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) MANAGEMENT OF THE HAEMODYNAMICALLY STABLE PATIENT WITH meningitis ACTION NOTES GOALS 1. ABC MANAGEMENT Assess and maintain airway and breathing as required Maintain O 2 saturation > 94% ADMINISTER 100% O 2 at 15 L/ MIN Assess circulation and secure vascular access (intravenous [IV] or intraosseous [IO]) IV access as large as practical, ideally 2, or intraosseous Establish secure access to permit fluid and medication delivery 2. SUMMON HELP, alert ICU team Ideally >1 doctor should be present to optimise initial management Facilitate resuscitation Permit early intubation if necessary 3. ORDER FIRST DOSE ANTIBIOTICS TO BE DRAWN UP while work proceeds Rapid sterilisation of blood and/or CSF using antibiotic of ANTIBIOTIC Cefotaxime or Ceftriaxone AGE 0 - 1 mos 1 – 2 mos > 2 mos 50 mg/kg 50 mg/kg or Not in neonates 50 mg/kg or 80 mg/kg 80 mg/kg 2g Max Dose (Adult dose) 2g Amoxicillin* 100 mg/kg 50 mg/kg 2g Gentamicin* 2.5 mg/kg 2.5 mg/kg Vancomycin 15 mg/kg 15 mg/kg 10-15 mg/kg (max 1g) *Patients under two months require specific Listeria and gram-negative organism cover In severe penicillin allergy Meropenem 40 mg/kg/dose (max 2g) can be used Ceftriaxone • Is contraindicated in newborns up to 28 days of age if they require (or are expected to require) IV calcium treatment, or calcium-containing infusions because of the risk of precipitation of ceftriaxone-calcium (refer to SPC). • In patients of any age must not be mixed or administered simultaneously with any calcium-containing IV solutions, even via different infusion lines or at different infusion sites. • In patients > 28 days, calcium-containing solutions may be administered sequentially if infusion lines at different sites are used or if the infusion lines are replaced or thoroughly flushed between infusions with physiological salt-solution to avoid precipitation. • In patients requiring continuous infusion with calcium-containing TPN solutions, healthcare professionals may wish to consider the use of alternative antibacterial treatments which do not carry a similar risk of precipitation. Add vancomycin if there is concern regarding possibility of beta-lactam resistant pneumococci, (e.g. Gram positive cocci (possibly pneumococci) seen on CSF Gram stain) and use until susceptibility of isolate is confirmed. Consultation with microbiologist is recommended adequate activity and potency in an appropriate dose 4. DRAW BLOODS STAT Listed in order of priority: Venous blood gas, FBC, Diff., Bacterial PCR as appropriate (meningococcal, pneumococcal, haemophilus, GpB Strep), PT, APTT, Fibrinogen, d-dimers, Protein C, Diastix, Blood culture, glucose, U & E, Ca, P0 4 , Mg, LFTs, Lactate, Group and hold Rapid diagnostic evaluation -24-
Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) 5. GIVE DEXAMETHASONE BEFORE OR AT THE TIME OF ANTIBIOTICS Ideally steroids should be given either before or at the time of antibiotic administration. They are unlikely to be of benefit if given more than 24 hours after antibiotic therapy has been commenced Dexamethasone phosphate 0.15mg/kg/dose every 6 hrs for 4 days Research evidence: • Proven benefit in children with Hib meningitis 16,26 • Improved outcome for adults with bacterial meningitis 27,29 • Inconsistent evidence from animal models of pneumococcal meningitis although benefit in children reported 30 • Not uniformly advocated 31 • Two regimens have been used with similar outcomes Improve outcome Minimise neurologic sequelae and prevent deafness 6. GIVE IV/IO ANTIBIOTICS WITHOUT UNDUE DELAY Antibiotics may be deferred until after LP where such is planned without delay If delay prior to LP is anticipated (such as time to obtain CT scan if deemed necessary) then antibiotics should not be withheld but should be given even if the LP has not yet been performed Ceftriaxone special precautions: see No.3 above For infants ≤ 8 weeks (2 months) the addition of amoxicillin is to provide cover for listeria and enterococci and the addition of gentamicin to enhance GNB cover and synergistic increase in activity against group B streptococci 7. COMMENCE IV FLUIDS If haemodynamically unstable refer to Sepsis Guideline Action section C, point 5 8. EVALUATE FOR PRESENCE OF CEREBRAL OEDEMA ASSUME PATIENT HAS CEREBRAL OEDEMA IF:- • Serum Na is < 135mmol/L and signs of raised ICP are present or • Serum Na is < 130mmol/L even in the absence of clinical signs of raised ICP MANAGEMENT OF PATIENTS WITH CEREBRAL OEDEMA REQUIRES CONSULTANT CONSULTATION Crystalloid fluids (e.g. Hartmann’s or 0.9% w/v NaCl) should start at 100% of maintenance requirements Assess need for bolus fluid :- e.g. 20 mls/kg isotonic crystalloid (e.g. Hartmann’s or 0.9% w/v NaCl) or colloid stat, if clinical evidence of dehydration Signs of raised ICP include • Decreased or fluctuating level of consciousness • Hypertension and relative bradycardia • Unequal, dilated or poorly responsive pupils • Focal neurological signs • Seizures, abnormal postures • Papilloedema Patients suspected of having cerebral oedema should be treated with 0.9% w/v NaCl or 5% w/v albumin Mannitol (0.25g/kg) or 3% saline (2-3 mls/kg) over 20 minutes bolus may be required. (Discuss with nephrology consultant if renal dysfunction present) Urinary catheter to monitor output Early brain CT to potentially confirm/out rule cerebral oedema DO NOT ATTEMPT LP IF SIGN(S) OF RAISED ICP Cautious rehydration Treat shock if present Early recognition of raised ICP Avoid brain herniation Avoid hypercapnia or hypoxia -25-
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