NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.

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1 Diagnosis of bacterial meningitis and meningococcal septicaemia in secondary bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: Pathway last updated: 20 January 2017 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved

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3 1 Child under 16 with suspected bacterial meningitis or meningococcal septicaemia No additional information 2 Specific investigations and immediate treatment when petechial rash is present Perform a very ful examination for signs of meningitis or septicaemia in children and young people presenting with petechial rashes (see Table 1 Symptoms and signs of bacterial meningitis and meningococcal septicaemia [See page 9]). When to give intravenous ceftriaxone Give intravenous ceftriaxone immediately to children and young people with a petechial rash if any of the following occur at any point during the assessment (these children are at high risk of having meningococcal disease): 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 to a health professional. See management in secondary in this interactive flowchart. Child with rash and fever If a child or young person has an unexplained petechial rash and fever (or history of fever) carry out the following investigations: full blood count CRP coagulation screen blood culture whole-blood PCR for N meningitidis blood glucose Page 3 of 15

4 blood gas. Child with rash and fever but no high-risk clinical manifestations In a child or young person with an unexplained petechial rash and fever (or history of fever) but none of the high-risk clinical manifestations: Treat with intravenous ceftriaxone immediately if the CRP and/or WBC count (especially neutrophil count) is raised, as this indicates an increased risk of having meningococcal disease. Be aware that while a normal CRP and normal WBC count mean meningococcal disease is less likely, they do not rule it out. The CRP may be normal and the WBC normal or low even in severe meningococcal disease. Assess clinical progress by monitoring vital signs (respiratory rate, heart rate, blood pressure, conscious level (Glasgow Coma Scale and/or APVU), temperature), capillary refill time, and oxygen saturations. Carry out observations at least hourly over the next 4 6 hours. If doubt remains, treat with antibiotics and admit to hospital. If the child or young person is assessed as being at low risk of meningococcal disease and is discharged after initial observation, advise parents or rs to return to hospital if the child or young person appears ill to them. Child with non-spreading rash without fever who does not appear ill Be aware that in children and young people who present with a non-spreading petechial rash without fever (or history of fever) who do not appear ill to a health professional, meningococcal disease is unlikely, especially if the rash has been present for more than 24 hours. In such cases consider: other possible diagnoses performing a full blood count and coagulation screen. Quality standards The following quality statement is relevant to this part of the interactive flowchart. 3. Management of petechial rash Page 4 of 15

5 3 Blood tests for bacterial meningitis and meningococcal disease C-reactive protein test and white blood cell count for suspected bacterial meningitis In children and young people with suspected bacterial meningitis, perform a CRP and WBC count: If the CRP and/or white blood cell count is raised and there is a non-specifically abnormal CSF (for example consistent with viral meningitis), treat as bacterial meningitis. Be aware that a normal CRP and WBC count does not rule out bacterial meningitis. Regardless of the CRP and WBC count, if no CSF is available for examination or if the CSF findings are uninterpretable, manage as if the diagnosis of meningitis is confirmed. Polymerase chain reaction test for bacterial meningitis and meningococcal disease Perform whole blood real-time PCR testing (EDTA sample) for N meningitidis to confirm a diagnosis of meningococcal disease. The PCR blood sample should be taken as soon as possible because early samples are more likely to be positive. Use PCR testing of blood samples from other hospital laboratories if available, to avoid repeating the test. Be aware that a negative blood PCR test result for N meningitidis does not rule out meningococcal disease. Submit CSF to the laboratory to hold for PCR testing for N meningitidis and S pneumoniae, but only perform the PCR testing if the CSF culture is negative. Be aware that CSF samples taken up to 96 hours after admission to hospital may give useful results. Quality standards The following quality statement is relevant to this part of the interactive flowchart. 7. Blood tests Page 5 of 15

6 4 Cranial CT examination for suspected bacterial meningitis Use clinical assessment and not cranial CT, to decide whether it is safe to perform a lumbar puncture. CT is unreliable for identifying raised intracranial pressure. If a CT scan has been performed, do not perform a lumbar puncture if the CT scan shows radiological evidence of raised intracranial pressure. In children and young people with a reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more) or with focal neurological signs, perform a CT scan to detect alternative intracranial pathology. Do not delay treatment to undertake a CT scan. Clinically stabilise children and young people before CT scanning. If performing a CT scan consult an anaesthetist, paediatrician or intensivist. 5 Lumbar puncture and CSF examination for suspected bacterial meningitis Perform a lumbar puncture as a primary investigation unless this is contraindicated. Do not allow lumbar puncture to delay the administration of parenteral antibiotics. CSF examination should include WBC count and examination, total protein and glucose concentrations, Gram stain and microbiological culture. A corresponding laboratory-determined blood glucose concentration should be measured. 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 (see Table 2 Signs of shock [See page 12]) extensive or spreading purpura after convulsions until stabilised coagulation abnormalities Page 6 of 15

