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MANAGEMENT OF MENINGOCOCCAL MENINGITIS AND SEPTICAEMIA CLINICAL GUIDELINE Developed in response to: CNST Best Practice Contributes to HCC Core Standard number C4a Version Number Issuing Directorate Approved by Approved on Implementation Date Next Review Date Author/Contact for Information Policy to be followed by (target staff) Distribution Method Related Trust Policies (to be read in conjunction with) 3.0 Governance Clinical Document Approval Group 28th March 2008 28th March 2008 1 November 2010 Infection Prevention Team All Trust Staff Intranet & Website All infection control policies Professional Approval Prior to Ratification, name and date. Circulated to Clinical Directors Document Review History Review No 1.0 2.0 3.0 Registration Number Reviewed by Infection control team Infection control team Infection Prevention team Review Date 2003 June 2004 January 2008 08030 Index 1. Introduction 2. Route of Spread 3. Characteristic of Meningococcal Disease 4. Immediate Response at Admission 5. Specimen Collection 6. Cases requiring Public Health Action 7. Cases not requiring Public Health Action 8. Infection Prevention and Control Management 9. Meningococci Group C Vaccination 10 Who should receive Prophylaxis 11 Action to be taken in hospital for contacts 12 Monitoring 13 Reference Appendix 1 Administration of Prophylactic Rifampicin for Prevention of Meningococcal Infections 2 1. Introduction 1.1 Neisseria meningitidis Neisseria meningitidis is the organism responsible for meningococcal disease. It is a human pathogen that resides in the nasopharynx of healthy carriers but causes disease when it enters the tissues or blood. Meningococcal meningitis is a severe, sometimes life threatening, infection of the membranous layers enclosing the brain and spinal cord. Meningococcal septicaemia is an even more severe infection in the blood stream. 1.2 Meningococcal infection occurs throughout the world with seasonal variations. In the United Kingdom most cases are reported in winter and spring. 1.3 The disease is most common in young babies, children and teenagers but may occur at any age. Rapid treatment of this infection is imperative. 2. Route of spread 2.1 Neisseria meningitidis is spread from one person to another by droplets from the respiratory tract. Spread may also occur during the first 48 hours of antibiotic therapy. 3. Characteristics of Meningococcal Disease 3.1 Transmission of Neisseria meningitidis is usually by droplet inhalation or direct contact with discharge from the nasopharynx. 3.2 The incubation period is up to 7 days after contact but normally 2-4days. 3.3 It is rare for contacts to develop the disease. However, contacts may acquire colonisation/carriage of the organism in their nasopharynx. These contacts may then transmit the organism to other people. 3.4 The onset of the meningitis is often sudden and characterised by fever, malaise, headache, nausea/vomiting and neck stiffness with or without photophobia. 3.5 Meningococcal disease may also be accompanied by a purpuric rash that does not blanch under pressure. 4. Immediate Response at Admission 4.1 If diagnosed by a GP, they should have given an injection of Benzylpenicillin immediately if a diagnosis of meningitis or septicaemia is suspected.. If the patient has not had this antibiotic prior to admission it should be given as soon as possible after arrival in hospital. 4.2 All patients with suspected meningococcal disease must be notified to the Infection Prevention and Control Team on admission. 4.2 Treatment following admission should be discussed with the Consultant Microbiologist. 4.3 Contacts at risk of colonisation should be identified and given the appropriate chemoprophylaxis. 3 5. Specimen Collection For patients who have a suspected diagnosis of Meningococcal disease the following specimens need to be taken: Cerebral Spinal Fluid (CSF) -If clinically indicated Blood Culture EDTA Blood for PCR examination Nose and Throat Swab (from the index case only) 6. Cases requiring Public Health Action 6.1 Confirmed case Clinical diagnosis of meningitis, septicaemia or other invasive disease (e.g. orbital cellulites, septic arthritis)* AND at least one of: Neisseria meningitides isolated from normally sterile site Gram negative diplococci in normally sterile site Meningococcal DNA in normally sterile site Meningococcal antigen in blood, CSF or urine Although not meeting the definition of a confirmed case, meningococcal infection of the conjunctiva is considered an indication for public health action because of the high immediate risk of invasive disease. 6.2 Probable case Clinical diagnosis of meningitis or septicaemia or other invasive disease where the public health physician, in consultation with the physician and microbiologist, considers that meningococcal infection is the most likely diagnosis. Some microbiological tests (e.g. rising antibody levels) that are not considered sufficient to confirm the diagnosis of meningococcal disease may change the case category from ‘possible’ to ‘probable’. 7. Cases not requiring public health action 7.1 Possible cases Clinical diagnosis of meningitis or septicaemia or other invasive disease where the public health physician, in consultation with the clinician and microbiologist, considers that diagnoses other than meningococcal disease are at least as likely. This category includes cases who may have been treated with antibiotics but whose probable diagnosis is viral meningitis. In such cases, prophylaxis for contacts in not indicated but giving out information about meningococcal disease may be helpful. 4 7.2 Infection in non-sterile sites Isolation of meningococci from sputum or from swabs taken from nasopharynx or genital tract is not by itself an indication for public health action as asymptomatic carriage in the respiratory and genital tract is common. However, when assessed together with other clinical and microbiological parameters, a positive throat swab may increase the index of suspicion that this is a probable case, especially if the isolate is a virulent strain. Meningococcal pneumonia is not an indication for public health action but may carry a low risk of transmission in healthcare settings especially to the immunocompromised. 