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Meningitis is an inflammation of the meninges which can be associated with modification of the cerebrospinal fluid which is contained between this membranes. More than a Spot Check – What does the NICE Quality Standard for bacterial meningitis and meningococcal septicemia in children and young people mean for the Emergency Dept?
If you work in the UK, I’m sure you’ve heard of NICE – the National Institute for Clinical Excellence.
NICE quality standards are “a concise set of statements designed to drive and measure priority quality improvements within a particular area of care.” They are considered to be the “Gold standard” of care delivered within the NHS. The quality standard for bacterial meningitis and meningococcal septicaemia in children and young people was published by NICE in June 2012, and has been endorsed by the Meningitis Research Foundation, the Meningitis Trust and (rather morbidly) the Royal College of Pathologists.
NICE is central to clinical governance in the NHS, ensuring that the right care is given by the right people at the right time.
Bacterial meningitis and meningococcal disease are reasonably rare (660 cases of invasive meningococcal disease in the UK in under-19s in 2010) but carry high mortality (10% quoted by NICE) and morbidity. The quality standard covers 14 quality statements, 10 of which are directly related to or raise issues relevant to ED care.
Let’s not beat about the bush; this is a nasty, aggressive disease, and for all we let the media malign our colleagues for missing it, sometimes the diagnosis just isn’t obvious until it’s barn-door. So, this quality statement is about communicating the paragraph above to the child’s parents without scaring the life out of them (not all that easy, actually!).
NICE wants us to communicate, specifically, where and when parents should access further care.
The parent or carer feels that the child is less well than when they previously sought advice.
The parent or carer is distressed, or concerned that they are unable to look after the child. How can you communicate this without the parents point-blank refusing to leave the department even though their snotty two-year-old is running around, cackling and breaking everything in sight?
This is more likely to be delivered by nursing staff, but it’s important to be aware of this standard. This statement references the bacterial meninigitis and meningococcal septicaemia clinical guideline. I’ve read around this quite a bit for my MSc in Emergency Medicine, and I think it’s probably worth drawing your attention to the work of Downes who found that 27.6% of babies at a “well baby” clinic had petechiae. As a result of this, a lot of kids get admitted for 48h antibiotics pending blood culture and PCR results (see statement 7); but remember my personal horror story and don’t be dissuaded by pushy specialty doctors.
This statement is useful for two reasons; firstly, advocating IO administration (great advice here although please don’t give children 2mls of 1% lidocaine down the IO! Secondly, the target of administration within an hour; with time-related targets in every ED in the UK, wouldn’t it be nice to get your blood results back within 60mins for the well-looking feverish children with petechiae, so you can give them antibiotics? All you really need to know about this standard is that there are enough exclusion criteria that unless you are skilled enough and particularly want to do so, this probably doesn’t need to be done by the ED doc. This is a slightly odd statement, as it has no rationale attached to it and no specified timeframe, but in essence it’s a reminder that sick kids should be seen by consultants.
There’s quite a long statement of indications for intubation and ventilation attached to this. Again, common sense; don’t transfer kids unless you are trained to deal with the potential consequences of their illness, including intubation, ventilation, seizure management, cardiac arrest and a whole host of other unpleasant situations.
The consultant paediatrician statement does seem odd without a time frame and it would be scary, if this day and age, at some point in the admission of a really sick child with meningococcal disease they weren’t assessed by a consultant.
A little thought for you about the mentality of the use of ABs in kids with petechial rashes in the ED. There seems to be a feeling that if you give one dose of IV ABs for a kid who might have septicaemia then you HAVE to keep the child on IVs, in hospital (usually) for 48 hours.
I have a problem with this as it can induce a mindset that in the equivocal case where suspicion is low, but not zero, clinicians might delay ABs until the bloods are back, the child has been observed, reviewed etc. I believe when we are talking about ABs in suspected septicaemia we should shoot first and ask questions later. It’s important that we put no real, or imagined barriers in place to encouraging all our clinicians to give antibiotics early if we suspect this devastating and humbling disease. I agree with Simon I think there is a tendency with some (usually more junior staff but not exclusively so) to not use antiobiotics in the well petechial patient incase it mandates 48hours of antibiotics.
A clinical problem that just won’t go away…vaccination improves, rates of serious bacterial illness [SBI] fall, presentations of children continue to increase, perception of risk of SBI rightly remains high and diagnostic conundrum remains unchanged!
