Joint Trust Guideline for the Management of: Bacterial Meningitis and Meningococcal Septicaemia in Children

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1 Jint Trust Guideline fr the Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children A clinical guideline recmmended fr use Fr Use in: By: Fr: Key wrds: Name and jb title f dcument authrs: Name and jb title f dcument authr s Line Manager: Supprted by: Assessed and apprved by the: Date f apprval: 30/10/2017 Ratified by r reprted as apprved t (if applicable): T be reviewed befre: This dcument remains current after 30/10/2020 this date but will be under review T be reviewed by: Dr Alex Brightwell Reference and / r Trust Dcs ID N: JCG0315 Id 1148 Versin N: 2 Descriptin f changes (fr revised versins): Cmpliance links: e.g. NICE If Yes - des the strategy/plicy deviate frm the recmmendatins f NICE? If s why? Children s Assessment Unit, Paediatric Wards, Accident and Emergency Medical and Nursing Staff dealing with suspected/cnfirmed cases Children and Yung Peple (Birth 16 years) with suspected /cnfirmed bacterial meningitis r meningcccal septicaemia Bacterial Meningitis and Meningcccal Septicaemia Dr Alex Brightwell, Cnsultant Paediatrician Dr Adam Heathcte, Paediatric ST Dr David Bth, Chief f Wmen s and Children s Services Dr E Bentsi-Enchill Lcum Cnsultant Paediatrician JPUH Guidelines Assessment Panel (CGAP) If apprved by cmmittee r Gvernance Lead Chair s Actin; tick here Clinical Standards Grup and Effectiveness Sub-bard Page 5 sentence abut circumference measurement added. Prphylaxis frm rifampicin t ciprflxacin in line with PHE updated recmmendatins NICE guideline CG102 N This guideline has been apprved by the Trust's Clinical Guidelines Assessment Panel as an aid t the diagnsis and management f relevant patients and clinical circumstances. Nt every patient r situatin fits neatly int a standard guideline scenari and the guideline must be interpreted and applied in practice in the light f prevailing clinical circumstances, the diagnstic and treatment ptins available and the prfessinal judgement, knwledge and expertise f relevant clinicians. It is advised that the ratinale fr any departure frm relevant guidance shuld be dcumented in the patient's case ntes. The Trust's guidelines are made publicly available as part f the cllective endeavur t cntinuusly imprve the quality f healthcare thrugh sharing medical experience and knwledge. The Trust accepts n respnsibility fr any misunderstanding r misapplicatin f this dcument Jint Clinical Guideline fr: Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children Authr/s: Dr Alex Brightwell Authr/s title: Cnsultant Paediatrician Apprved by: CGAP Date apprved: 30/10/2017 Review date: 30/10/2020 Available via Trust Dcs Versin: 2 Trust Dcs ID: JCG0315 Id 1148 Page 1 f 7

