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

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Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) Chapter 3: Hospital Management Key points • 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. • If a patient has clinical signs or symptoms suggestive of invasive meningococcal disease (meningitis or septicaemia) they should be given parenteral antibiotics immediately. • All patients should ideally be placed in isolation in a single room for the first 24 hours of treatment. • If there are no signs of meningeal irritation or meningitis is not suspected, lumbar puncture is not required on initial assessment. • Consider lumbar puncture for a person in whom meningitis is suspected only if there are no contraindications (the patient is neurologically stable and there are no signs of increased intracranial pressure or other contraindications). • Treatment should not be delayed while awaiting results of diagnostic tests. • Collect blood samples as soon as possible for PCR and culture, and full blood count. • If petechiae or frank bleeding is evident, formal coagulation studies should be undertaken. • The patient should be given chemoprophylaxis when able to take oral medication and before discharge from hospital, unless the disease had already been treated with ceftriaxone. • The department of public health (medical officer of health) should be notified immediately so that a public health response can be determined. • Hospitals and departments of public health should have local protocols for dealing with chemoprophylaxis including out-of-hours. 3.1 Introduction 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. and/or bacterial meningitis is suspected. In both scenarios it is imperative that appropriate antimicrobials are given as soon as the diagnosis of sepsis 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 is approximately 3-10%, but can reach as high as 20-40% in severe sepsis/meningitis. In a review of 407 children in Ireland, with meningococcal infection who survived to hospital admission between 1995 and 2000, the overall mortality rate was 3.6-4.8%. 19 From 1999 – 2005, the overall case fatality rates for meningococcal infection in Ireland ranged from 3-5% with somewhat higher rates observed in adults (7-8%). 20 Despite the efficacy of the MenC vaccine, meningococcal infection remains the most common cause of bacterial meningitis in Ireland. Serogroup B isolates account for the overwhelming majority of cases now diagnosed in Ireland. The speed with which meningococcal infections are recognized and treated is critical to achieving a -20-
Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) successful outcome and clinical suspicion alone mandates treatment. If meningococcal infection is suspected, administration of benzylpenicillin by the GP may be life-saving 21 and is recommended. Although results of studies of the benefit of pre-admission antibiotics have been inconsistent, 22-24 this has variably been attributed to their retrospective nature and confounding factors such as by illness severity (those most severely ill may be more likely to receive antibiotics). 9 Overall, pneumococcal infection is currently the second most common form of bacterial meningitis and the most common form of bacterial meningitis in the elderly. The incidence of Hib meningitis declined steeply following the introduction of this Hib vaccine. The following guidelines are presented in sections - evaluation, management of each individual case (sepsis or meningitis): Section A Clinical evaluation for suspected bacterial meningitis or meningococcal septicaemia Section B Guidelines for the management of the haemodynamically stable patient with meningitis Section C Guidelines for the management of community acquired bacterial sepsis/meningitis, including meningococcal infection -21-
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