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Clinical Practice Guidelines

Acute meningococcal disease

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    PIC Endorsed

  • See also:

    Meningitis and encephalitis
    Sepsis
    Fever and petechiae/purpura
    Local antimicrobial guidelines

    Key points

    1. IV ceftriaxone/cefotaxime should be given as soon as meningococcal disease is suspected. If unavailable, give benzylpenicillin
    2. If IV access cannot be obtained within 15 minutes, administer IM or via intraosseus
    3. Collect blood cultures prior to antibiotics if possible, but do not delay antibiotic administration

    Background

    • Acute meningococcal disease may present as severe sepsis with a progressive non-blanching petechial/purpuric rash, or meningitis with or without a rash
    • Rarer presentations include septic arthritis, pneumonia, pharyngitis and occult bacteraemia
    • There are 13 serogroups of Neisseria meningitidis (the cause of meningococcal disease) in Australia - the 5 most common are A, B, C, W and Y

    Assessment

    Red flags in red

    History

    • Rapid onset (<12 hours) of headache, loss of appetite, nausea, vomiting, sore throat and coryza
    • Fever
    • Infants may have reduced feeds, irritability
    • Leg pain or myalgia

    Examination

    • Signs of sepsis: see Sepsis
    • Abnormal skin colour (pallor or mottling) and/or cool peripheries
    • Late signs (>12 hours)
      • Altered conscious state
      • Neck stiffness, headache, photophobia, bulging fontanelle
      • Non-blanching rash: petechiae/purpura

    Note: a blanching rash does not exclude meningococcal disease (can initially be macular or maculopapular)

    Examples of rash: Click to see additional full size pictures

      blanching rash 1 blanching rash 2 


    Management

    Investigations:

    Investigations should NOT delay antibiotic administration

    • Blood (or intraosseus):
      • Culture: should be obtained prior to antibiotic administration if possible.
      • PCR (separate EDTA tube, minimum volume 0.2 mL)
    • CSF (once initially stabilised and no contraindication to lumbar puncture): Gram stain (Gram negative diplococci), biochemistry, culture, and meningococcal PCR

    Treatment:

    Resuscitate as appropriate

    Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines

    Ceftriaxone 100 mg/kg (4 g) IV daily or 50 mg/kg (2 g) IV 12 hourly or

    Cefotaxime 50 mg/kg (2 g) IV 12 hourly (week 1 of life), 6-8 hourly (week 2-4 of life), 6 hourly (>week 4 of life)

    • If no IV/intraosseus access, give IM (may need two injections due to volume/muscle size and repeat the dose once IV access available)
    • If ceftriaxone/cefotaxime unavailable, administer benzylpenicillin 60 mg/kg IV 12 hourly (week 1 of life) 6 hourly (week 2–4 of life) 4 hourly (>week 4 of life) (max 2.4 g)

    Duration of antibiotics is 5 days

    If meningococcal infection is not yet confirmed treat as per Sepsis

    For additional management see Sepsis and Meningitis and encephalitis

    Ward management / other treatment considerations:

    Isolation
    Meningococcal disease is spread person-to-person by respiratory droplets.
    Patients should be isolated and droplet precautions continued for 24 hours after administration of appropriate antibiotics.

    Notification
    All cases of presumed or confirmed meningococcal disease require immediate notification to the local state authority:

    • NSW: Public Health Units of local Hospital & Health Service by telephone 1300 066 055 and PHU form
    • QLD: Public Health Units of local Hospital & Health Service by telephone ( list of PHUs )
    • VIC: Department of Human Services by telephone – 1300 651 160 ( DHHS notification procedure)
    • WA: Department of Health PHU

    Chemoprophylaxis
    Chemoprophylaxis should be given to contacts as soon as possible

    Vaccination

    • MenB vaccine
    • MenC vaccine
    • MenACWY (quadrivalent) vaccine

    Meningococcal B and ACWY immunisations are recommended as per the Australian Immunisation handbook. MenACWY vaccine has been provided free through the National Immunisation Program ( NIP) to all children since 2018. From July 2020 the meningococcal B vaccine is also provided free to Aboriginal and Torres Strait Islander children. There is currently no vaccine against serogroup X.

