Bacterial Meningitis and Meningococcal Disease

Overview

• This guideline covers recognizing, diagnosing, and managing bacterial meningitis and meningococcal disease.
• The aim is to reduce death and disability by helping healthcare professionals recognize and treat it quickly and effectively.
• For babies up to 28 days corrected gestational age, see the NICE guideline on neonatal infection.
• The guideline does not cover people with immunodeficiency, confirmed viral, tuberculous or fungal meningitis, confirmed viral encephalitis, brain tumors, hydrocephalus, or previous neurosurgical procedures.
• It does not cover known cranial or spinal anomalies that increase the risk of bacterial meningitis.

Intended Audience

• Healthcare professionals.
• Commissioners and providers.
• People with bacterial meningitis or meningococcal disease, their families, and carers.

Recognizing Bacterial Meningitis and Meningococcal Disease

• Be aware that bacterial meningitis or meningococcal disease are rapidly evolving conditions.
• They can present with non-specific symptoms/signs.
• Young babies and older adults may show non-specific symptoms and signs without the red flag combination for bacterial meningitis.
• It may be difficult to distinguish from other infections with similar symptoms and signs.
• Symptoms and signs may be more difficult to identify in young people and young adults, who may appear well at presentation.
• Meningitis and sepsis can occur at the same time, particularly in people with a rash.

Assessing Signs, Symptoms and Risk Factors

• Assess based on sections on:
  • When to suspect bacterial meningitis, including red flag combination.
  • When to suspect meningococcal disease, including red flag symptoms.
• Also consider reports of symptoms from family members and carers, if relevant.
• For people with reduced consciousness or communication difficulties, ask family members or carers about recent changes in symptoms.

When to Suspect Bacterial Meningitis

• Strongly suspect in people with all the symptoms in the red flag combination: fever, headache, neck stiffness, and altered level of consciousness or cognition (including confusion or delirium).
• Bacterial meningitis can still be strongly suspected based on clinical assessment, even in people who do not have all the symptoms in the red flag combination.
• Suspect bacterial meningitis based on assessment of the symptoms and signs in table 1 (for babies, children and young people) or table 2 (for adults), and the section on risk factors.
• Bacterial meningitis can present with any of these symptoms and signs.
• The more symptoms and signs a person has, the more likely it is that they have bacterial meningitis.
• If you suspect or strongly suspect bacterial meningitis, transfer the person to hospital as an emergency.

Symptoms and Signs in Babies, Children and Young People

• Red flag combination: Fever, headache, neck stiffness, and altered level of consciousness or cognition (including confusion or delirium).
  • Fever and neck stiffness are less common in babies.
  • Headache and neck stiffness are harder to identify in babies and young children.
• Appearance- Bulging fontanelle: In babies and young children with an open fontanelle.
• Fever:
  • Fever, headache, neck stiffness and altered level of consciousness or cognition are the red flag combination for bacterial meningitis.
  • Fever is less common in babies.
  • Ask the child or young person (or their family members or carers) if they have taken antipyretics, because this may make fever harder to identify.
  • For other possible causes of fever in under 5s, see table 3 in the NICE guideline on fever in under 5s.
  • For children under 6 months, see recommendation 1.2.11 in the NICE guideline on fever in under 5s.
• III appearance: Ask the child or young person (or their family members or carers) if they have taken antipyretics, because this may make ill appearance harder to identify.
• Non-blanching petechial or purpuric rash: Mainly in meningococcal disease (with or without meningococcal meningitis).
  • Check all over the body and look for petechiae in the conjunctivae.
  • May be difficult to see on brown, black or tanned skin.
• Pale, mottled skin or cyanosis: May be difficult to see on brown, black or tanned skin.
• Irritability: Common in babies and young children.
• Lethargy: Common in babies and young children.
• Reduced feeding: In babies.
• Unusual behaviour: For example, the person may be agitated, aggressive or subdued.
  • Ask family members or carers about changes in the child or young person's behaviour.
  • For more guidance on identifying changes in babies, children and young people who do not communicateverbally, see recommendation 1.2.14 in the NICE guidelineon babies, children and young people's experience ofcare.
• Weak, high-pitched or continuous cry: In babies.
• Early signs of sepsis
• Signs of shock: See table 3 on symptoms and signs that may indicatemeningococcal disease.
• For more guidance on assessing for sepsis, see thesections on evaluating risk in the NICE guideline onsuspected sepsis.
• Altered level ofconsciousness or alteredcognition (includingconfusion or delirium) :Fever, headache, neck stiffness and altered level ofconsciousness or cognition are the red flag combinationfor bacterial meningitis.
• Focal neurological deficits
• Headache: Fever, headache, neck stiffness and altered level ofconsciousness or cognition are the red flag combinationfor bacterial meningitis. Babies and children and young people with cognitiveimpairment or communication difficulties may not be ableto report headache.
• Neck stiffness, includingmore subtle discomfort orreluctance to move the neck: Fever, headache, neck stiffness and altered level of consciousness or cognition are the red flag combinationfor bacterial meningitis.
  • Neck stiffness is less likely and harder to identify in babies.
  • Neck stiffness is harder to identify in children and youngpeople with cognitive impairment or communicationdifficulties.
• Photophobia: Harder to identify in babies.
• Tachypnoea, apnoea, andgrunting: Non-specific signs of illness, including sepsis and meningitis in babies.
• Unexplained body pain ,including limb, back orabdominal pain

