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) Section C: Guidelines for the MANAGEMENT OF Community Acquired Bacterial sepsis/ meningitis, including Meningococcal Infection for the Haemodynamically UNSTABLE patient Summary of management approach 1. ABC management Assess and maintain airway and breathing as required Administer 100% O 2 at 15 L/Min Assess circulation and secure vascular access (Intravenous or Intraosseous) 2. Summon help, alert ICU Team 3. Order first dose antibiotics to be drawn up 4. Draw bloods stat 5. Initiate fluid resuscitation 6. Give IV/IO antibiotics without delay 7. Reassess clinically 8. Lumbar puncture should NOT be carried out at this time 9. Consider intubation 10. Continue resuscitation 11. For patients who are unresponsive to fluid and inotrope resuscitation - give low dose steroids 12. Manage coagulopathy if present 13. If meningococcal infection suspected obtain throat swab and/or pernasal swab 14. Consider further consultation (microbiology/haematology/nephrology/infectious diseases) 15. Consider renal replacement therapy 16. Notify public health & infection control. Initiate contact chemoprophylaxis and information as per agreed protocol if necessary -28-
Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) MANAGEMENT OF THE HAEMODYNAMICALLY UNSTABLE PATIENT WITH SEPSIS/MENINGITIS ACTION NOTES GOALS 1. ABC MANAGEMENT ADMINISTER 100% O 2 at 15 L/min Assess and maintain Airway and Breathing as required Assess Circulation and secure vascular access (intravenous or intraosseous) IV access as large as practical, ideally 2, or intraosseus Maintain O 2 saturation > 94% 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 adequate activity and potency in an appropriate dose Antibiotic Age cefotaxime or ceftriaxone 0 - 1 month 1 – 2 mos > 2 mos Max. Single Dose (Adult dose) 50 mg/kg 50 mg/kg or Not in neonates 50 mg/kg or 2g 80 mg/kg 80 mg/kg 2g amoxicillin* 100 mg/kg 50 mg/kg 2g gentamicin* 2.5 mg/kg 2.5 mg/kg vancomycin 15mg/kg 15mg/kg 10-15mg/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 re possibility of beta-lactam resistant pneumococci, e.g. if Gram positive cocci (possibly pneumococci) seen on CSF gram stain and use until susceptibility of isolate confirmed. Consultation with microbiologist is recommended 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 & hold Rapid diagnostic evaluation -29-
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