2 Jint Trust Guideline fr the Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children Algrithm fr the Unwell Child Pssible Meningcccal Disease e.g. fever, nn-blanching rash, meningism Immediate Assessment and Management A&B -Give Oxygen + mnitr C - IV r IO access, take bld samples < 3 mnths IV ceftaxime and IV amxicillin (Fr Dse see BNFc 3 mnths and lder: Dexamethasne 0.15mg/Kg (t max 10mg) if meningitic signs and nt shcked. Ceftriaxne 80mg/kg Cnsider herpes encephalitis and need fr acyclvir INFORM CONSULTANT Shck 20mL/Kg 0.9% sdium chlride ver 5-10 minutes. Reassess. Further blus f 20mL/Kg 0.9% sdium chlride and infrm cnsultant paediatrician If still shcked after 40mL/kg, call Anaesthetist n Bleep 0012 and discuss apprpriate place f admissin Onging Management n Buxtn Ward HDU Cnsider NG tube Cnsider Urinary catheter Cnsider Chest X-ray (pulmnary edema) Initially 2 hurly U&E/gases + BM stix Strict fluid balance charting and hurly neur bs LP when stable (if nt already) GP t give IM r IV Benzylpenicillin >9 years: 1200mg 1-9 years: 600mg <1 year: 300mg DO NOT DELAY TRANSFER TO HOSPITAL Investigatins Bld tests: FBC, Cag, grup and save U&Es, CRP, Ca, Mg, PO 4, Glucse, BM stix Bld culture, PCR, bld gas LFTs, Trpnin Thrat swab Cnsider LP - Check Cntraindicatins Cntraindicatins t LP (see pg. 4 fr mre detail) Signs f raised Intracranial Pressure Abnrmal cagulatin(if btained), platelets <100x10 9 /L Shck. Or extensive, rapidly spreading purpura (likely shck) After seizures until stabilised/ back t nrmal Respiratry cmprmise, lcal infectin at LP site If in dubt d nt delay treatment Admit t ITU pending transfer t PICU Cntact Addenbrkes PICU SpR n call t discuss case and request a bed Cntact CATS n if Addenbrkes unable t transfer/unable t take Reassessment Reassess initially minimum 4 hurly, recrd findings Cllate lab results, treat specific abnrmalities At reassessment, check all bservatins, examine fr raised ICP and fluid balance status Discuss with Cnsultant Cmmunicable Disease Cntrl Reprt t HPA Cnsultant Cmplete referral card Antibitic prphylaxis fr husehld cntacts Infrmatin leaflets Fllw Up Hearing test in all befre discharge (r within 4 weeks) Out patients appintment at 4-6 weeks Check vaccinatin status Lng term: cnsider disruptin t grwth plates Lk ut fr leg length discrepancy. Link t NICE meningitis guidelines Meningitis cnfirmed and nt in shck Any f the fllwing: Frankly purulent CSF CSF WBC cunt>1000/micrlitre Raised CSF WBC cunt and prtein >1g/L Bacteria n gram stain Give Dexamethasne 0.15mg/kg t a maximum f 10mg, QDS fr 4 days Raised Intracranial Pressure Signs Decreasing r fluctuating level f cnsciusness Relative bradycardia and hypertensin Dilated, unequal r prly reactive pupils Abnrmal (decrticate/decerebrate) psturing Other fcal neurlgical signs Papilledema (late sign) Abnrmal dll s eye mvements Treatment Mannitl 0.25 g/kg IV blus ver 5 min Elevate head (30 degrees) Cnsider elective intubatin Treat seizures Obtain CT scan Arrange admissin t ITU and transfer t PICU as abve - full guideline Jint Clinical Guideline fr: Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children Authr/s: Dr Alex Brightwell Authr/s title: Cnsultant Paediatrician Apprved by: CGAP Date apprved: 30/10/2017 Review date: 30/10/2020 Available via Trust Dcs Versin: 2 Trust Dcs ID: JCG0315 Id 1148 Page 2 f 7

3 Jint Trust Guideline fr the Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children Objective All infants and children attending NNUHFT with suspected Meningitis and Meningcccal Septicaemia shuld be treated accrding t the NICE guideline linked abve. The quick reference algrithm abve is based entirely n this, but with specifics arund lcal care such as cntact telephnes numbers/bleeps/when t cntact the cnsultant etc. Please refer t the full NICE dcument fr mre detailed infrmatin cncerning the diagnsis and management f this disease. Backgrund Withut rapid resuscitatin and aggressive management, children die f meningcccal sepsis. There is gd evidence fr ptimum care. This dcument draws this evidence tgether fr use in the NNUHFT. In suspected meningitis withut a rash, meningcccus (N. meningitides grup B) is the mst likely cause, with pneumcccus the next mst likely. Peak incidence is in winter but ccurs thrughut the year. Features assciated with a wrse prgnsis: shck rash spreading after antibitic treatment shrt histry absence f meningism Lw platelets (<150 x 10 9 /L) Lw white cell cunt (<4.0 x 10 9 /L) hyperpyrexia (>40ºC) cagulpathy Severe disease prgresses rapidly t haemdynamic cllapse, disseminated intravascular cagulatin, multisystem rgan dysfunctin, cma and death. Shck and raised intracranial pressure are the primary life threatening prcesses. Circulatry cllapse is a result f a cmbinatin f capillary leak, intravascular vlume depletin, vasdilatin and mycardial failure. Recgnitin Cnsider in cases f fever & nn-blanching rash, especially with altered cnsciusness. The prdrme is ften nn-specific with malaise, vmiting, myalgia, headache and altered sensrium. Exercise a high index f suspicin. Rash Classically haemrrhagic petechial r purpuric The early rash can be nn-specific - macular and blanch n pressure Always ask the registrar t review patients with petechial/purpuric rashes Jint Clinical Guideline fr: Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children Authr/s: Dr Alex Brightwell Authr/s title: Cnsultant Paediatrician Apprved by: CGAP Date apprved: 30/10/2017 Review date: 30/10/2020 Available via Trust Dcs Versin: 2 Trust Dcs ID: JCG0315 Id 1148 Page 3 f 7

