Bacterial meningitis and meningococcal septicaemia Implementing NICE guidance

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: – – – 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: – – – – 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 20 ml/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: – – – 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/CGXX for: • • • 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