei. A recent meta-analysis has shown no significant difference in terms of clinical effectiveness and safety of shortened (7 days or less) duration of treatment for community acquired bacterial meningitisii. Longer duration of antibiotics (21 days) considered for Gram negative / Listeria meningitis Over 3 months with an unconfirmed but clinically suspected bacterial meningitis treat with IV Ceftriaxone Under 3 months with an unconfirmed but clinically suspected bacterial meningitis treat with cefotaxime plus amoxicillin for at least 14 days depending on symptoms, signs and course of the illness. This should be under guidance of the Consultant +/- microbiology and Consultant for infectious diseases. |
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Switch to oral agent(s) | |||||||||||
See relevant LTHT guidelines for recommendations. | |||||||||||
Treatment Failure | |||||||||||
If the child is not responding to therapy as expected then obtain:
Recommendation: Prophylaxis is not required for the index case if they have been given a third generation cephalosporin. Recommendation: Prophylaxis may be indicated for close contacts of the index case following discussion with Consultant in Communicable Diseases/ Public Health. Tel (0113) 3059798 (within hours) (0113) 2063283 (out of hours). Use the Meningococcal Prophylaxis Prescription (depicted below table) for prescribing meningococcal prophylaxis
Vaccinations recommendations for close contacts from the Green Book (September 2016): Confirmed capsular group A, W or Y infections, non-immunised & previously immunised (>1 year previously) - Men ACWY conjugate vaccine single dose (aged <1 year requires 2 doses, >1 month apart) Un-immunised individuals - follow routine immunisation schedule
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Provenance
Record: | 2575 |
Objective: | Aims
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Clinical condition: | Suspected acute CNS infection |
Target patient group: | Children with suspected CNS infection |
Target professional group(s): | Pharmacists Secondary Care Doctors Secondary Care Nurses |
Adapted from: |
Evidence base
References
NICE clinical guideline 47, Feverish illness in children. 2007
NICE clinical guideline 102, Bacterial meningitis and meningococcal septicaemia in children. 2010
Hviid A, Melbye M. The epidemiology of Viral Meningitis Hospitalization in Childhood. Epidemiology 2007;18:695-701
Lissauer. T, Clayden G. Illustrated textbook of Paediatrics 2nd Edition. Mosby 2001
Riordan FAI, Cant AJ. When do a lumbar puncture. Arch Dis Child 2002;87:235-237
Basher H El, Laundy M, Booy R. Diagnosis and treatment of bacterial meningitis. Arch Dis Child 2003;88:615-620
Bitnun A, Ford-Jones E, Blaser S, Richardson S. Mycoplasma
pneumoniae encephalitis. Semin Pediatr Infect Dis. 2003;14:96 - 107
Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004;39:1267 - 84.
Karageorgopoulos DE, Valkimadi PE, Kapaskelis A, Rafalidis PI, Falagas M E. Short versus long duration of antibiotic therapy for bacterial meningitis: a meta-analysis of Randomized Controlled trials in children:Arch Dis Child 2009;94:607 - 614
Maconochie IK, Baumer JH, Stewart M. Fluid therapy for acute bacterial meningitis.
Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004786. DOI: 10.1002/14651858.CD004786.pub3
Van de Beek D, de Gans J, Mcintyre P, Prasad K. Corticosteroids for acute bacterial meningitis. Cochrane database of systematic reviews 2007, issue 1. Art no.: CD004405
Karageorgopoulos DE, Valkimadi PE, Kapaskelis A, Rafalidis PI, Falagas M E. Short versus long duration of antibiotic therapy for bacterial meningitis: a meta-analysis of Randomized Controlled trials in children:Arch Dis Child 2009;94:607 - 614
Approved By
Improving Antimicrobial Prescribing Group
Document history
LHP version 1.0
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