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)
the early stage of development the rash may blanch with pressure thus resembling a viral rash. The rash can appear
rapidly on any part of the body including the palms and soles. The petechial rash presents as discrete 1 to 2 mm in
diameter lesions that may proceed to form larger ecchymotic lesions. The rash commonly appears in clusters in areas
where pressure occurs from elastic in underwear and stockings. The rash may go unnoticed unless the acutely unwell
patient with a systemic febrile illness is completely undressed so that a thorough search for a haemorrhagic rash can
be undertaken.
Less commonly, the rash has a maculopapular appearance, with the discrete pink macules or papules blanching
under pressure. They may progress to become haemorrhagic and nonblanching later or fade away. 10
Additional features that should alert clinicians to the possibility of meningococcal infection include:
• an unwillingness to interact or make eye contact
• an altered mental state, or
• pallor despite a high temperature. 11
A UK study published in 2006 12 reported on the variety of clinical presentations found among children under 16
years of age diagnosed with meningococcal disease. The authors found that:
• leg pain
• cold extremities
• and abnormal skin colour
were frequently seen in the first 12 hours of meningococcal disease (median onset 7-12 hours).
More recently in 2011 the authors reported five “red flag symptoms”:
• confusion
• leg pain
• photophobia
• rash and
• neck pain/stiffness.
In this study cold hands and feet had limited diagnostic value, while headache, and pale colour did not discriminate
meningococcal disease in children. 13
In contrast, the classic clinical features:
• haemorrhagic rash
• meningism, and
• impaired consciousness were
relatively late signs (median onset 13-22 hours). 12,14
These early features should therefore be sought to aid the early recognition of invasive meningococcal disease in
children less than 16 years of age. These symptoms and signs however, can be non-specific and some may be present
with other bacterial and viral infections including self-limiting viral illnesses.
• Doctors should be encouraged to review the situation within 4–6 hours if early meningococcal disease
cannot be ruled out at the first assessment. 12,14
If a GP decides that a patient with a non-specific febrile illness does not require referral to a hospital, the GP
should advise the carer to keep the patient under frequent and regular review. Any deterioration or development
of rash should trigger contacting the GP again or going immediately to a hospital emergency department. Rarely,
meningococcal disease may present as conjunctivitis. Primary meningococcal conjunctivitis may be associated with
invasive disease and should be treated systemically. 15
2.3 Early antibiotic treatment for suspected bacterial septicaemia/meningitis
It is imperative that antibiotic therapy be commenced early if deaths from meningococcal septicaemia are to be
avoided. Immediate administration of benzylpenicillin to suspected cases of meningococcal septicaemia by general
practitioners was associated with reduced mortality in three retrospective studies in England. 10,14,16 When the
studies were aggregated (487 patients), it was calculated that those not given parenteral penicillin before hospital
admission were twice as likely to die than those given penicillin. 17 The greatest benefit of parenteral penicillin was
seen in those who were most ill i.e. those with a haemorrhagic rash. 14
-18-