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Suspected Meningitis

Dr Rajesh Varma

How should I manage suspected bacterial meningitis with a non-blanching rash or meningococcal septicaemia?

  1. Admit the person to hospital as an emergency by telephoning 999.

  2. Administer a single dose of parenteral benzylpenicillin (in primary/secondary care) at the earliest opportunity, but this should not delay urgent transfer to hospital.

  3. Ideally, benzylpenicillin should be given intravenously, or intramuscularly if a vein is not available.

  4. If given intramuscularly, it should be given as proximally as possible — preferably into a part of the limb that is still warm (as cold areas will be less well perfused).

  5. Benzylpenicillin should be withheld only in people who have a clear history of anaphylaxis after a previous dose
    A history of a rash following penicillin is not a contraindication.

Dosage:

Age <1y 300 mg.

Age 1–9y 600 mg.

Age >10y 1200 mg.

  • Benzylpenicillin should be carried in GP emergency bags, and checked regularly to ensure that it is within its expiry date.

  • Paramedics also have the mandate to give benzylpenicillin for suspected meningococcal disease.

How should I manage suspected bacterial meningitis without a non-blanching rash?

  1. Admit the person to hospital as an emergency by telephoning 999.

  2. Do not give parenteral antibiotic treatment unless urgent transfer to hospital is not possible (for example in remote locations or owing to adverse weather conditions).
    If this is the case, parenteral antibiotics should be administered in primary care.

  3. The priority is to transfer to hospital.

  4. Choice of empiric antibiotic will depend on availability or local policy. Options include benzylpenicillin, cefotaxime, or chloramphenicol.

  5. Cefotaxime may be an alternative in penicillin allergy; chloramphenicol may be used if history of immediate hypersensitivity reaction to penicillin or to cephalosporins.

Managing close contacts

Bacterial meningitis and meningococcal disease are notifiable diseases in England and Wales.

Prophylaxis against meningococcal disease should be considered for the following close contacts, regardless of meningococcal vaccination status:

  • People who have had prolonged close contact with the case in a household-type setting during the 7 days before onset of illness (for example, people who are living or sleeping in the same household, pupils in the same dormitory, boy/girlfriends, or university students sharing a kitchen in a hall of residence).

  • People who have had transient close contact with a case only if they have been directly exposed to large particle droplets/secretions from the respiratory tract of a case around the time of admission to hospital

The management of close contacts (involving prophylactic measures) should be undertaken in conjunction with the local or regional health protection unit.

Causes of meningitis

Bacterial meningitis is a condition caused by inflammation of the meninges as a result of bacterial infection.

children aged 3 months or older and adults
Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae type b (Hib)

In neonates (younger than one month of age)
Streptococcus agalactiae
Escherichia coli
S. pneumoniae
Listeria monocytogenes

Transmission

Transmission occurs through close contact, droplets, or direct contact with respiratory secretions.
The annual incidence of acute bacterial meningitis in developed countries is estimated to be 2–5 per 100,000 population.

Complications

Death

30–50% of survivors experiencing permanent neurological sequelae

  • Hearing loss (33.6%)

  • Seizures (12.6%)

  • Motor deficit (11.6%)

  • Cognitive impairment (9.1%)

  • Hydrocephalus (7.1%)

  • Visual disturbance (6.3%)

Diagnosis

Common

  • Fever.

  • Vomiting/nausea.

  • Lethargy.

  • Irritability/unsettled behaviour.

  • Ill appearance.

  • Refusing food/drink.

  • Headache.

  • Muscle ache/joint pain.

  • Respiratory symptoms/signs or breathing difficulty.

Less common

  • Chills/shivering.

  • Diarrhoea, abdominal pain/distension.

  • Sore throat/coryza or other ear, nose, and throat symptoms/signs.

Specific

  • Non-blanching rash.

  • Stiff neck.

  • Capillary refill time of more than 2 seconds, cold hands and feet.

  • Unusual skin colour.

  • Shock and hypotension.

  • Leg pain.

  • Back rigidity.

  • Bulging fontanelle.

  • Photophobia.

  • Kernig's sign (person unable to fully extend at the knee when hip is flexed).

  • Brudzinski's sign (person’s knees and hips flex when neck is flexed).

  • Unconsciousness or toxic/moribund state.

  • Paresis.

  • Seizures.

  • Focal neurological deficit including cranial nerve involvement and abnormal pupils.