Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Early Assessment
Signs and Symptoms
Initial Assessment
D - A generalised petechial rash, beyond the distribution of the superior vena cava, or purpuric rash in any location, in an ill child, are strongly suggestive of meningococcal septicaemia and should lead to urgent treatment and referral to secondary care.
D - The following features in an ill child should prompt consideration of a diagnosis of Invasive meningococcal disease (IMD):
- Petechial rash
- Altered mental state
- Cold hands and feet
- Extremity pain
- Fever
- Headache
- Neck stiffness
- Skin mottling
D -:
- Meningococcal disease should not be automatically excluded as a potential diagnosis if young children present with non-specific symptoms such as fever, lethargy, poor feeding, nausea, vomiting and irritability or a non-blanching rash, within the first four to six hours of illness.
- If there is sufficient clinical suspicion, appropriate treatment should be commenced and assessment in secondary care should be arranged.
Managing Children with Non-Specific Symptoms
GPP - Parents or carers of children with non-specific symptoms who are unlikely to have meningococcal disease should be advised to call back if the child's condition deteriorates. This advice should take account of local access to health care.
Interval Assessment
D - Children with symptoms or signs which are highly suggestive of meningococcal disease should not have their treatment delayed by interval assessment.
GPP - Children with non-specific symptoms at initial presentation, in whom meningococcal disease cannot be excluded, should be reassessed within four to six hours.
GPP - Carers should seek further clinical advice if the child's condition deteriorates prior to planned reassessment (e.g., rash changes). This advice should take account of local arrangements for health care.
Early Treatment
Antibiotic Therapy
D - Parenteral antibiotics (either benzylpenicillin or cefotaxime) should be administered in children as soon as invasive meningococcal disease (IMD) is suspected, and not delayed pending investigations.
Out-of-Hospital Care
D - Pre-hospital practitioners should follow guidance produced by the Joint Royal Colleges Ambulance Liaison Committee and the Meningitis Research Foundation when treating children and young people with suspected IMD.
Service Delivery
D - Following arrival at hospital, children with suspected IMD should be reviewed and treated promptly by a senior and experienced clinician.
D - Management of children with progressive IMD should be discussed with intensive care at an early stage.
GPP - Robust local protocols should ensure that children with IMD have rapid access to appropriate levels of supervision and care that take into account local services and geography.
Confirming the Diagnosis
Laboratory Diagnosis
Blood Culture
To confirm the diagnosis in all children with suspected IMD, blood should be taken for:
C - Bacterial culture
D - Meningococcal polymerase chain reaction (PCR)
Lumbar Puncture
GPP - Lumbar puncture is not recommended in the initial assessment of suspected IMD with features of septicaemia. Lumbar Puncture (LP) may be considered later if there is diagnostic uncertainty or unsatisfactory clinical progress, and there are no contraindications.
C - Lumbar puncture should be performed in patients with clinical meningitis without features of septicaemia (purpura) where there are no contraindications.
D - Cerebrospinal fluid should be submitted for microscopy, culture and PCR.
Illness Severity and Outcome
Clinical Variables
C - Clinicians should be aware that the following are associated with high mortality:
- A platelet times neutrophil product of <40 x 109/l
- A procalcitonin level of >150 ng/l
D - Clinicians should be aware that meningococcal meningitis carries a lower risk of adverse neurological outcome than meningitis due to other bacteria.
Scoring Systems
D - Children diagnosed with IMD should have sequential Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS) performed and any deterioration should be discussed with intensive care.
Treatment
Intravenous Fluids
B - If there are signs of shock, administer a rapid infusion of intravenous (IV) fluids as isotonic crystalloid or colloid solution up to 60 mL/kg given as three boluses of 20 mL/kg, with reassessment after each bolus.
GPP - Fluid resuscitation in excess of 60 ml/kg and inotropic support are often required.
GPP - Evidence of circulatory failure and the need for repeated IV fluid boluses should prompt early consultation with intensive care as inotropic support and ventilation may be required.
Antibiotics
Initial Antibiotic Therapy
B - Parenteral cefotaxime should be used as initial treatment of previously well children over three months with a diagnosis of IMD.
GPP - Once daily ceftriaxone monotherapy may be substituted if calcium containing parenteral agents have not been used in the preceding 48 hours.
GPP - When parenteral antibiotics are indicated for infants less than three months of age, cefotaxime plus an antibiotic active against listeria (e.g., ampicillin or amoxicillin) should be given.
Duration of Antibiotic Treatment
GPP - In children with invasive meningococcal disease the duration of antibiotic therapy should be seven days.
Corticosteroid Therapy
Meningococcal Septicaemia
B - Steroids are not recommended for the treatment of children with meningococcal septicaemia (see section below titled "Inotropes" for an exception to this in the case of inotrope-resistant shock).
Meningococcal Meningitis
A - In children beginning empirical antibiotic treatment for bacterial meningitis of unknown aetiology, parenteral dexamethasone therapy (0.15 mg/kg six hourly) should be commenced with, or within 24 hours of, the first antibiotic dose, and be continued for four days.