4 Jint Trust Guideline fr the Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children Petechiae n a well child can be managed cnservatively, see p11 NICE guideline Meningism stiff neck, Kernig s & Brudzinski s sign, phtphbia Headache Altered sensrium (Management f a Child (aged 0-18 years) with a Decreased Cnscius Level. Bulging fntanelle (CG47 Feverish Illness in children Septicaemia investigate and treat the infectin as belw. Aggressively treat shck with 20mL/Kg f 0.9% sdium chlride ver 5-10 minutes. Reassess and repeat if needed, infrm the cnsultant paediatrician n call. If mre than 40mL/Kg is needed, infrm anaesthetist n bleep 0012 and cnsider apprpriate place f admissin. If a third blus is required, make plans fr intubatin and ventilatin and start treatment with vasactive drugs. Give further fluids based n respnse, bld results and discussin with intensivist. Large vlumes f fluid may be required ver a shrt perid f time. Meningitis alne (nt septicaemic shck) Investigatins: Treatment FBC, bld culture, CRP, U&E, LFT, Caggulatin, LP (see cntraindicatins) -CSF fr culture, prt, glucse, PCR. Infants and children > 3 mnths IV Dexamethasne 0.15mg/Kg nce. Cntinue QDS fr fur days if CSF shws: WCC >1000/micrlitre Raised CSF WBC cunt (>5cells/micrlitre r >1 neutphil/micrlitre) and prtein >1g/L Bacteria n gram staining (see NICE guideline) IV Ceftriaxne 80mg/Kg Infants and nenates < 3 mnths IV ceftaxime and IV amxicillin (dses accrding t age in days as per BNFC) Cntraindicatins t LP Signs f raised intracranial pressure Reduced r fluctuating level f cnsciusness Relative bradycardia and hypertensin Fcal neurlgical signs Abnrmal psture r psturing Jint Clinical Guideline fr: Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children Authr/s: Dr Alex Brightwell Authr/s title: Cnsultant Paediatrician Apprved by: CGAP Date apprved: 30/10/2017 Review date: 30/10/2020 Available via Trust Dcs Versin: 2 Trust Dcs ID: JCG0315 Id 1148 Page 4 f 7

5 Jint Trust Guideline fr the Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children Unequal, dilated r prly respnsive pupils Shck Papilledema (late sign) Abnrmal dll s eye mvements Extensive and/r spreading purpura (likely t becme shcked) After seizures until stabilised/back t nrmal cnscius level Cagulatin abnrmalities (if btained): results utside nrmal range, platelets <100x10 9 /L, Receiving anticagulant therapy Lcal superficial infectin at LP site Significant respiratry insufficiency (psitining fr LP may cause deteriratin) Onging management Duratin f treatment is dependent n the rganism and the respnse t antibitics. See NICE guideline and seek micrbilgy advice (Cnsult Dr Catherine Tremlett). All infants and children t have an audilgy assessment as sn as they are well enugh t d s (and within 4 weeks f disease) Cnsultant fllw up 4-6 weeks (pst audilgy) If severe r prfund deafness, refer ENT urgently fr assessment fr cchlear implants as sn as pssible. Regular ccipit-frntal head circumference measurement in infants (at least mnthly) and prmpt referral t paediatrics if crssing centile lines upwards. Health Prtectin Agency (HPA) Reprt the case t the HPA Cnsultant ASAP: This is a legal duty Office hurs: Out f hurs: via Medicm (Ask fr the Public Health Dctr n call fr Nrflk) Cmplete HPA referral card: 4 categries fr referral: Pssible as fr prbable but ther diagnses are at least as likely - These cases d nt need t be reprted Prbable clinical diagnsis withut micrbilgical cnfirmatin, where meningcccal disease is the mst likely diagnsis. Clinically certain Micrbilgically cnfirmed Antibitic prphylaxis fr husehld cntacts Prphylaxis is fr all risk categries except pssible Prphylaxis shuld be given within 24 hurs and shuld be arranged with the HPA and GP Jint Clinical Guideline fr: Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children Authr/s: Dr Alex Brightwell Authr/s title: Cnsultant Paediatrician Apprved by: CGAP Date apprved: 30/10/2017 Review date: 30/10/2020 Available via Trust Dcs Versin: 2 Trust Dcs ID: JCG0315 Id 1148 Page 5 f 7

