Diagnosis
- Meningococcal disease = Bacterial Menigitis and Meningococcal Septicaemia
- Common non-specific signs especially children: Fever; N+V; Lethargy; Irritable; Ill appearance; Refusing food / drink; Headache; Muscle ache; Respiratory symptoms
- Specific Signs:
| Bacterial Meningitis | Meningococcal Septicaemia | Meningococcal Disease | |
|---|---|---|---|
| Non Blanching Rash | Y | Y | Y |
| Stiff neck/ Kernig’s sign | Y | NK | Y |
| Photophobia | Y | NK | Y |
| Altered mental state | Y | Y | Y |
| Cap refill | NK | Y | Y |
| Shock | Y | Y | Y |
| Hypotension | NK | Y | Y |
| Focal Neurology | Y | NK | Y |
| Bulging Fontanelle | Y | NK | Y |
- EWS hourly if signs
Investigation
- Unexplained fever and petechial rash:
- Full blood count
- C-reactive protein (CRP)
- Coagulation screen
- Blood culture
- Whole-blood polymerase chain reaction (PCR) for N meningitides; negative doesn’t rule out
- Blood glucose
- Blood gas
- LP / CSF interpretation: primary investigation unless contraindicated, but don’t allow it to delay Abx
- CSF assay: WCC, Protein, Glucose and Microbiological culture, Gram stain, within 4 hrs
- LP contra-indications: Raised ICP, shock, coag abnormal, infection at site, respiratory insufficiency, use clinical assessment and not CT to determine is safe to LP, but if have CT and signs don’t do
- Delay LP until contra-indications resolve as worthwhile if diagnostic uncertainty
- ABx if CSF WCC > 20 cells/microliter in neonates, > 5 cells/microliter in children & adults
- If CSF within range consider alternate diagnosis especially Herpes simplex encephalitis
- If focal neurology or GCS < 9 then perform CT to look for alternate diagnoses
Management
Pre-hospital management
Primary health care professionals contact 999
- Suspected bacterial meningitis w/o non-blanch rash: tx to secondary care w/o parenteral Abx
- Suspected meningococcal disease: parenteral Abx i.e. Benzylpenicillin IM or IV, but don’t delay tx
- Withold Abx only in those with clear Hx of anaphylaxis, a rash is not a contra-indication
Secondary care:
- Give Ceftriaxone immediately to young patient if: petechial rash spreads, become pruritic, signs of bacterial meningitis or meningococcal septicaemia or appears ill
- Give Ceftriaxone to young patient if: unexplained petechial rash and fever AND raised CRP / WCC
- If child has non spreading petechial rash, no fever, does not look ill unlikely meningococcal disease
- If no rash but suspected, and CRP / WCC raised and CSF abnormal then treat for bacterial meningitis, and if CSF not available
- If < 3mths give Cefotaxime + Amoxicillin
- If Herpes simplex encephalitis considered then treat with anti-viral
Specific Bacterial Infection
- H influenzae Type B: Ceftriaxone 10 days IV
- S Pneumoniae Meningitis: Ceftraixone 14 days IV
- L Monocytogenes: Amoxicillin + Gentamicin IV
- Gram negative bacilli: Cefotaxime 21 days IV
- Unconfirmed Bacterial Meningitis: Ceftriaxone 10 days IV
- Confirmed Meningococcal disease: Ceftriaxone 7 days IV
Treat metabolic disturbance
- Treat shock per CG84 and sepsis six bundle
Cortico-steroids:
- If CSF frankly purulent, bacteria on gram stain, WCC > 1000, protein > 1 g/litre give Dexamethasone 0.15mg/kg (max 10 mg) QDS, avoid if tuberculosis in differential as may be harmful
- If meningococcal septicaemia then no more than 0.6 mg/kg/day
Discharge:
- Consider their requirements for follow-up, taking into account potential sensory (hearing), neurological, psychosocial, orthopaedic, cutaneous and renal morbidities
- Test for complement deficiency if > 1 episode of meningococcal disease or any other serogroup than B