B - In children with meningococcal meningitis, parenteral dexamethasone therapy (0.15 mg/kg six hourly) should be commenced with, or within 24 hours of, the first antibiotic dose, and be continued for four days.
Intensive Care
D - Transfer to Pediatric Intensive Care unit (PICU) should be arranged for patients who continue to deteriorate despite appropriate supportive therapy (oxygen, fluids and antibiotics).
Intensive Care Management
Ventilation and Airway Management
D - In patients with progressive meningococcal disease:
- Airway and breathing should be rigorously monitored and maintained
- The decision to intubate and ventilate should be made if there is increased work of breathing, hypoventilation, low level of consciousness or presence of a moribund state
- Volume loading should be considered before and during intubation, and anaesthetic induction agents that maintain cardiovascular stability should be used
- Lung-protective ventilation strategies should be instituted
GPP -:
- High frequency oscillation ventilation should be considered for patients when conventional ventilation is failing.
- Early ventilatory support should be considered for children with fluid resistant shock, after institution of inotrope therapy.
Inotropes
D - Children with fluid resistant shock should receive early inotropic therapy, and ventilatory support should be considered.
GPP - In children with refractory hypotension (inotrope-resistant septic shock), IV vasopressin and steroid dose titration are appropriate rescue strategies.
Monitoring
D - Non-invasive monitoring should be applied in all children with fluid sensitive shock.
D - Central venous and arterial access should be considered in children with fluid resistant septic shock.
Renal Replacement Therapy
GPP - Continuous venovenous haemofiltration may be considered in children with inotrope dependent septic shock, severe metabolic acidosis, acute or impending renal failure and complex or problematic fluid balance.
Extra Corporeal Membrane Oxygenation
GPP - Extra corporeal membrane oxygenation (ECMO) should not be used as a standard therapy for refractory shock in children with IMD.
GPP - ECMO may be considered in patients with acute respiratory distress syndrome (ARDS) secondary to IMD who have failed to respond to conventional intensive care management.
Haematological and Immunological Support
GPP - Activated protein C should not be used in the treatment of meningococcal sepsis in children.
Surgical Management
D - Compartment pressure monitoring should be considered in children with extensive limb involvement.
GPP - Urgent specialist referral is necessary for assessment and interpretation of compartment pressure monitoring.
D - Urgent surgical debridement should be performed in the presence of secondary wound infection if the child's condition allows.
GPP - Orthopaedic and plastic surgery teams should be consulted early for needs assessment.
Prevention of Secondary Transmission
Prophylactic Antibiotics
C - Chemoprophylaxis should be offered to those who have prolonged close contact in a household setting with a child with meningococcal disease during the seven days before onset of illness.
D - In isolated cases of meningococcal disease, prophylaxis is not indicated for pupils in the same nursery, school or class as a child diagnosed with meningococcal disease, unless they are a close contact.
D - Chemoprophylaxis should be offered to healthcare workers whose mouth or nose is directly exposed to droplets or respiratory secretions from a child with meningococcal disease during the acute illness prior to completion of 24 hours of antibiotics.
Vaccination
D - Prior to discharge from hospital, Men C vaccine should be offered to:
- Any patient who has not been immunised, whatever the serogroup
- Patients with confirmed serogroup C disease who have previously been immunized with Men C
Infection Control
D - Children with suspected meningococcal infection should be admitted to a single room in hospital, where practical.
D - Infection control measures for droplet infection should be implemented when a child with suspected meningococcal infection is admitted to hospital. These can be discontinued after 24 hours of effective treatment.
D - Healthcare staff at high risk of exposure to respiratory secretions should use appropriate personal protective equipment.
Follow–up Care
Long Term Complications
Hearing Loss
GPP - All children who have had a diagnosis of meningitis should have their hearing tested to allow any therapies required to be started as early as possible.
Recommendations on Morbidities
D - Children and families or carers of children who have survived invasive meningococcal disease should be made aware of potential long term complications of the disease.
C - When assessing the follow-up needs of children with meningococcal disease healthcare professionals should consider the following potential morbidities:
- Hearing loss
- Neurological complications
- Psychiatric, psychosocial and behavioural problems
- Bone and joint complications, with awareness that these may not be apparent for many years after illness
- Post necrotic scarring with possible requirements for amputations and skin grafting. Long term follow-up may be needed for children for scar revision, surgical repair of deformities, leg length discrepancy, angular deformities and poorly fitting prosthesis
- Renal impairment, particularly in those who required renal replacement therapy during their acute illness
GPP - All children who have had meningococcal sepsis or meningitis should have a follow-up appointment and be carefully assessed for evidence of any immediate or potential long term complications.
GPP - An individual care plan should be developed for each patient on leaving hospital.
Impact on Families and Carers
C - Healthcare professionals involved in the follow-up of children with meningococcal disease need to be aware of the potential for post-traumatic stress disorder in both the children and their families and carers.
Definitions:
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
Grade A: At least one meta-analysis, systematic review, or randomised controlled trial (RCT) rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
Grade B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
Grade C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
Grade D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group.
Levels of Evidence
1++ - High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+ - Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1- - Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++ - High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+ - Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2- - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3 - Non-analytic studies (e.g., case reports, case series)
4 - Expert opinion
