Advice on assessment and appropriate action will improve out-of-hospital management of children and young people with IMD, explains Dr Jilly Hamilton

The Scottish Intercollegiate Guidelines Network (SIGN) has published a new guideline on Management of invasive meningococcal disease in children and young people.1 The disease most commonly presents as meningitis but can cause meningococcal septicaemia in up to 20% of patients, which is the cause of greater mortality.

Invasive meningococcal disease (IMD) can be devastating and has a significant mortality and morbidity but it is treatable and early treatment can alter the outcome. Since the introduction of the meningococcal C vaccine (MenC) in 1999 the number of cases has fallen by 50%.1 In Scotland, the incidence has fallen to 140–160 new cases a year, and figures for the first quarter of 2008 have shown 36 new cases (compared to 53 for the same period in 2007). Group B disease (for which there is no currently licensed vaccine in the UK) was the major subgroup responsible for these cases, of which two were fatal.2

Improvements in outcome have come from:1

  • increasing awareness
  • public health measures
  • early resuscitation
  • improved resuscitation techniques
  • advances in critical care
  • surgical interventions
  • investment in rehabilitation.3

With most children being vaccinated against meningitis C, and with the lower case prevalence of IMD, the disease comes lower down the list of differential diagnoses. The publication of the SIGN guideline can only help to increase practitioners’ (including primary care provider) awareness and aid disease recognition. This may improve early intervention and speed of access to experienced specialist help. Most deaths from IMD occur within the first 24 hours,1 so primary care healthcare practitioners need to be alert to the possibility of this infection.

Assessment

There are generally three different patterns of presentation of meningococcal disease. These are:

  • meningococcal septicaemia
  • clinical meningitis
  • mixed picture of septicaemia and meningitis.

Features suggestive of IMD in a child that is ill are:1

  • petechial rash
  • altered mental state
  • cold hands and feet
  • pain in the extremities
  • fever
  • headache
  • stiff neck
  • mottling of the skin

Non-specific signs such as nausea, vomiting, fever, lethargy, irritability, loss of appetite, or non-blanching rash in young children within the first 4–6 hours of illness should not automatically exclude a diagnosis of IMD. If there is sufficient clinical suspicion, the child should be treated appropriately and referred to secondary care for further assessment.

Out-of-hospital care

The out-of-hospital care recommended in the guideline is based on guidance from the Joint Royal Colleges Ambulance Liaison Committee and the Meningitis Research Foundation.4 Provision of care in GP surgeries and in out-of-hours primary care services for suspected IMD should follow the procedure outlined in Figure 1 (above), including:

  • early assessment if suspected IMD when triaged
  • interval assessment in 4–6 hours if there is any concern about the diagnosis—but if a diagnosis of IMD is likely, treatment should not be delayed by interval assessment
  • ABCD (Airway, Breathing, Circulation, and Disability) with airway management, oxygen therapy, rapid transportation to nearest hospital, and administration of intravenous or intramuscular benzylpenicillin, intravenous crystalloid, and identification and treatment of hypoglycaemia—alert hospital of expected arrival including the age of the patient4
  • early treatment—expert opinion advises starting antibiotic treatment before admission to hospital due to the speed with which children with meningococcal disease can deteriorate, and because it is unlikely to do harm (unless the child is allergic to penicillin5—benzylpenicillin and ceftriaxone are widely used and have been shown to be effective in the treatment of meningococcal disease6).

Figure 1: Model of early assessment

IMD=invasive meningococcal disease Scottish Intercollegiate Guidelines Network. Management of invasive meningococcal disease in children and young people. SIGN 102. SIGN: Edinburgh, 2008. This material was reproduced with kind permission of the Scottish Intercollegiate Guidelines Network.

Public health issues

Health protection teams will determine who needs preventive prophylaxis. Chemoprophylaxis should be offered to those who have had prolonged close contact in a household setting with a child with meningococcal disease during the 7 days before onset of illness.1 Healthcare workers who may have been exposed to respiratory droplets from the patient within the acute illness phase before 24 hours of antibiotics have been given should also receive prophylaxis. Health protection teams are informed by the hospital team looking after the child or young adult, as meningococcal disease is notifiable. Public health services will decide who will benefit from prophylaxis and then arrange for this to be prescribed. Ideally this will be via the recipient’s GP but arrangements vary and can also be arranged by public health directly or through the out-of-hours doctor or the hospital doctor who is looking after the admitted patient.

Problems in implementing care

There can be difficulties in implementing some aspects of recommended primary care for children and young people with suspected IMD such as how to communicate adequately with the out-of-hours service and parents/carers. These potential difficulties are set out in Table 1.