Enter your email address to subscribe to this blog and receive notifications of new posts by email. Meningococcal disease can progress rapidly, and early symptoms are not easily recognized and are difficult to distinguish from other more common infections like the flu. Students who notice these symptoms (in themselves, friends, or others) should contact the University Health Center at 541-346-2770. If the symptoms are unusually sudden or severe, they should consider going directly to a local emergency room.
The meningitis B vaccine was approved by the CDC for limited use (by currently-enrolled UO undergraduate students and those in high-risk populations) to prevent the spread of meningococcal disease during the 2015 outbreak. There are several FDA approved 4-strain (MCV4) vaccines that have been available for many years. The Health Center has the new Type B vaccine that was approved by the CDC to prevent the spread of meningococcal disease during the 2015 outbreak.
UO prohibits discrimination on the basis of race, color, sex, national or ethnic origin, age, religion, marital status, disability, veteran status, sexual orientation, gender identity, and gender expression in all programs, activities and employment practices as required by Title IX, other applicable laws, and policies.
Many diseases, like cancer or connective tissue diseases, like lupus erythematosus or sarcoidosis may be accompanied by an inflammatory reaction of the meninges. Meningitis can occur due to allergies to medicines, some cancers and autoimmune diseases such as lupus. Each statement sets a standard of care with the aim of assessing local practice and expressing results as a proportion receiving care to the suggested standard.
NICE recognises that not all children with a temperature and in a bad mood have invasive meningococcal disease, and conversely not all children who are diagnosed with invasive meningococcal disease present with fever, vomiting and a purpuric rash. Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia have their temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition monitored at least hourly until stable.
Having done an audit of triage observations for children presenting with temperature (as in the NICE Feverish Illness guideline), I can tell you that this is something we do badly.
Children and young people presenting with a petechial rash receive antibiotics in accordance with NICE guidance. If you were concerned enough to start antibiotics, stand by your decision and get the child admitted. Children and young people with suspected bacterial meningitis or meningococcal septicaemia receive intravenous or intraosseous antibiotics within an hour of arrival at hospital. Helpfully, the Royal College of Pathologists has endorsed the standards, so it should be easier to get bloods processed. Notably, you need to have normal coagulation; so in children with a petechial or purpuric rash, LP shouldn’t be carried out until platelet and coag results are available and confirmed normal.
Children and young people with suspected bacterial meningitis or meningococcal septicaemia have whole blood meningococcal polymerase chain reaction (PCR) testing. Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia, who have signs of shock or raised intracranial pressure, are assessed by a consultant paediatrician. Children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation have the procedure undertaken by an anaesthetist experienced in paediatric airway management. Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals are escorted by a healthcare professional trained in advanced paediatric life support.
Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia requiring transfer to a paediatric intensive care unit or high dependency unit in another hospital are transferred by a specialist paediatric retrieval team.

This is either available to you or it isn’t – so I’m going to take the opportunity to big-up the fabulous NEWTS team.
I think this is particularly so when the petechiae are in an SVC distribution ( and I’m sure we all know that it svc distribution alone doesnt exclude meningococcaemia). At RMCH they take 48h to give a result, but they don’t usually get processed immediately if out of hours.
As you know we have a PED short stay unit so we have the option to keep kids for up to 24 hours under the care of the ED. An experienced clinician in (paediatric) emergency medicine will have a different set of alarm bells than someone less experienced.
The disease is unpredictable, and no one really knows all the reasons why some carriers become sick while others do not. In addition, at its June 2015 meeting, the Advisory Committee on Immunization Practices (ACIP) recommended that adolescents and young adults aged 16-23 years not in the outbreak situation may be vaccinated. This vaccine is different from the 4-strain vaccine that many students received as adolescents.
Meningitis is a very serious disease and requires urgent diagnosis and initiation of treatment. A group of viruses known as the enteroviruses, causing stomach problems, are responsible for approximately 90% of recorded viral meningitis. In the absence of treatment, the infection will spread to the brain (meningo-encephalitis) and can lead to coma, behavioral disorders, paralysis and convulsions. Infants and children treated for meningitis should always be monitored after they healed and should be checked to prevent long-term complications such as hearing loss. They may not look particularly unwell to begin with; in fact, back in late 2011 I saw an alarming case where a child with a temp had been admitted to the observation ward, had some vomiting and diarrhoea, normal WCC and CRP of 4. IO access is brilliant, the EZIO (the “baby drill”, as I like to call it) makes it ridiculously easy, and you honestly do look even cooler drilling into a baby’s leg than you do getting the cannula no-one else could manage.
Although in reality if you call the lab, ask nicely and explain why you need the results, it will probably work better than taking the “because NICE says so” route. My top tip; take a blood culture and PCR sample at the same time as your FBC and CRP, and put them to one side (labelled, of course).
