Guidelines for the Early Clinical and Public Health Management of ...

Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease)
Chapter 2. Pre-admission Management
Key points
• A presumptive diagnosis of bacterial meningitis is a medical emergency and immediate referral to
hospital is required.
• Meningococcal septicaemia has a higher mortality rate than meningococcal meningitis. Septicaemia is
often characterised by a rapidly evolving petechial or purpuric rash that does not blanch under pressure.
However, in the early stage of development the rash may blanch with pressure thus resembling a viral
rash, or it may be absent, or may be atypical. If present it may consist only of a few haemorrhagic spots
located in a place such as the groin or feet.
• Meningococcal disease may have clinical features not normally encountered in children with acute
systemic self limiting febrile illnesses.
• “Red flag symptoms” include confusion, leg pain, photophobia, rash and neck pain/stiffness.
• Health care providers should ensure that any patient with a systemic febrile illness, particularly a child,
can be reassessed without delay if their condition deteriorates.
• Doctors should be encouraged to review the situation within 4-6 hours if early meningococcal disease
cannot be ruled out at first assessment.
• All GPs and advanced paramedics should have benzylpenicillin available when attending patients and
should be ready to administer it without delay to patients with a systemic febrile illness and a petechial
or purpuric rash. Ceftriaxone or cefotaxime are suitable alternatives if available.
2.1 Introduction
Meningococcal disease usually presents as meningitis or septicaemia, or a combination of the two. Septicaemia, with
or without meningitis, can be particularly severe and is associated with a considerably greater mortality rate than
meningococcal meningitis without bloodstream infection. 8
Meningococcal septicaemia can have a fulminant and rapidly fatal course. The development of signs suggestive of
acute sepsis and/or meningitis is a medical emergency and mandates prompt intervention. Management priorities
differ depending on the clinical presentation i.e. that of severe sepsis with or without associated meningitis, or that of
meningitis.
Acute meningococcal disease, the most common cause of life threatening infection in healthy children and young
adults, commonly presents as severe sepsis and/or meningitis. Rarely, other forms of invasive meningococcal
infection are encountered. The overall mortality rate for meningococcal infection typically ranges from 3-10%, but
can reach as high as 20-40% in severe sepsis/meningitis (see Chapter 5 for further detail). Meningococcal infection
remains the most common cause of bacterial meningitis in Ireland.
The speed with which meningococcal infections are recognized and treated is critical to achieving a successful
outcome and clinical suspicion alone mandates treatment. If meningococcal infection is suspected, administration
of benzylpenicillin by the GP or advanced paramedic may be life-saving and is strongly recommended. Although
results of studies of the benefit of pre-admission antibiotics have been inconsistent, this has variably been attributed
to their retrospective nature and confounding factors such as illness severity (those most severely ill may be more
likely to receive antibiotics). 9,10
2.2 Clinical presentation of invasive meningococcal disease
The most characteristic feature of meningococcal septicaemia is a haemorrhagic (i.e. petechial or purpuric) rash
that does not blanch under pressure. However, a rash is not always present, particularly in the early stages. In
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