Clinical Practice Guidelines

Acute meningococcal disease


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  •  See also

    Important notes

    • IV antibiotics should be given as soon as meningococcal disease is suspected (if IV access cannot be obtained within 15 minutes, IM or IO administration is warranted)
    • If possible collect blood cultures prior to antibiotic administration
    • Ceftriaxone IV/IM or Cefotaxime IV is the first choice antibiotic.  If unavailable, use penicillin IV/IM.
    • Other investigations should not delay antibiotic therapy.

    Background to condition

    Common presentations
    • Meningitis (see also meningitis guideline).
    • Meningococcaemia (classically fever + purpura but can be non-specific)

    Meningitis and meningococcaemia commonly occur together.

    purpura Meningocaccal rash pic 2 Meningococcal rash pic 3 Menigococcal rash pic4
    Meningococcal rash pic5 Meningococcal rash pic 7 Meningococcal rash pic8
    Examples of rash. Click here to see full size

    Less common presentations

    • Arthritis
    • Pneumonia
    • Pharyngitis
    • Occult bacteraemia

    How to assess 

    History and Examination

    • Rapid onset of symptoms
    • Typically fever, malaise, lethargy, vomiting, headache, myalgia, arthralgia, reduced conscious state
    • May present shocked
    • Findings suggestive of meningococcal infection include:
      • Confusion
      • Leg pain
      • Photophobia (occurs > 12 hours)
      • Rash (occurs > 12 hours)
      • Neck pain/ stiffness (occurs >12 hours)
    • Petechiae or purpura are present in most, but not all, patients but occur late (12-36 hours). A blanching rash does not exclude meningococcus.
    • Preceding viral infection does not exclude meningococcus

     Any child with meningococcal disease, including one who appears non-toxic, may deteriorate rapidly.

    Investigations

    If possible blood culture should be obtained prior to, or very soon after, commencing antibiotics.

    The other investigations should be obtained within the following hour if possible.  These include:

    •  Meningococcal PCR (2-5ml in EDTA tube) if blood cultures have been obtained post-antibiotics (including prior oral antibiotics)
    • Full blood count and differential
    • Glucose, urea and electrolytes
    • Coagulation screen if appropriate

    Lumbar puncture would not be recommended in the initial management of an unwell child with fever and purpura. Lumbar puncture may be appropriate in suspected meningitis when no other contraindications exist

    Acute management

    Antibiotics

    Gain intravenous access (or intraosseous access if IV not possible within 15 minutes).

    Take blood (or marrow) for culture if possible and immediately administer Ceftriaxone (50mg/kg) or Cefotaxime (50mg/kg). See drug doses

    Alternatively penicillin can be used if Ceftriaxone and Cefotaxime not available.

    Fluids

    If shocked, give 20ml/kg normal saline.   See Severe sepsis guideline

    For meningitis alone, careful fluid management is important as many children have increased ADH secretion. See meningitis guideline.

    Steroids

    Consider dexamethasone (0.15mg/kg IV) if undifferentiated meningitis.  This should be administered within an hour of first antibiotics but should not delay antibiotics or fluids. 

    Ward management

    Isolate cases (if possible) until they have had >12 hours antibiotic treatment.

    Notification

    All cases of presumed or confirmed Neisseria meningitidis disease should be urgently notified to the Department of Human Services by telephone on 1300 651160 (fax 1300 651170) (after hours pager 03 9625 5000, pager number 46870). 

    Contact chemoprophylaxis

    It is important that prophylaxis be given within 24 hours to contacts.

    • All household, daycare or intimate contacts who have been exposed to index case within 7 days of onset.
    • Any person who gave mouth-to-mouth resuscitation to the index case.
    • The index case should also receive prophylaxis if penicillin only was used
    • RCH usually provides prescription for immediate family members and DHS supplies other contacts.
    • Prophylaxis is provided free from the hospital pharmacy and families should contact DHS if they have any problems obtaining free supplies outside RCH
    • DHS contact:  Infectious Disease Unit: Nurse 03 9637 4124, Medical Officer 03 9637 4127
    • Infants and children>1 month of age,
      Rifampicin 10 mg/kg po 12 hourly (max 600 mg) for 2 days
    • Adults
      Rifampicin   600 mg 12 hourly for 2 days
    • Infants < 1 month of age
      Rifampicin 5 mg/kg po 12 hourly for 2 days
    • Pregnancy / contraindication to Rifampicin
      Ceftriaxone 125 mg (<12 y) / 250 mg (/>12 y) intramuscularly as a single dose

    Rifampicin causes orange-red discolouration of tears, urine and contact lenses, and may also cause skin rashes and itching, and gastrointestinal disturbance. It negates the effect of the oral contraceptive pill and should not be used in pregnancy, breastfeeding women, or severe liver or renal disease.

    Out of hours: If medication is required after hours, a limited supply of Rifampicin pre-packaged 300 mg capsules and 20 mg/ml suspension is available in the PICU / Rosella medication room (cupboard below bench). The prescriber should complete details on the pack label, and a prescription should be left for collection by pharmacy.

    Parent Information Sheet (Print version - PDF)

    Parent Information Sheet (HTML version)

    Information Specific to RCH - Including who to consult for inpatients.

    All patients should be admitted under General Medicine. 

    Additional notes

    • Small vessel thrombosis / tissue loss - involve Plastic Surgery early. Analgesia is important for skin necrosis or peripheral gangrene.   Opiate infusions may be needed.
    • Reactive arthritis or pericarditis may occur in a few patients between days 3 to 7.
    • Fever persisting for more than 7 days -this is common and may be due to: tissue damage (if there is extensive vasculitis), nosocomial infection, subdural effusion (in the case of meningitis), other foci of suppuration, or reactive complications. Uncommon causes include inadequately treated meningitis, a parameningeal focus or drugs.eet (HTML version)