I am certain that (unpleasant exam willing) when I am a consultant, this is definitely the sort of patient I want to know about. Having spent the last three months working (and training) alongside these guys, I can see why this standard exists; not only are they highly skilled in looking after sick kids, they also set up infusions etc. And if not, does the NICE flow chart actually give us a pretty reasonable (if not validated) clinical decision rule?
A shoot first ask questions later policy in respect of SBI in children is clearly safe but when I will shoot will be different from the juniors I work with. Questions may be referred to the Title IX Coordinator, Office of Affirmative Action and Equal Opportunity, or to the Office for Civil Rights. At the time her purpura appeared (approx 11h after her attendance at PED), her EWS had been “green” for more than four hours and it was Mum’s assertion that she “just wasn’t right” combined with a blood glucose of 2.9 that had made me hang on to her a little longer. Because EDs are busy, and ED nurses (despite being the best nursing staff in the hospital – I genuinely believe this!) are busy and often stretched beyond the capacity of mere humans. And this comes from someone who lists IV cannulation as one of her two skills (the other is ABGs – thanks for asking). No-one likes stabbing a child repeatedly, so if your results or a change in clinical condition necessitates antibiotics, you can send the culture and PCR; if not, and you are discharging the child, you can discard them. It’s a perfect time to get out there and audit; identify the weaknesses and take steps to fortify them. If ALL children who were perceived at any risk had admission and antibiotics (even if only for short duration and one dose) then systems would struggle.
Contact information, related policies, and complaint procedures are listed on the statement of non-discrimination. She grew Neisseria meningiditis from the blood culture taken at the same time as her baseline bloods. It makes sense, of course – we know that these children can deteriorate quickly, so we need to keep a close eye on them. Well, they are anaesthetists who are current APLS providers (or equivalent) – or other clinicians experienced in paediatric airway management (which presumably means the same APLS standard).
Another exercise in communication then; asking the super-stretched nurses to perform hourly observations without annoying them too much – or maybe doing them yourself?? There’s a little reminder to let your local PICU’s consultant oncall know if you are intubating; the child is going to end up there and we do like to know about these things in advance (as sometimes we need to discharge other patients). This study analyzed trends in probable bacterial meningitis before and after the introduction of Hib vaccine in the Dominican Republic and estimated vaccine effectiveness against Hib meningitis. Laboratory criteria were used to classify meningitis cases with probable bacterial etiology; confirmed cases had positive bacterial culture or antigen detection in cerebrospinal fluid. During 2002–2004, after vaccine introduction, annual rates of probable bacterial meningitis were 65% lower at 16 cases per 100 000, and Hib accounted for 26% of confirmed cases.
Pocos estudios han evaluado el impacto de la vacunación contra Hib sobre los casos no confirmados mediante cultivo. El impacto estimado de la vacunación contra Hib fue dos veces mayor cuando se consideraron los casos no confirmados mediante cultivo. Hib was a leading bacterial cause of meningitis in Latin American children before the introduction of conjugate vaccines (2, 3), which led to dramatic reductions in the number of cases of Hib meningitis (4–6). However, confirmed cases of Hib meningitis represent only a fraction of all Hib disease.
Analysis of laboratory data from hospitals in Argentina, South Africa, and Rwanda showed significant reductions in suspected bacterial meningitis cases of undetermined etiology after Hib vaccine was introduced in these countries, suggesting the potential to use surrogate markers of bacterial meningitis to measure the impact of Hib vaccine (7, 8).
Demonstration of the impact of the introduction of Hib vaccine on reductions in disease burden is important for the sustainability of the vaccination program.
Before the introduction of Hib conjugate vaccines into the routine infant immunization schedule in 2001, Hib was the leading cause of bacterial meningitis in children after the first month of life (11). Its child mortality rate of 35 deaths per 1 000 live births ranks second highest behind Haiti among Caribbean nations and ninth among the 35 countries in the Americas region (12, 13). The Dominican Republic, with a per capita gross national income of more than US $2 000, is not among the 72 poorest countries eligible to receive support for immunizations through the Global Alliance for Vaccines and Immunization (14).
The national government funds approximately 60% of routine immunizations in the Dominican Republic (12), with the balance provided by international donors. In 1998 and 1999, active, population-based surveillance for bacterial meningitis in eight hospitals (four public and four private) in the National District documented an incidence of 13 cases of Hib meningitis per 100 000 children less than 5 years of age (11).