8. Infection Prevention and Control Management 8.1 The patient must be nursed in a single room with the door kept closed. A risk assessment should be undertaken with the infection prevention and control team as to whether an individual patient’s care will be compromised in a side room. 8.2 Disposable gloves and aprons should be worn for direct contact with the patient or any equipment 8.3 Protective clothing should be removed and disposed of inside the room and hands washed before leaving. 8.4 These precautions should be maintained for 48 hours for meningococcal disease. 8.5 Prior to discontinuing isolation the patient must be given a complete course of specified oral antibiotics (usually Rifampicin), this will be different to them given for treatment and will eliminate nasopharyngeal carriage of the organism. 9. Meningococcal Group C Vaccination Since 1999 there has been a vaccination available for babies, children and young adults against Group C Meningococcal Disease. Staff and parent /relatives must be encouraged not to discount a diagnosis of meningococcal disease because an individual has been vaccinated. Groups A and B meningococcal disease continue to cause disease in the UK. 10. Who should receive Prophylaxis 10.1 It is the responsibility of the Health Protection team to trace contacts and organise prophylaxis. Clinical teams may be asked to prescribe if any delay could otherwise occur. 10.2 Decisions regarding the administration of chemoprophylaxis within the community will be made by the Consultant in Communicable Disease Control 10.4 Prophylaxis should be given to appropriate contacts whenever a patient presents in whom meningococcal meningitis, septicaemia or other invasive infection with meningococci is considered the most likely diagnosis. 10.5 Household contacts have a slightly increased risk of developing meningococcal disease in comparison with the general population. This is the only group that requires prophylaxis, other than kissing contacts of the index case. Most secondary cases will occur within the first 7-14 days, but an increased risk is present for up to a year. Thus 5 when the infecting organism is group C, A, W135 or Y, vaccination is also offered to those who received antibiotics. For W135 and Y strains vaccination is on a named patient basis. 10.6 Hospital staff only require prophylaxis if an individual has been splashed by respiratory secretions in association with infection. Contacts should begin antibiotic prophylaxis within 24 hours of diagnosis of the index case. 11 Action to be taken in Hospital for Contacts 11.1 The clinical team caring for the patient to prescribe antibiotics from the hospital pharmacy for those in the immediate household (normally parents and siblings). This is because household contacts will often be sitting with the patient and will find it difficult to visit their GP within 24 hours. 11.2 Rifampicin is usually prescribed for chemoprophylaxis, see the British National Formulary for doses. 11.3 Rifampicin should not be given in the presence of jaundice or known allergy. It interacts with the action of anticoagulants, reduces the efficacy of the contraceptive pill and stains contact lenses. 11.4 If Rifampicin is contraindicated please discuss alternatives with the Consultant Microbiologist on-call. 12. Monitoring 12.1 The effectiveness of the policy is monitored through the annual trust wide documentation audit coordinated through the Clinical Audit Department. The Infection Prevention and Control Committee reviews the Infection Control policies and Divisions are required to develop localised action plans which are monitored through their Directorate Governance Improvement Plans. 12.2 A Trust wide Clinical Documentation summary report is presented annually to the Information Governance Committee for review to enable monitoring at a wider level across the organisation-good standards of clinical documentation help reduce the potential for clinical risk incidents occurring. 13 Reference: PHLS Guidelines for public health management of meningococcal disease in the UK. (2002) Vol. 5 No 3 Reprint PP 187-204 plus Appendices. 6 APPENDIX 1 Administration of Prophylactic Rifampicin for Prevention of Meningococcal Infections Doses Adults: Two capsules (600mg) twice a day for two days Child; Varies with the age and weight of the child. Should be 10mg/kg for children 1-12 yr, and 5 mg/kg for those under 1yr. This should also be taken twice a day for two days Take the Rifampicin at 12 hourly intervals and ONE hour before meals to obtain the best effect Side Effects As no drug is entirely free of side effects the following should be noted; Rifampicin will stain urine, sputum and tears orange, and permanently stain soft contact lenses if they are worn while the tears are coloured Rifampicin can interfere with oral contraceptives (The Pill). Family Planning Association Advice (FPA) is that extra precautions should be taken for at least 4 weeks, and there should be no break between courses of tablets (inactive tablets should be omitted). Avoid drinking alcohol while on the drug Headache, feeling sick and/or stomach pain may occur while on the drug. Please contact your doctor if symptoms are severe or other symptoms develop. The aim of the antibiotics is to remove the meningitis bacteria from the throat, so that they cannot be passed on to others, NOT to prevent infection in those already incubating the illness. Therefore there is a small chance that in spite of antibiotics you will still develop meningitis. Seek medical help promptly if you are worried. Alternatives For the treatment of contacts of patients with meningococcal disease ONLY Ciprofloxacin 500 mg ONCE. Slightly less effective, not licensed for use in children or pregnant women, but convenient Ceftriaxone 250 mg ONCE (125 mg in child under 12 yr). Given as an injection. Useful in pregnancy and where children will not take oral treatment For further information 7