7 local superficial infection at the lumbar puncture site respiratory insufficiency (lumbar puncture is considered to have a high risk of precipitating respiratory failure in the presence of respiratory insufficiency). In children and young people with suspected bacterial meningitis, if contraindications to lumbar puncture exist at presentation consider delaying lumbar puncture until there are no longer contraindications. Delayed lumbar puncture is especially worthwhile if there is diagnostic uncertainty or unsatisfactory clinical progress. CSF WBC counts, total protein and glucose concentrations should be made available within 4 hours to support the decision regarding adjunctive steroid therapy. Start antibiotic treatment for bacterial meningitis if the CSF WBC count is abnormal: in neonates at least 20 cells/microlitre (be aware that even if fewer than 20 cells/microlitre, bacterial meningitis should still be considered if other symptoms and signs are present (see Table 1 Symptoms and signs of bacterial meningitis and meningococcal septicaemia [See page 9] in this interactive flowchart) in older children and young people more than 5 cells/microlitre or more than 1 neutrophil/ microlitre, regardless of other CSF variables. See treatment with antibiotics in this interactive flowchart. In children and young people with suspected bacterial meningitis, consider alternative diagnoses if the child or young person is significantly ill and has CSF variables within the accepted normal ranges. Consider herpes simplex encephalitis as an alternative diagnosis. If CSF white cell count is increased and there is a history suggesting a risk of tuberculous meningitis, evaluate for the diagnosis of tuberculous meningitis in line with assessing for active tuberculosis in the NICE interactive flowchart on tuberculosis. Perform a repeat lumbar puncture in neonates with: persistent or re-emergent fever deterioration in clinical condition new clinical findings (especially neurological findings) or persistently abnormal inflammatory markers. Page 7 of 15

8 Do not perform a repeat lumbar puncture in neonates: who are receiving the antibiotic treatment appropriate to the causative organism and are making a good clinical recovery before stopping antibiotic therapy if they are clinically well. Quality standards The following quality statement is relevant to this part of the interactive flowchart. 5. Lumbar puncture for suspected bacterial meningitis 6. CSF microscopy for suspected bacterial meningitis 6 Skin samples Do not use any of the following techniques when investigating for possible meningococcal disease: skin scrapings, skin biopsies, petechial or purpuric lesion aspirates (obtained with a needle and syringe). 7 Management in secondary See Bacterial meningitis and meningococcal septicaemia / Management of bacterial meningitis and meningococcal septicaemia in secondary 8 Non-meningococcal septicaemia See what NICE says on sepsis. Page 8 of 15

9 Table 1 Symptoms and signs of bacterial meningitis and meningococcal septicaemia Common non-specific symptoms / signs (not always present, especially in neonates) Symptom / sign Bacterial meningitis (meningococcal meningitis and meningitis caused by other bacteria) Meningococcal disease (meningococcal meningitis and/or meningococcal septicaemia) Meningococcal septicaemia Fever Y Y Y Vomiting / nausea Y Y Y Lethargy Y Y Y Irritable / unsettled Y Y Y Ill appearance Y Y Y Refusing food / drink Y Y Y Headache Y Y Y Muscle ache / joint pain Y Y Y Respiratory symptoms / signs or breathing difficulty Y Y Y Page 9 of 15

10 Less common non-specific symptoms / signs Symptom / sign Bacterial meningitis (meningococcal meningitis and meningitis caused by other bacteria) Meningococcal disease (meningococcal meningitis and/or meningococcal septicaemia) Meningococcal septicaemia Chills / shivering Y Y Y Diarrhoea, abdominal pain / distension Y Y Not known Sore throat / coryza or other ear, nose and throat symptoms / signs Y Y Not known More specific symptoms / signs Symptom / sign Bacterial meningitis (meningococcal meningitis and meningitis caused by other bacteria) Meningococcal disease (meningococcal meningitis and/or meningococcal septicaemia) Meningococcal septicaemia Non-blanching rash a Y Y Y Stiff neck Y Y Not known Page 10 of 15

11 Altered mental state b Y Y Y Capillary refill time more than 2 seconds Not known Y Y Unusual skin colour Not known Y Y Shock Y Y Y Hypotension Not known Y Y Leg pain Not known Y Y Cold hands / feet Not known Y Y Back rigidity Y Y Not known Bulging fontanelle c Y Y Not known Photophobia Y Y N Kernig's sign Y Y N Brudzinski's sign Y Y N Unconsciousness Y Y Y Toxic / moribund state Y Y Y Page 11 of 15

12 Paresis Y Y N Focal neurological deficit including cranial nerve involvement and abnormal pupils Y Y N Seizures Y Y N Y: symptom or sign present; N: symptom or sign not present; Not known: not reported in the evidence. a Be aware that a rash may be less visible in darker skin tones check soles of feet, palms or hands and conjunctivae; b Includes confusion, delirium and drowsiness, and impaired consciousness; c Only relevant in children under 2 years. Table 2 Signs of shock Signs of shock include: capillary refill time more than 2 seconds unusual skin colour tachycardia and/or hypotension respiratory symptoms or breathing difficulty leg pain cold hands/feet Page 12 of 15

13 toxic/moribund state altered mental state/decreased conscious level poor urine output Glossary APVU Alert, voice, pain, unresponsive. CRP C-reactive protein CSF Cerebrospinal fluid CT Computed tomography EDTA ethylenediaminetetraacetic acid H influenzae Haemophilus influenzae L monocytogenes Listeria monocytogenes N. meningitidis Neisseria meningitidis Page 13 of 15

14 PCR polymerase chain reaction SPC summary of product characteristics _S pneumoniae Streptococcus pneumoniae WBC white blood cell Sources Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management (2010 updated 2015) NICE guideline CG102 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after ful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Page 14 of 15

15 Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT Page 15 of 15