During this 2-year period, surveillance officers regularly reviewed laboratory records and admission logs to identify case patients and completed standardized case report forms. Robert Reid Cabral (CIRRC), the main pediatric referral hospital in the country, accounted for approximately 80% of all confirmed and probable cases of bacterial meningitis identified. Between 1998 and 2004, clinical criteria for hospitalizing children with suspected meningitis and for performing lumbar puncture, as well as routine laboratory testing for etiologic agents, did not change at CIRRC.
In 2004, we retrospectively reviewed all admissions and laboratory records for children hospitalized at CIRRC with bacterial meningitis. Confirmed bacterial meningitis was defined as a child hospitalized with suspected meningitis with positive bacterial culture or antigen detection by latex agglutination in CSF. For trend analyses, probable case counts include all confirmed cases that met criteria for probable bacterial meningitis. Children hospitalized during the study period (26 August 2001 to 26 October 2004) with confirmed Hib meningitis were enrolled as cases. Case patients had to be at least 60 days old and reside in the National District at the time of illness. Hib vaccine doses were considered valid if administered at least 15 days before illness.

For both cases and controls, children had to be born on or after 13 August 1998 and therefore eligible to receive at least one dose of Hib vaccine, either during the national campaign or as part of the routine immunization series. Control children had to have been at least 60 days old at the time of the case patient's illness, and they had to have been residing in the National District for at least 1 month before the case patient's hospitalization. We used the following criteria to match by age: birth dates of matched controls had to be within 60 days of the case patient's birth date if illness occurred within the first year of life or within 180 days if illness occurred between ages 1 and 4 years.
Dates of vaccination were recorded from the child's health card, certificates from vaccination campaigns, or vaccination and medical records at the health centers where vaccinations were received. In the absence of a documented vaccination history, interviewers solicited information about the route and site of administration for each vaccination reported by the caregiver.
For case patients, vaccination history solicited at the time of hospital admission was used in the absence of other documents indicating vaccination status. We calculated relative risk (RR) and 95% confidence intervals (CIs) comparing average rates of confirmed and probable bacterial meningitis in 1998 and 1999, during active surveillance, or in 2000 and 2001, during passive surveillance, with rates for 2002 through 2004, after the introduction of Hib conjugate vaccine. To compare vaccination status, we calculated ORs and exact 95% CIs by using conditional logistic regression.
Receipt of two or three doses of Hib conjugate vaccine was combined in the final analysis.
Because vaccination status could not be determined for several control children, we conducted a sensitivity analysis assuming that all control children with unknown vaccination status were not vaccinated.
In all, there were 336 confirmed cases of bacterial meningitis during the period; 21 (6%) confirmed cases did not fulfill laboratory criteria for probable bacterial meningitis.
Hib accounted for 172 of 336 (51%) confirmed cases (Table 1); 163 (95%) were confirmed by culture and 113 (66%) were positive by latex agglutination in CSF. In 1998 and 1999, before widespread use of conjugate vaccine, Hib was the leading cause of bacterial meningitis in children, accounting for 62% of confirmed cases and 31% of probable cases. From 2002 through 2004, Hib accounted for 26% of confirmed cases and 13% of probable cases of bacterial meningitis in children. There were 44 fatal cases of probable bacterial meningitis during the surveillance period; of the 8 (18%) fatal cases due to Hib, 1 occurred after the introduction of Hib conjugate vaccine. For the period 2002–2004, the odds of identifying Hib from cases of probable bacterial meningitis were significantly lower than during the prevaccine period. Ten (31%) of the case patients had received Hib conjugate vaccine, including one who had received two doses of vaccine before illness (Table 3). Among 87 control children for whom any report of vaccination history could be obtained, 50 (57%) had received at least one dose and 23 (26%) had received at least two doses of Hib conjugate vaccine before the case patient's illness (Table 3). Control children were similar to case patients with respect to sex, history of breastfeeding, daycare attendance, exposure to household smoke, parental education, and possession of certain household items (data not shown). When analyses were limited to the 32 case patients and 71 matched control children with documented vaccination histories, two or more doses were 92% effective (95% CI, 37% to 100%). In the sensitivity analysis, assuming all nine control children with unknown vaccine history had not received Hib vaccine, two or more doses were 93% effective (95% CI, 55% to 100%). Including potential confounding variables in bivariate models did not change the effectiveness estimates for receipt of at least two doses of Hib conjugate vaccine (data not shown). In addition, Hib vaccination was most likely responsible for significant reductions observed in the incidence of probable bacterial meningitis of undetermined etiology, while the incidence of pneumococcal meningitis did not change.
