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Early Management of Suspected Meningitis and 3rd Edition Meningococcal Sepsis in Immunocompetent Adults Jan 2016

Warning Signs Early recognition is crucial The following signs require urgent senior review +/- Critical Care Consider meningitis or meningococcal sepsis if ANY of the following are present: input: I I I Rapidly progressive rash Headache Neck Stiffness I I Fever I Rash Poor peripheral perfusion I Altered I Seizures – Capillary refill time > 4 secs, oliguria or systolic BP I Consciousness Shock < 90mmHg I Respiratory rate < 8 or >30 / min I Pulse rate < 40 or >140 / min Immediate Action I I Acidosis pH < 7.3 or Base Airway excess worse than -5 I reathing - Respiratory rate & O saturation B 2 I White blood cell count I Circulation - Pulse; capillary refill time; urine output; blood pressure (hypotension occurs late) < 4 x 109/L I Disability - Glasgow coma scale; focal neurological signs; seizures; papilloedema; capillary glucose I Lactate > 4 mmol/L I Senior review +/- Critical Care review if any Warning Signs are present I Glasgow coma scale <12 or a drop of 2 points I Poor response to initial fluid Suspected Meningitis Suspected meningitis Signs of severe resuscitation with signs suggestive sepsis or a rapidly (meningitis without signs of Delay LP shock, severe sepsis or signs of shift of brain evolving rash suggesting brain shift) if any of the following are present: compartments secondary (with or without symptoms I I Signs of severe sepsis or Blood cultures to raised intracranial and signs of meningitis) rapidly evolving rash I Lumbar puncture pressure I Get Critical Care input I SEVERE respiratory/ cardiac I Dexamethasone 10mg IV I compromise I Secure airway and give I Get Critical Care input Ceftriaxone OR Cefotaxime 2g high flow oxygen I Significant bleeding risk * I Secure airway, high flow IV immediately following LP I Fluid resuscitation I oxygen Signs suggesting shift of (see also I brain compartments (CT I Blood Cultures alternative initial antibiotics) Take bloods including Blood scan before LP is warranted, as I Ceftriaxone OR I CT scan normally not indicated Cultures long as patient is stable) I Cefotaxime 2g IV I Careful fluid resuscitation (avoid Give Dexamethasone 10mg IV – Focal neurological signs I immediately after blood fluid overload) Give Ceftriaxone OR cultures taken – Presence of papilloedema Cefotaxime 2g IV immediately *If LP cannot be done in the first I Delay LP – Continuous or uncontrolled after blood cultures taken seizures hour, antibiotics must be given I Delay LP Follow Surviving Sepsis immediately after blood cultures – GCS ≤12 I Arrange neurological imaging Guidelines at: have been taken (once patient is stabilised) http://www.survivingsepsis .org/guidelines Alternative initial antibiotics Penicillin/Cephalosporin anaphylaxis Careful Monitoring and Repeated Review is essential Chloramphenicol 25mg/kg IV ≥60 years old (not allergic) OR immunocompromised Additional Investigations (including alcohol dependency Blood CSF (if LP performed) and diabetes), I I Ceftriaxone OR Cefotaxime 2g IV FBC, renal function, glucose, lactate, clotting Glucose (with concurrent blood glucose), protein, PLUS Amoxicillin 2g IV profile** microscopy and culture I Meningococcal and Pneumococcal PCR (EDTA) I Lactate Penicillin/Cephalosporin anaphylaxis and ≥60 years old I I Blood gases Meningococcal and Pneumococcal PCR OR immunocompromised I **unless a clotting defect is suspected, do LP without Enteroviral, Herpes Simplex and Varicella Zoster (including alcohol dependency PCR and diabetes), waiting for results Chloramphenicol 25mg/kg I Consider investigations for TB meningitis AND Co-trimoxazole Other 10-20mg/kg (of the trimethoprim component) in four divided doses I Throat swab - for meningococcal culture Recent travel/risk of penicillin resistant pneumococci Infection Control Public Health Ceftriaxone/Cefotaxime 2g IV Source isolate all patients until Meningococcal Disease is Notify all cases to the relevant public health authority for PLUS excluded or Ceftriaxone has been given for 24 hours (or a contact tracing, give antimicrobial prophylaxis and vaccination Vancomycin 15-20mg/kg IV single dose of Ciprofloxacin) where necessary OR Rifampicin 600mg PO/IV Notify microbiology

The UK Joint Specialist Societies Guideline on the Diagnosis and Management of Acute Meningitis and Meningococcal Sepsis in Immunocompetent Adults.

Further copies from www.meningitis.org or Meningitis Research Foundation 0333 4056262. A charity registered in England and Wales no 1091105, in Scotland no SC037586 and in Ireland 20034368. McGill F, Heyderman R, Michael B, Defres S, Beeching N, Borrow R, Glennie L, Gaillemin O, Wyncoll D, Kaczmarski E, Nadel S, Thwaites G, Cohen J, Davies N, Miller A, Rhodes A, Read R, Solomon T; The UK Joint Specialist Societies Guideline on the Diagnosis and Management of Acute Meningitis and Meningococcal Sepsis in Immunocompetent Adults, Journal of Infection (2016), doi: 10.1016/j.jinf.2016.01.007.