Symptoms and Signs in Adults

• Red flag combination: Notes. Fever, headache, neck stiffness, and altered level of consciousness or cognition(including confusion or delirium)
• Fever: Fever is less common in older adults.
• III appearance Ask the person (or their family members or carers) ifthey have taken antipyretics, because this may make ill appearance harder to identify.
• Non-blanching petechial ormainly in meningococcal meningitis andpurpuric rashmeningococcal disease (with or withoutmeningococcal meningitis). See table 3 on symptomsand signs that may indicate meningococcal disease.
• Check all over the body and look for petechiae in theconjunctivae.
• Pale, mottled skin or cyanosisMay be difficult to see on brown, black or tanned skin.
• Irritability
• LethargyCommon in older adults.
• Unusual behaviour For example, the person may be agitated, aggressiveor subdued. Bacterial meningitis may be missed in older adultswith delirium or altered consciousness. In young people and young adults, altered behaviourafterwards may be incorrectly assumed to be caused by alcoholsubstance misuse, and bacterial meningitis can bemissed as a result.
• Altered level of consciousness F fever, headache, neck stiffness and altered level of or altered cognition (including | consciousness or cognition are the red flagconfusion or delirium) combination for bacterial meningitis. Bacterial meningitis may be missed in older adultswith delirium or altered consciousness. In young people and young adults, altered level ofconsciousness (cognitive) may be incorrectly assumed to becaused by alcohol or substance misuse, and bacterialmeningitis can be missed as a result.
• Focal neurological deficits
• Headache Fever, headache, neck stiffness and altered level of consciousness, cognition are the red flag combination for the bacterial meningitis.
• Adults with cognitive impairment or communicationdifficulties may not be able to report a headache.
• Neck stiffness, including more Fever, headache, neck stiffness and altered level ofsubtle discomfort or reluctanc consciousness, cognition are the red flag combination to move the neckfor bacterial meningitis. Neck stiffness is less likely and harder to identify involde rolders. Neck stiffness is harder-to-identify ind-identify adis with cognitive impairment, communication difficulties,dementia, arthritis.
• Photophobia

Risk Factors for Bacterial Meningitis

• Missed relevant immunizations, such as meningococcal, Haemophilus influenzae type b (Hib) or pneumococcal vaccines.
• Reduced or absent spleen function.
• Congenital complement deficiency or acquired inhibition.
• Student in further or higher education, particularly if they are in large shared accommodation (such as halls of residence).
• Family history of meningococcal disease.
• Contact with someone with Hib disease or meningococcal disease.
• Living in an area with an outbreak of meningococcal disease.
• Previous episode of bacterial meningitis or meningococcal disease.
• Cerebrospinal fluid leak.
• Cochlear implant.

When To Suspect Meningococcal Disease

• Strongly suspect meningococcal disease in people with any of these red flag symptoms: haemorrhagic, non-blanching rash with lesions larger than 2 mm (purpura).
• Rapidly progressive and/or spreading non-blanching petechial or purpuric rash and any symptoms and signs of bacterial meningitis (see tables 1 and 2), when combined with a non-blanching petechial or purpuric rash.
• Do not rule out meningococcal disease just because a person does not have a rash.
• Suspect meningococcal disease based on assessment of the symptoms and signs in table 3, and the section on risk factors.
• Meningococcal disease can present with any combination of the non-specific symptoms and signs of severe illness in table 3.

