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Bacterial meningitis and
meningococcal septicaemia
Implementing NICE guidance
June 2010
NICE clinical guideline 102
What this presentation covers
• Background
• Scope
• Key priorities for implementation
• Costs and savings
• Discussion
• Find out more
Definitions
The term meningococcal disease has been used within
this presentation.
Meningococcal disease has two predominant patterns
of illness: meningitis and septicaemia
A proportion of cases show features of both.
Meningococcal disease most commonly presents as:
- bacterial meningitis (15% of cases)
- septicaemia (25% of cases)
- or a combination of the two (60% of cases)
Background and scope
• In children and young people aged 3 months or older
bacterial meningitis is most frequently caused by:
- Neisseria meningitidis (meningococcus)
- Streptococcus pneumoniae (pneumococcus)
- and Haemophilus influenzae type b (Hib).
• Meningococcal disease:
– has a 10% case fatality rate
– is the leading infectious cause of death in
early childhood.
Key priorities for implementation
• Symptoms and signs of bacterial meningitis and meningococcal
septicaemia
• Management in the pre-hospital setting
• Diagnosis in secondary care
– Non-specific tests for meningococcal disease
– Polymerase chain reaction (PCR)
– Lumbar puncture
• Use of ceftriazone*
• Management in secondary care
– Fluids for bacterial meningitis
– Intravenous fluid resuscitation in meningococcal
septicaemia
• Long-term management
Symptoms and signs
• Healthcare professionals should be trained in the
recognition and management of meningococcal
disease.
• Consider bacterial meningitis and meningococcal
septicaemia in children and young people who present
with the symptoms and signs outlined in table 1 in the
NICE guideline.
Symptoms and signs
Be aware that in children and young people:
–
some will present with mostly non-specific symptoms or
signs which may be difficult to distinguish from other less
important (viral) infections presenting in this way
–
those with specific symptoms and signs are more likely to
have bacterial meningitis or meningococcal septicaemia.
The symptoms and signs may become more severe and
more specific over time.
Symptoms and signs
Recognise shock and manage urgently in secondary care.
Signs of shock
• Capillary refill time more than 2 seconds
• Unusual skin colour
• Tachycardia and/or hypotension
• Respiratory symptoms or breathing difficulty
• Leg pain
• Cold hands/feet
• Toxic/moribund state
• Altered mental state/decreased conscious level
• Poor urine output
Management in
pre-hospital setting
Transfer children and young people
with suspected bacterial meningitis
or meningococcal septicaemia to
secondary care as an emergency by
telephoning 999.
Diagnosis in secondary care
• Give intravenous ceftriaxone immediately to children and
young people with a petechial rash if any of the following
occur at any point during assessment:
–
–
–
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petechiae start to spread
the rash becomes purpuric
there are signs of bacterial meningitis
there are signs of meningococcal septicaemia
the child or young person appears ill.
• Perform whole blood real-time PCR testing (EDTA
sample) for N meningitidis to confirm a diagnosis
of meningococcal disease.
Lumbar puncture
Perform a lumbar puncture unless any of the following
contraindications are present:
–
–
–
–
–
–
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signs suggesting raised intracranial pressure
shock
extensive or spreading purpura
after convulsions until stabilised
coagulation abnormalities
local superficial infection at the lumbar puncture site
respiratory insufficiency.
Use of ceftriaxone
• Use intravenous ceftriaxone to treat children and young
people aged 3 months or older with suspected or
confirmed bacterial meningitis or meningococcal disease.
• Where ceftriaxone is used, do not administer it at the
same time as calcium-containing infusions.
Instead use cefotaxime.
• Treat children younger than 3 months with suspected
bacterial meningitis without delay using intravenous
cefotaxime plus either amoxicillin or ampicillin.
Management in secondary care
Do not restrict fluids in cases of bacterial meningitis
unless there is evidence of:
– raised intracranial pressure or
– increased antidiuretic hormone secretion.
Management in secondary care
Intravenous fluid resuscitation
in suspected or confirmed meningococcal septicaemia
Stage
Administer fluids
Intervention
Signs of
shock
present
20 ml/kg sodium chloride 0.9%
over 5–10 minutes
Reassess immediately
after fluids administered
Signs of
shock
persist
20 ml/kg sodium chloride 0.9%
or human albumin 4.5%
over 5–10 minutes
Reassess immediately
after fluids administered
Signs of
shock still
persist
20 ml/kg sodium chloride 0.9%
or human albumin 4.5%
over 5–10 minutes
Call for anaesthetic assistance
and start vasoactive drugs
Signs of
shock still
persist
Consider a further 20ml/kg sodium
chloride 0.9%
or human albumin 4.5%
Administration based on
clinical signs and appropriate
laboratory investigations
Long-term management
Children and young people should be reviewed by a
paediatrician (along with the results of their hearing test)
4–6 weeks after discharge from hospital.
Specifically consider the following morbidities:
–
–
–
–
–
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hearing loss
orthopaedic complications
skin complications
psychosocial problems
neurological and developmental problems
renal failure.
Costs and savings
The guideline on bacterial meningitis and meningococcal
septicaemia is unlikely to result in a significant change in
resource use in the NHS. However, recommendations in the
following areas may result in additional costs/savings depending
on local circumstances:
• healthcare professionals should be trained in the
recognition and management of meningococcal disease
• investigation of children and young people with petechial
rash
• transfer suspected cases to secondary care as an
emergency by telephoning 999.
Discussion
When considering cases of bacterial meningitis and
meningococcal disease:
How could training on the recognition, assessment and
management of both suspected and confirmed cases
be improved in our Trust?
What is our first line antibiotic?
What are our local protocols for the administration of
fluids?
What are our long-term management
pathways?
Find out more
Visit www.nice.org.uk/guidance/CG102 for:
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the guideline
the quick reference guide
‘Understanding NICE guidance’
costing statement
audit support
Visit www.learning.bmj.com for modules on:
• Meningococcal disease in children
• Feverish illness in children
• Febrile toddler in the emergency department