Our analyses suggest that the vaccine-preventable burden of Hib disease was greater than had been estimated previously (11), as has been demonstrated in randomized trials of Hib conjugate vaccines in developing countries (18). The study was not able to determine the effectiveness of the national campaign to administer a single dose of Hib vaccine to all children < 3 years old before Hib conjugate was added to the routine childhood series. The estimated effectiveness of the Hib component of the pentavalent combination vaccine in the routine immunization program was similar to that of Hib–tetanus toxoid conjugate vaccine in Chile (19), Uganda (20), and The Gambia (21) as well as to that of other Hib conjugate vaccines (22). Among control children born after June 2002, 15 (68%) of 22 had received one or more doses of Hib-containing vaccine, approximately equivalent to national estimates of Hib vaccine coverage. The case-control investigation suggested that undervaccination of eligible children contributed to ongoing Hib disease transmission after introduction of the vaccine. Reductions in rates of probable bacterial meningitis of unknown etiology were comparable to declines in confirmed Hib meningitis, suggesting that the vaccine-preventable burden of Hib disease was higher than that confirmed by culture and antigen detection alone.
Interestingly, no reduction in culture-negative purulent meningitis cases was noted after the introduction of Hib vaccine in Malawi, where nearly 80% of cases of purulent meningitis were confirmed by culture (23). In the Dominican Republic, a substantial proportion of Hib meningitis cases may have been missed because of antibiotic use before admission, insensitivity of diagnostic methods, or specimens that could not be tested. This retrospective review of hospital and laboratory records was unable to evaluate the impact of Hib vaccination on the proportion of Hib meningitis survivors who had neurologic sequelae before and after introduction of the vaccine.
The current evaluation focused on meningitis, a small proportion of the burden of Hib disease in developing countries. Pneumonia, which makes up a larger proportion of the global Hib disease burden, was not included in the prevaccine surveillance system, and the case-control study focused only on confirmed cases of Hib meningitis.
First, use of the Hib conjugate vaccine before national immunization was not well documented.
In addition, some children in the National District may have received Hib vaccine in the private sector before it was introduced nationwide.
A second limitation is the use of only one hospital for our longitudinal study of meningitis surveillance data and for case identification for the case-control study.
Methods of case identification and record keeping were not maintained consistently at other hospitals within the National District after the active surveillance period in 1998–1999. At CIRRC, the largest number of cases of probable bacterial meningitis was observed during the active surveillance period, and changes in record-keeping practices after this period may account for apparent declines in cases of bacterial meningitis in 2000, before widespread use of the Hib vaccine.
Although CIRRC is the major pediatric referral hospital in the Dominican Republic, the findings from our analysis of surveillance data and the case-control study may not be representative of the population at large. Estimates of vaccine effectiveness remained high if we assumed that control children with unknown vaccine histories were not vaccinated. Despite early documented success, these vaccines had not been introduced in the poorer countries in the region before 2000 because of the high cost of the vaccines.
In 2006, the government of the Dominican Republic began purchasing pentavalent vaccine containing Hib conjugate through the Pan American Health Organization's Revolving Fund, which purchases vaccines in bulk for countries in the region to obtain lower prices. Demonstration of reduced disease burden after the introduction of Hib conjugate vaccine was important to justify the increase in spending on immunization.
When governments are faced with the decision to increase immunization budgets to sustain vaccination programs, demonstration of vaccine impact and effectiveness is critical to the decision-making process. This study was supported by the Japan International Cooperation Agency, UNICEF, and the United States Agency for International Development. The authors are grateful for the assistance of Elizabeth Gómez, Maria Cristina Pedreira, Anne Schuchat, Elizabeth Zell, and the team of interviewers (Juan de Leon, Patricia Grullon, Angelica Henriquez, Danilo Mariano, Beatriz Martinez, Clara Molina, Esperanza Rufino, Rafael Severino, Francisco Torres) in the Dominican Republic. Normas nacionales para la vigilancia epidemiológica de enfermedades transmisibles y otros eventos. Effectiveness of Haemophilus influenzae type b conjugate vaccine introduction into routine childhood immunization in Kenya. Elimination of Haemophilus influenzae type b (Hib) disease from The Gambia after the introduction of routine immunisation with a Hib conjugate vaccine: a prospective study. The impact of routine infant immunization with Haemophilus influenzae type b conjugate vaccine in Malawi, a country with high human immunodeficiency virus prevalence. Twelve year outcomes following bacterial meningitis: further evidence for persisting effects.
Effectiveness of Haemophilus influenzae type b vaccination against bacterial pneumonia in Colombia.

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18.04.2016, author: admin

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