When Looking For A Rash

• Check all over the body (including nappy areas), and check for petechiae in the conjunctivae.
• Note that rashes can be hard to detect on brown, black or tanned skin (look for petechiae in the conjunctiva).
• Tell the person and their family members or carers to look out for any changes in the rash, because it can change from blanching to non-blanching.
• If you suspect or strongly suspect meningococcal disease, transfer the person to hospital as an emergency.

Transfer To Hospital and Antibiotics

• Transfer people with suspected bacterial meningitis or meningococcal disease to hospital as an emergency.
• Tell the hospital that a person with suspected bacterial meningitis or meningococcal disease is being transferred and need assessment by a "senior clinical decision maker".
• Do not delay transfer to hospital to give antibiotics to people with suspected or strongly suspected bacterial meningitis or meningococcal disease.
• If there is likely to be a clinically significant delay in transfer to hospital for people with strongly suspected bacterial meningitis, give intravenous or intramuscular ceftriaxone or benzylpenicillin outside of hospital.
• For people with strongly suspected meningococcal disease, give intravenous or intramuscular ceftriaxone or benzylpenicillin as soon as possible outside of hospital, unless this will delay transfer to hospital.
• Do not give antibiotics outside of hospital if the person has "severe antibiotic allergy" to either ceftriaxone or benzylpenicillin.

Information and Support for Suspected Cases

• Discuss the reasons for their suspected diagnosis, and any uncertainty about this.
• Discuss When they can expect to know more.
• The need for investigations (including lumbar puncture for bacterial meningitis)
• The timing of investigations and antibiotics.
• Provide emotional and pastoral support for people and their family members and carers during hospitalisation.
• If unlikely to have bacterial meningitis or meningococcal disease but were sent home from hospital with an unconfirmed diagnosis, explain specific symptoms and signs for which to look out and what changes should prompt return to hospital.

Investigating Suspected Bacterial Meningitis in Hospital

• Timing of investigations and antibiotics: A senior clinical decision maker should perform an initial assessment and ensure that:
  • Antibiotics start within 1 hour of the person with suspected bacterial meningitis arriving at hospital.
  • Blood tests and lumbar puncture are performed before starting antibiotics (if it is safe to do so and will not cause a clinically significant delay to starting antibiotics). – Confirm a diagnosis of the bacterial meningitis based on a "clinical features", "blood test results",and "lumbar puncture results". –For people with suspected bacterial meningitis, perform bacterialthroat swab for meningococcal culture before starting antibiotics.
• Blood Tests:
  • Blood culture
  • White blood cell count (including neutrophils)
  • Blood C-reactive protein (CRP), or procalcitonin (PCT) if CRP is not available
  • Blood glucose
  • Whole-blood diagnostic polymerase chain reaction (PCR), including meningococcal and pneumococcal
  • HIV test
• Do not rule out bacterial meningitis based only on a normal CRP, PCT, or whiteblood cell count.
• For guidance on blood tests for sepsis, see NICE guideline on suspected sepsis.
• Do not routinely perform neuroimaging before lumbar puncture.
• Perform imaging if the person has risk factors for an evolving space-occupyinglesion or has symptoms or signs that might indicate raised intracranial pressure: new focal neurological features, abnormal pupillary reactions or a Glasgow Coma Scale (GCS) score of 9 or less.
• Do not perform a lumbar puncture until these factors have been resolved.
• Perform a lumbar puncture before starting antibiotics.
• If the person has started on antibiotics before having a lumbar puncture, perform a lumbar puncture as soon as possible (if it is safe to perform).
• Unprotected airway
• Respiratory compromise
• Shock
• Uncontrolled seizures
• Bleeding risk
• Do not perform lumbar puncture if there is extensive or rapidly spreading purpura / infection at the lumbar puncture site.
• Measure blood glucose in people immediately before lumbar puncture, so that the cerebrospinal fluid to blood glucose ratio can be calculated..
• Perform the following Cerebrospinal fluid investigations: Red and white cell count and cell type (including differential white cell count), Total protein, Glucose concentration (to calculate cerebrospinal fluid to blood glucose ratio), Microscopy for bacteria, Microbiological culture and sensitivities and PCR. Ensure that cerebrospinal fluid, cell counts, total protein and glucoseconcentrations are available within 4 hours of lumbar puncture.