Table 1: Key priorities for primary care and difficulties faced in achieving them

Priority Problem Advice
Early assessment Non-specific first presentation of IMD The NICE guideline on Feverish illness in young children7 sets out how to distinguish a child that is ill and in need of further assessment from one that can be managed in primary care
Interval assessment if IMD cannot be ruled out (treatment must not be delayed if IMD is suspected) When to arrange a time for assessment to ensure the patient’s condition has not deteriorated Arrange an appointment within 4–6 hours to monitor the patient’s condition. This may have to be arranged with the out-of-hours service or the patient’s own GP. This may need to be brought forward if there are concerns from/about the patient
Communication between care providers How to ensure communication between the out-of-hours service and usual GP care if there is concern about the patient’s condition and interval assessment is needed Ensure adequate communication between the practice and out-of-hours service, e.g. if review is needed by out-of-hours healthcare professional or if he or she suggests review by GP practice, there needs to be a robust system to allow this to happen. This can be via email, fax, or telephone
'Safety netting’—letting patients and carers know what to look out for and when to seek help What information should be given to parents/carers?

Most parents/carers are aware of the glass test, rashes that do not blanch need to be examined by a healthcare professional as soon as possible.
If carers have concerns, or a child’s condition deteriorates, there should be clear instructions to contact either the GP or out-of-hours service.
Give simple instructions and contact numbers—if there are concerns about the parent/carer’s understanding and ability to risk manage, it may be sensible to arrange a paediatric or medical admission for observation (even for a few hours)

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Follow-up care

Most of the long-term complications of IMD will be managed in secondary care. All children with a diagnosis of meningococcal sepsis or meningitis should have a follow-up appointment and be carefully assessed for evidence of any immediate or potential long-term complications. These include:1

  • hearing loss—all children who have had a diagnosis of meningitis should have a hearing test
  • neurological complications
  • psychiatric, psychosocial, and behavioural problems
  • bone and joint complications
  • postnecrotic scarring
  • renal impairment.

The impact on family and carers, with the possible development of post-traumatic stress disorder (especially in mothers), should also be taken into consideration.1

The SIGN guideline includes details of a number of organisations that can offer support to patients, parents, and carers, for example Action for Sick Children (Scotland), Cruse Bereavement Care, and ENABLE Scotland.

Impact of the guideline

The guideline should improve the diagnosis and management of meningococcal disease in children and young people by highlighting the impact of this potentially devastating disease. It summarises best practice and discusses the evidence for management and treatment. Early treatment is vital, as soon as IMD is suspected, and should not be delayed while test results are awaited. The primary healthcare practitioner should institute early resuscitation with airway management and oxygen if required. Antibiotics should be given if IMD is suspected and the healthcare professional should arrange for the child to be transferred to hospital for assessment by a paediatrician or specialist in managing IMD as soon as possible for further assessment and treatment, which may improve the outcome, saving lives and reducing lifelong impairment. This in turn will improve patient care.

Click here for CPD questions on this article and the SIGN guideline on invasive meningococcal disease in children and young people

References

  1. Scottish Intercollegiate Guidelines Network. Management of invasive meningococcal disease in children and young people. A national clinical guideline. SIGN 102. Edinburgh: SIGN, 2008.
  2. Health Protection Scotland. Surveillance Systems: Meningococcal Invasive Disease Augmented Surveillance (MIDAS). [Cited 22/7/08]
  3. Booy R, Habibi P, Nadel S et al. Reduction in case fatality rate from meningococcal disease associated with improved healthcare delivery. Arch Dis Child 2001; 85 (5): 386–390.
  4. Fisher J, Brown S, Cooke M, eds. UK Ambulance Service Clinical Practical Guidelines. London: Joint Royal Colleges Ambulance Liaison Committee and the Ambulance Services Association; 2006. [Cited 23/7/08]
  5. Health Protection Agency Meningococcus Forum. Guidance for public health management of meningococcal disease in the UK. London: HPA, 2006.
  6. Prasad K, Singhal T, Jain N, Gupta P. Third generation cephalosporins versus conventional antibiotics for treating acute bacterial meningitis. Cochrane Database Syst Rev 2007; (2): CD001832.
  7. National Institute for Health and Care Excellence. Feverish illness in children—assessment and initial management in children younger than 5 years. Quick reference guide. Clinical Guideline 47. London: NICE, 2007.G
  • IMD is still a significant public health issue, although the incidence is steadily declining
  • Commissioners should ensure all primary care and emergency services are aware of the SIGN guideline and implement its recommendations
  • Primary care services need to ensure clear communication channels between GPs in the practice and out-of-hours services to allow for interval review of patients
  • Primary care services should continue to strive to ensure maximal take up of the meningitis C vaccine
  • Commissioners should ensure the public is made aware of the key symptoms and signs of IMD through local and national public information campaigns