GUIDELINE FOR THE MANAGEMENT OF MENINGOCOCCAL DISEASE Reference: MCD Version No: 1 Applicable to Children with suspected or confirmed meningococcal disease Classification of document: Area for Circulation: Authors: Group Consulted: Ratified by: Guideline Children s Hospital for Wales Dr J Stevens (ST6) Dr N MacDermott (ST4) Dr C Rossitter (GPST) Dr J Evans (Consultant) Practitioners within the CHfW Current literature Child Health Guideline Meeting February 2012 Date Published: July 2012 Version Number Planned Date of Review Reviewer Name Completed Action Approved By Date Approved New Review Date 1 2014 Disclaimer These have been ratified at the Child Health Guideline Meeting, however clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
Meningococcal Disease Meningococcal disease (MCD) is caused by systemic infection with Neisseria meningitides; type B is most common. It often results in a clinical picture of septicaemia and can occur with or without meningitis. Signs and symptoms of meningitis and meningococcal disease Signs/Symptoms Bacterial meningitis Meningococcal septicaemia Notes Common non-specific signs/ symptoms Fever Vomiting/nausea Lethargy Irritability Ill appearance Refusing food/fluid Headache Myalgia / arthralgia Respiratory distress Not always, especially neonates. Less common non-specific signs/symptoms Rigors Abdominal pain / distension / diarrhoea NK Upper resp tract signs or symptoms NK More specific signs/symptoms Non-blanching rash Difficult in darker skin tones. Stiff neck NK Altered mental state CRT > 2 seconds NK Unusual skin colour NK Hypotension NK Cool peripheries NK Leg pain NK Back rigidity NK Bulging fontanelle NK < 2 years Photophobia X Kernig s sign X Brudzinki s sign X Unconsciousness Moribund/toxic state Paresis X Focal neurological deficit X Seizures X X not present, present, NK not known within evidence, CRT capillary refill time.
Signs of shock: Tachycardia/ hypotension CRT > 2 seconds / unusual skin colour / cool peripheries Respiratory distress / hypoxia Leg pain Toxic/moribund state Altered mental state Poor urine output < 1ml/kg/hr Base deficit > -5 mmol/l Lactate >2 mmol/l Classical signs of meningitis may be difficult to determine in infants and children and young people tend to present with non-specific signs and symptoms. Meningococcal disease and meningitis often occur together. Be sure to record: HR, RR, temp, BP, perfusion, conscious level, oxygen saturations at least hourly in any child with suspected meningitis or meningococcal disease. Prepare to consult with PICU about all cases of suspected meningococcal disease and meningitis< 2years. Investigation and management of a child with suspected meningococcal septicaemia: Gain IV access send blood samples for FBC, CRP, U+E, glucose, calcium, magnesium, clotting, blood gas, lactate, Blood culture and meningococcal PCR. Give IV ceftriaxone 80 mg/kg. Continue at a once daily dose. Give for 7 days in both confirmed and unconfirmed/suspected cases. Chloramphenicol may be used in type 1 sensitivity to cephalosporins, 40 mg/kg bolus then 25mg/kg 8 hourly IV/PO. Fluids MCD is often associated with hypovolaemia. If signs of shock give 20 ml/kg of 0.9% saline over 5-10 mins immediately and reassess. If still in shock give another 20 ml/kg of 0.9% saline or 4.5% human albumin and reassess. If shock persists give another 20 ml/kg of 0.9% saline or 4.5 % albumin and call for PICU + anaesthetist to prepare for intubation. These children can need a lot of fluid to restore their circulating volume. Never use 5 or 10% dextrose. These children will need regular reassessment even if good improvement is seen. Reassessment should be based on the child s clinical condition but in a child who has shown good improvement it is still recommended they be reassessed after 30 minutes and then on an hourly basis until sure the child is in a stable condition. Do not give corticosteroids for meningococcal septicaemia.