Antibiotics for Bacterial Meningitis

When using ceftriaxone, follow MHRA safety advice - ceftriaxone is incompatible with solutions containing calcium.

• Take blood samples before giving antibiotics. If it is safe to do so and will causesignificant delay, perform a lumbar a lumbar puncture before starting antibiotics.
• If suspected bacterial meningitis, give IV antibiotics as soon as is suspected within 1 hour of the point of arrival in hospital.
• Get infection specialist advice for all cases of bacterial meningitis. This is particularly important for; -those who have recently travelled outside the UK and be at risk of antimicrobial resistance.
  • Those who are colonised by cephalosporin-resistant.
• See recommendations on antibiotic allergy for each alternative causative organism based on recommendations.
• Give ceftriaxone (use the highest doses recommended by the BNF or BNFCor local antimicrobial guidance) for suspected bacterial meningitis.
• If ceftriaxone, is contraindicated, consider cefotaxime.

Corticosteroids for Bacterial Meningitis and Meningococcal Disease

• For bacterial meningitis in people over 3 months with strongly suspected or confirmed bacterial meningitis, give IV dexamethasone
• For babies between 28 days and 3 months old with suspected or confirmed bacterial meningitis, get infection specialist advice on using dexamethasone.
• When they are found:
  • Continue dexamethasone if it is pneumococcus or Haemophilus influenzae typeb
  • Stop dexamethasone for all other organisms.
• For people receiving dexamethasone: Give the first dose with or before the first dose of antibiotics/do not delay antibiotics for being started - if dexamethasone is delayed for less than 12 hours after the start of antibiotics, give dexamethasone as soon as possible/if dexamethasone is delayed for more than 12 hours after the start of antibiotics, get advise whether it is beneficial.
• Fluid Restriction
  • Do not Routinely restrict fluid unless less than maintenance needs. Give maintenance fluids by mouth , if possible, or through the enteral tube.
• Osmotic Agents; don't use glycerol. Seek a specialist if there are features of raised intracranial pressure or hydrocephalus.
• Monitoring Intracranial Pressure; do not routinely use and seek specialist advice if features of above signs are present.

Immunodeficiency

• HIV testing; perform this on adults with bacterial meningitis or meningococcal disease. On children/babies if they have signs of it or at risk of HIV.
• If pneumococcal meningitis is present, refer the child for immunology
• All with above, take a Hx of ,Head Trauma, Surgery and immunization records.

For HIV

• Have people with a higher risk of pneumococcal illnesses along side of testing. Have people a sign of pneumococcal for testing then have a specialist review with children for pneumococcal test and infection control.

Meningitis Information & Support for Diagnosis.

• In the confirmed case of meningitis with disease discuss the following; what might happen / what is the diagnosis , pass infection & effect of sedative. - Repeat the info - if required as some may be restless - and provide info like NHS services for child + Adults. Give emotional support and pastoral care on the situation. Psychological intervention might be required at all times.

Care after Hospital discharge (for what's been covered before)

• Identify all those who had what been discussed and take cognition (development/Skin and Hearing). refer all to follow up from the services as needed but it may not needed until hospital discharge . All those under 12 months; review with paediatrician after their hospital discharge and assess for their developmental outcomes (orthopaedic sensory , psycho & other) -All those; family , health and visitors with health professionals need to monitor the Heath (all) All support on the new transition for schools and nurseries as needed , in their new community. Refer all services to review (2 years) for discharged patients. Assess any needs with adaption needed, and review for their phased return of education with return support ( all).

Current bacterial Meningitis/ Recurrent Meningococcal Disease

• Risk factor to the body.Review Immunize Hx, check for surgical Hx (cSF is at a high risk and must have Hx. Tests can be put in place then treat re occurrence - babies must do a scalp/spine back to check for sinus infection Investigate and get the HIV, specialist, etc.

Definitions of All Kinds of Groups (Ages) For Reference.

• Adult is 18 and above.
• Babies is 29 days to 1 year
• Child is 1-11.
• Young People is 12 -19
• Teen is 18-29
• Clinical descion makers or senior; paediactric /emergency. or equivalent with competencies for people under 18 allergy : Hx and antibiotics ( nature) but it’s not strongly suspected 4 key clinical flags or descions