6 Jint Trust Guideline fr the Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children Prphylaxis reduces the risk f invasive disease, withut it the attack rate in cntacts rises fld. It des nt eliminate the risk. Asymptmatic naspharyngeal carriage -10% Prphylaxis is given t eliminate nasal carriage. Thrat swabs frm cntacts is nt necessary Prphylaxis shuld be given t Any persn wh, since 7 days prir t the nset f illness in the case, has lived and slept in the same husehld and/r had muth-tmuth kissing cntact with a case/suspected case f meningcccal disease Recrd cntacts in the ntes: name, address, age, GP, cllege/schl/playgrup Staff: staff wh have been intimately expsed t respiratry secretins, eg. during deep suctin r intubatin shuld discuss with Occupatinal Health the need fr prphylaxis. Ciprflxacin is nw recmmended fr use in all age grups and in pregnancy. Adults & children >12 years ld Children aged 5-12 years Children <5 years 500mg single dse 250mg single dse 30 mg/kg up t a maximum f 125mg single dse (suspensin cntains 250mg/5ml) Antibitics shuld be ffered as sn as practicable - ideally within 24 hurs after diagnsis f the case. Where there is delayed cnfirmatin f diagnsis, cntacts shuld still be ffered antibitics up t fur weeks after the nset f illness in the case. Identifying the causative rganism The precise identificatin f the causative rganism is imprtant t the management f bth the index case and cntacts. It is crucial fr epidemilgy in the surveillance f clusters and utbreaks f invasive meningcccal disease. Cnfirming the sertype f the infectin is imprtant t cnfirm the efficacy and detect nn-respnders t the MenC vaccine. Thus perfrm thrat swab and PCR (bld EDTA sample, CSF fr PCR in plain bttle). Clinical audit standards All cases f meningitis alne t have IV dexamethasne befre the administratin f ceftriaxne. Septicaemia cases treated accrding t the algrithm ABC, insertin f cannula and rapid administratin f antibitics (within 15 mins f admissin t CAU). Rapid treatment f shck Develpment The guideline was drafted by the authrs listed and discussed in the paediatric guideline meeting, frm which several changes were made. Paediatric anaesthetic clleagues and A&E clleagues were circulated and their cmments incrprated. With acknwledgement t Dr Adam Heathcte ST3 Paediatrics fr his help in the literature search and recmmendatins. Jint Clinical Guideline fr: Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children Authr/s: Dr Alex Brightwell Authr/s title: Cnsultant Paediatrician Apprved by: CGAP Date apprved: 30/10/2017 Review date: 30/10/2020 Available via Trust Dcs Versin: 2 Trust Dcs ID: JCG0315 Id 1148 Page 6 f 7

7 Jint Trust Guideline fr the Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children Distributin: NNUH intranet References/ surce dcuments 1. N. Ninis, S. Nadal, St Mary s Hspital Lndn; L. Glennie, Meningitis Research Fundatin. 2. NICE guideline CG102, June 2010, revised September 2010, Bacterial meningitis and meningcccal septicaemia: management f bacterial meningitis and meningcccal septicaemia in children and yung peple yunger than 16 years in primary and secndary care. 3. Health Prtectin Agency Meningcccus Frum (August 2006), Guidance fr public health management f meningcccal disease in the U.K. 4. Pllard A.J. et al. Emergency management f meningcccal disease. Arch.Dis.Child : Annual Spring Meeting f the RCPCH. Yrk Imprved survival f children admitted t intensive care with meningcccal disease. 6. Avidable deficiencies in the delivery f health care t children with meningcccal disease. J.Accid.Emerg.Med : McIntyre et al. Dexamethasne as adjunctive therapy in bacterial meningitis. A meta-analysis f clinical trials. JAMA Sept : Meningcccal Infectin. Meningitis and septicaemia. PL/CMO/97/1 9. Guidelines fr the early clinical and public health management f meningcccal disease in Australia. Cmmunicable Disease Netwrk PAL Wylie et al., Epidemilgy and clinical management f meningcccal disease in West Glucestershire: retrspective, ppulatin based study. BMJ : NE Rsenstein et al., Meningcccal Disease. NEJM : R Kneen et al., The rle f lumbar puncture in suspected CNS infectin a disappearing skill? Arch Dis Child : R By et al., Reductin case fatality rate frm meningcccal disease assciated with imprved healthcare delivery. Arch Dis Child : P Balmer & E Miller, Meningcccal disease: hw t prevent and hw t manage. Current Opinin Infectius Diseases : EA Kirsch et al., Pathphysilgy, treatment and utcme f meningcccaemia: A review and recent experience. Pediatric Infectius Disease Jurnal : FAI Rirdan & AJ Cant, When t d a lumbar puncture. Arch Dis Child : J Gans & D van de Beek, Dexamethasne in adults with bacterial meningitis. NEJM : Jint Clinical Guideline fr: Management f: Bacterial Meningitis and Meningcccal Septicaemia in Children Authr/s: Dr Alex Brightwell Authr/s title: Cnsultant Paediatrician Apprved by: CGAP Date apprved: 30/10/2017 Review date: 30/10/2020 Available via Trust Dcs Versin: 2 Trust Dcs ID: JCG0315 Id 1148 Page 7 f 7