Acute complications: ABC: ensure airway patent, airway manoeuvres + adjuncts, oxygen, anaesthetic review, intubation. Shock: see above signs and fluid management. Acidosis Hypoglycaemia: 5ml/kg 10% dextrose. Hypokalaemia / hypocalcaemia/ hypomagnesaemia. Raised ICP: ABC, oxygen, head raised 30 o, mannitol 0.25g/kg, intubate + ventilate (PaCO 2 4-4.5kPa). Deranged clotting. Seizures. Manage as per APLS. Later complications: Small vessel thrombosis / tissue loss involve wound team, pain team and plastics. Appropriate analgesia, may need opiates. Reactive arthritis or pericarditis can occur from day 3-7. Fever persisting beyond 7 days tissue damage (vasculitis), nosocomial infection, subdural effusion, suppurative foci, inadequately treated meningitis, parameningeal focus or drugs. Notification: All cases of confirmed or presumed N. Meningitidis should be urgently notified to public health. Contact via ambulance control 01495 751388. Contact chemoprophylaxis (meningitis and meningococcal disease): Needs to be given within 24 hours. All household/day care contacts who have been exposed within 10 days of onset. Anyone who gave mouth to mouth resuscitation to index case. Infants < 1 month Rifampicin 20 mg PO 12 hourly for 2 days. Infants 1 month - 4 months Ciprofloxacin 125 mg as stat dose. Infants 5 months 1 year Ciprofloxacin 250 mg as stat dose. Children > 1 year Ciprofloxacin 500 mg as stat dose. Warn contacts on Rifampicin about orange-red discolouration of bodily fluids, can cause itching, skin rash and GI disturbance. Negates effect of contraceptive pill. Contraindicated in pregnancy / breastfeeding/ severe liver and renal disease.
Long term management and follow-up: All patients with meningitis and meningococcal septicaemia need paediatric follow-up to monitor the occurrence of the following complications: Hearing loss (associated with meningitis) All children require age appropriate test prior to discharge. Repeat test 6 weeks after discharge if fail first test. Out-patients appointment within 6 weeks to discuss results of the test. To arrange hearing test please contact ext 43011 at Denbigh house. Orthopaedic complications damage to bones and joints. Skin complications - scarring from necrosis. Psychosocial problems children can remember their ordeal. Neurodevelopmental problems. Renal failure. Be sure to inform the GP, health visitor and school nurse of the child s condition. Ensure that adequate discussion has taken place with the family about follow-up care, relevant complications and how to access relevant support ie through charities / counselling. Documents to read with this guideline o Flowchart on following page o Petechiae and Purpura Guideline 2012
Algorithm for the early management of Meningococcal septicaemia RECOGNITION: may present with septicaemia with shock, meningitis with ICP, purpuric/petechial rash. If high clinical suspicion or confirmed case, notify public health and consider chemoprophylaxis of close contacts. Call SPR, paeds/ed consultant. Assess for shock and ICP. DO T PERFORM LUMBAR PUNCTURE ABC: oxygen 15 L/min Large IV/IO access: gluc, FBC, coag, U+E, Ca, Mg, gas, men PCR, blood culture Ceftriaxone 80 mg/kg IV/IO Use cefotaxime 50 mg/kg if calcium-containing fluids or age <3 months Go to meningitis algorithm DO T a DO LP. 20 ml/kg 0.9% saline bolus SHOCK? ICP? Signs of meningitis? Further 20 ml/kg 0.9% saline or 4.5% albumin if shock persists. Check Glu Observe response DO T DO LP, Check Glu Mannitol (0.25g/kg) Repeat review for signs of shock / ICP After 40 ml/kg still signs of shock? Repeated review for signs of shock Call anaesthetist/picu NG/ catheter Treat shock then cautious fluids Children can deteriorate quickly. Call anaesthetist + PICU Treat seizures 20 ml/kg 0.9% saline/4.5% albumin. May need repeat boluses. Prepare ET tube, NG tube, urinary catheter. Go to meningitis guideline and algorithm Consider inotropes- dopamine/ adrenaline. Consider metabolic disturbances. Reassess.