Bacterial meningitis and

meningococcal septicaemia
Implementing NICE guidance

June 2010
NICE clinical guideline 102
What this presentation covers
Background
- Bacterial meningitis
- Meningococcal disease
Key priorities for implementation
Costs and savings
Discussion
Find out more

Bacterial meningitis
Bacterial meningitis is an infection of the surface of the brain
(meninges).
In children and young people aged 3 months or older, it is
most frequently caused by:
- Neisseria meningitidis (meningococcus)
- Streptococcus pneumoniae (pneumococcus)
- and Haemophilus influenzae type b (Hib).
In neonates the most common causative organisms are:
- Streptococcus agalactiae (Group B streptococcus)
- Escherichia coli, S pneumoniae
- and Listeria monocytogenes.
Meningococcal disease
Meningococcal disease covers two major illnesses:
- meningococcal meningitis (a type of bacterial meningitis)
- and meningococcal septicaemia (blood poisoning).
Meningococcal disease most commonly presents as:
- meningococcal (bacterial) meningitis (15% of cases)
- septicaemia (25% of cases)
- or a combination of the two (60% of cases).
Meningococcal disease is the leading infectious cause of
death in early childhood and has a 10% case fatality rate
Key priorities for implementation

Symptoms and signs of bacterial meningitis and meningococcal
septicaemia

Management in the pre-hospital setting
Investigation in secondary care
Investigation and management in children and young
people with petechial rash
Polymerase chain reaction (PCR)
Lumbar puncture

Use of ceftriazone*
Management in secondary care
Fluids for bacterial meningitis
Intravenous fluid resuscitation in meningococcal
septicaemia
Long-term management


Healthcare professionals should be trained in the
recognition and management of meningococcal
disease.

Consider bacterial meningitis and meningococcal
septicaemia in children and young people who present
with the symptoms and signs outlined in table 1 in the
NICE guideline.


Symptoms and signs
Bacterial meningitis and meningococcal septicaemia

Be aware that in children and young people:
some will present with mostly non-specific symptoms or
signs and the conditions may be difficult to distinguish
from other less important (viral) infections presenting in
this way

those with more specific symptoms and signs are more
likely to have bacterial meningitis or meningococcal
septicaemia. The symptoms and signs may become
more severe and more specific over time.
Symptoms and signs
Recognise shock and manage urgently in secondary care.







Symptoms and signs
Signs of shock
Capillary refill time more than 2 seconds
Unusual skin colour
Tachycardia and/or hypotension
Respiratory symptoms or breathing difficulty
Leg pain
Cold hands/feet
Toxic/moribund state
Altered mental state/decreased conscious level
Poor urine output
Transfer children and young people
with suspected bacterial meningitis
or meningococcal septicaemia to
secondary care as an emergency by
telephoning 999.
Management in
pre-hospital setting
Give intravenous ceftriaxone immediately to children and
young people with a petechial rash if any of the following
occur at any point during assessment:
petechiae start to spread
the rash becomes purpuric
there are signs of bacterial meningitis
there are signs of meningococcal septicaemia
the child or young person appears ill.

Perform whole blood real-time PCR testing (EDTA
sample) for N meningitidis to confirm a diagnosis
of meningococcal disease.

Investigation in secondary care

In children and young people with suspected meningitis or
suspected meningococcal disease, perform a lumbar
puncture unless any of the following contraindications are
present:
signs suggesting raised intracranial pressure
shock
extensive or spreading purpura
after convulsions until stabilised
coagulation abnormalities
local superficial infection at lumbar puncture site
respiratory insufficiency.




Investigation in secondary care
Lumbar puncture

Suspected or confirmed bacterial meningitis:
- treat children and young people aged 3 months or older
without delay using intravenous ceftriaxone
- treat children younger than 3 months without delay using
intravenous cefotaxime plus either amoxicillin or ampicillin.
Suspected or confirmed meningococcal disease:
- treat without delay using intravenous ceftriaxone.
Where ceftriaxone is used, do not administer it at the
same time as calcium-containing infusions.
Instead use cefotaxime.





Use of ceftriaxone

Do not restrict fluids in cases of bacterial meningitis
unless there is evidence of:
raised intracranial pressure or
increased antidiuretic hormone secretion.
Management in secondary care
Management in secondary care
Stage Administer fluids Intervention
Signs of
shock
present

20 ml/kg sodium chloride 0.9%
over 510 minutes
Reassess immediately
after fluids administered
Signs of
shock
persist
20 ml/kg sodium chloride 0.9%
or human albumin 4.5%
over 510 minutes
Reassess immediately
after fluids administered
Signs of
shock still
persist
20 ml/kg sodium chloride 0.9%
or human albumin 4.5%
over 510 minutes
Call for anaesthetic assistance
and start vasoactive drugs
Signs of
shock still
persist
Consider a further 20ml/kg sodium
chloride 0.9%
or human albumin 4.5%
over 510 minutes
Administration based on
clinical signs and appropriate
laboratory investigations
Intravenous fluid resuscitation
in suspected or confirmed meningococcal septicaemia
Children and young people should be reviewed by a
paediatrician (along with the results of their hearing test)
46 weeks after discharge from hospital.

Specifically consider related morbidities for example,
hearing loss or orthopaedic complications
Offer children and young people with a severe or
profound deafness an urgent assessment for cochlear
implants as soon as they are fit to undergo testing.

Long-term management
Costs and savings
The guideline on bacterial meningitis and meningococcal
septicaemia is unlikely to result in a significant change in
resource use in the NHS. However, recommendations in the
following areas may result in additional costs/savings depending
on local circumstances:
healthcare professionals should be trained in the
recognition and management of meningococcal disease
investigation of children and young people with petechial
rash
transfer suspected cases to secondary care as an
emergency by telephoning 999.

Discussion
When considering cases of bacterial meningitis and
meningococcal disease:
How could training on the recognition, assessment and
management of both suspected and confirmed cases
be improved in our Trust?
What is our first line antibiotic?
What are our local protocols for the administration of
fluids?
What are our long-term management
pathways?
Find out more
Visit www.nice.org.uk/guidance/CG102 for:
the guideline
the quick reference guide
Understanding NICE guidance
costing statement
audit support
Visit www.learning.bmj.com for modules on:

Meningococcal disease in children
Feverish illness in children
Febrile toddler in the emergency department