    Consider consultation with local paediatric team when

    All cases of suspected meningococcal disease in children.

    Consider transfer when

    All cases of acute meningococcal disease should be managed in a facility with the capacity to provide intensive care.
    If these facilities are unavailable, the patient should be stabilised and transferred as appropriate.

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Parent information

    Kids Health Info: Meningococcal Infection

    Last revised July 2020

  • Reference List

    1. Apicella M 2019, Treatment and prevention of meningococcal disease. Retrieved from https://www.uptodate.com/contents/treatment-and-prevention-of-meningococcal-infection (viewed June 2020)
    2. Apicella M 2019, Clinical manifestations of meningococcal disease. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-of-meningococcal-infection (viewed June 2020)
    3. Assiri AM et al 2009, Corticosteroid administration and outcome of adolescents and adults with acute bacterial meningitis: A meta-analysis, Mayo Clinic Proceedings 84(5) pp403–9
    4. Australian Technical Advisory Group on Immunisation 2019, Meningococcal Disease, Retrieved from Austalian Immunisation Handbook  https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/meningococcal-disease (viewed June 2020)
    5. Brouwer MC et al 2018, Corticosteroids for acute bacterial meningitis (Review) Cochrane Database Systematic Review 9
    6. Coldiron ME, et al 2018, Single-dose oral ciprofloxacin prophylaxis as a response to a meningococcal meningitis epidemic in the African meningitis belt: A 3-arm, open-label, cluster-randomized trial, PLOS Medicine 15(6) pp1–19
    7. Curtis S et al 2010, Clinical Features Suggestive of Meningitis in Children: A Systematic Review of Prospective Data, Pediatrics, 126(5) pp952–60.
    8. Ecb W et al 2013, Osmotic therapies added to antibiotics for acute bacterial meningitis, Cochrane Collaborative 3
    9. Ik M, Bhaumik S 2016, Fluid therapy for acute bacterial meningitis (Review) Cochrane database Systematic Review 5
    10. Kids NSW 2014 Infants and Children : Acute Management of Bacterial Meningitis
    11. Le Saux N, Society CP 2018, Guidelines for the management of suspected and confirmed bacterial meningitis in Canadian children older than one month of age. Retrieved from The Canadian Paediatric Society, http://www.cps.ca/documents/position/management-of-bacterial-meningitis (viewed June 2020)
    12. Lukšić I et al 2014, Estimating global and regional morbidity from acute bacterial meningitis in children: assessment of the evidence, Croatian Medical Journal 54(6) pp510–8.
    13. McMillan M et al 2019, B Part of It study: a longitudinal study to assess carriage of Neisseria meningitidis in first year university students in South Australia, Human Vaccines and Immunotherapeutics 15(4) pp987–94
    14. Olbrich KJ et al 2018, Systematic Review of Invasive Meningococcal Disease: Sequelae and Quality of Life Impact on Patients and Their Caregivers, Infectious Diseases and Therapies, 7(4) pp421–38.
    15. National Institute for Health and Care Excellence Pathways, 2012, Bacterial meningitis and meningococcal septicaemia in under 16s. (April):1–12.  Retrieved from https://pathways.nice.org.uk/pathways/bacterial-meningitis-and-meningococcal-septicaemia-in-under-16s (viewed June 2020)
    16. Peterson ME et al 2019, Serogroup-specific meningococcal carriage by age group: a systematic review and meta-analysis, British Medical Journal 9(4):1-9
    17. UpToDate 2011, Microbiology and pathobiology of Neisseria meningitidis. Retrieved from UpToDate https://www.uptodate.com/contents/microbiology-and-pathobiology-of-neisseria-meningitidis (viewed June 2020)
    18. van de Beek D et al 2016, ESCMID guideline: Diagnosis and treatment of acute bacterial meningitis, Clinical Microbiology and Infection, 22:S37–62.
    19. Waterfield T et al 2018, A protocol for a systematic review of the diagnostic accuracy of Loop-mediated-isothermal AMPlification (LAMP) in diagnosis of invasive meningococcal disease in children. Systematic Reviews 7(1):1–5.