meningitis management passmed Flashcards
How should suspected bacterial meningitis be managed in pre-hospital settings?
If meningococcal disease is suspected, intramuscular benzylpenicillin may be administered in a pre-hospital setting (e.g., a GP surgery), provided it does not delay hospital transfer.
Describe the initial approach for managing suspected bacterial meningitis in the hospital.
Initial hospital management involves an ABC approach (Airway, Breathing, Circulation), disability assessment (GCS, focal neurological signs, seizures, papilloedema), and urgent senior review if warning signs present.
When and why should a lumbar puncture be delayed in suspected bacterial meningitis?
Lumbar puncture should be delayed in the presence of severe sepsis, evolving rash, severe respiratory/cardiac compromise, significant bleeding risk, signs of raised intracranial pressure, focal neurological signs, continuous seizures, or GCS ≤ 12.
What are the management steps for patients with suspected bacterial meningitis without indications for delayed LP?
For patients without delayed LP indications: ensure IV access, take bloods and cultures, perform lumbar puncture if possible within the first hour, administer IV antibiotics (cefotaxime or ceftriaxone, add amoxicillin if >50 years old), give IV dexamethasone.
What are the management steps for patients with signs of raised intracranial pressure?
Manage with critical care input, secure airway, provide high-flow oxygen, ensure IV access, take bloods and cultures, administer IV dexamethasone, and antibiotics as earlier, arrange neuroimaging.
What are the management steps for patients with signs of severe sepsis or a rapidly evolving rash?
Manage with critical care input, secure airway, provide high-flow oxygen, ensure IV access, conduct blood cultures, administer IV fluid resuscitation, and give IV antibiotics as earlier.
What investigations are recommended in suspected bacterial meningitis?
Recommended investigations include full blood count, renal function, glucose, lactate, clotting profile, CRP, CSF analysis if LP done, and additional tests like blood gases and throat swabs for culture.
What are the BNF antibiotic guidelines for different scenarios in managing bacterial meningitis?
BNF recommends IV cefotaxime (or ceftriaxone) for most patients, with additions based on age and specific pathogens (e.g., amoxicillin for those over 50, gentamicin for Listeria). Alternative antibiotics for those allergic to penicillin or cephalosporins include chloramphenicol.
How should contacts of a patient with confirmed bacterial meningitis be managed?
Prophylaxis with oral ciprofloxacin or rifampicin is recommended for close contacts within 7 days before onset of symptoms. Meningococcal vaccination should be offered based on serotype results. Prophylaxis for pneumococcal meningitis may be needed in cluster cases.
A 5-year-old child presents to their GP with a rash. She became unwell with a fever yesterday and developed a rash on her feet which has quickly spread and now covers both legs.
On examination, she appears drowsy and unwell. There is a purple, non-blanching rash covering both of her legs and spots are now appearing on her back and abdomen. She is febrile at 39ºC and tachycardic.
She previously developed a mild itchy rash after penicillin which settled without treatment.
The GP arranges immediate paediatric admission.
What is the most appropriate management while awaiting ambulance transfer?
IM benzylpenicillin
IM gentamicin
IV chloramphenicol
IV vancomycin
Oral ceftriaxone
IM benzylpenicillin
A history of rash with penicillin is not a contraindication to using benzylpenicillin or ceftriaxone in meningococcal sepsis. For penicillin anaphylaxis NICE recommends urgent transfer to hospital and IV chloramphenicol
Important for meLess important
This is a classic history of meningococcal disease, this child is very sick and needs immediate transfer to hospital.
NICE guidelines recommend one dose of IM benzylpenicillin to be given in primary care for suspected meningococcal disease, as long as this will not delay transfer. A history of rash with penicillin is not a contraindication to using IM benzylpenicillin in this case. IM access is preferable to IV access in children in primary care as it can be done more quickly and easily than attempting to site a cannula in a young child which could delay hospital transfer.
IM gentamicin is incorrect. IM gentamicin is not a recommended treatment for suspected meningococcal disease in primary care.
IV chloramphenicol can be used instead of benzylpenicillin or ceftriaxone in cases of suspected meningococcal disease where there is previous anaphylaxis to penicillin. However, in this case, the child had an itchy rash but no anaphylaxis, therefore IM benzylpenicillin is the appropriate first-line choice.
IV vancomycin is incorrect. IV vancomycin may be added as an additional antibiotic treatment in cases of suspected meningococcal disease where there has been recent foreign travel, however, this would be a secondary care decision and not a first-line option in primary care.
Oral ceftriaxone is incorrect. IV ceftriaxone is the recommended treatment in secondary care for meningococcal disease in children over 3 months old, but it cannot be given orally.
