Meningococcal disease (invasive) for health professionals

Invasive infection with Neisseria meningitidis (the meningococcus) frequently manifests as either septicaemia or meningitis. Meningococcal septicaemia is more common than meningococcal meningitis and has a higher mortality rate (5 to 10%).

Clinical presentation

Invasive meningococcal infection should be considered in the differential diagnosis of any systemic febrile illness in any age group.

If a doctor considers that a patient with a non-specific febrile illness does not require referral to a hospital, the doctor should advise the carer to keep the patient under frequent and regular review and seek immediate medical attention if the patient subsequently deteriorates in any way or develops a rash.

Clinical presentation of invasive meningococcal infection may include the following:

• fever, sweats, rigors, pallor, vomiting, nausea, headache
• prostration, drowsiness, irritability, altered conscious state.
• neck stiffness, photophobia, cranial nerve palsies, seizures (if meningitis)
• joint pain, myalgia, backache, difficulty walking
• a rash

In early stages of infection the rash may be atypical or not present. In meningitis unaccompanied by bacteraemia a rash may never occur. The classic presentation is of non-blanching petechial or purpuric rash, often in clusters that may first appear where pressure occurs from elastic. However, the rash may blanch and resemble a viral exanthema or be a non-blanching maculopapular rash.

Infants

In infants and children the following may also occur:

• irritability, dislike of being handled, refusal of food, poor eye contact
• tiredness, floppiness, drowsiness, twitching
• grunting, moaning
• leg pain, cold extremities and abnormal skin colour are frequently seen in the first 12 hours of disease (before classic symptoms and signs develop) in children under 16 years of age.

Pre-hospital management

Benzylpenicillin should be given immediately on suspicion of invasive meningococcal infection.

Benzylpenicillin should preferably be given intravenously (IV) but if unable then give intramuscularly (IM). Use: benzylpenicillin 2.4 g (child: 60 mg/kg up to 2.4 g) IV or IM.

Benzylpenicillin should not be used if there is a clear history of anaphylactic or immediate penicillin hypersensitivity reaction (such as difficulty breathing, angioedema or generalised urticarial rash). Such patients should be discussed with the on-call clinician at a referral hospital. Most people who report penicillin allergy do not have such a history and can safely be given benzylpenicillin.

Ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g)IV or IM is an acceptable alternative to benzylpenicillin for empirical treatment prior to transfer to hospital. Ceftriaxone is suitable in patients hypersensitive to penicillin (excluding immediate hypersensitivity).

Patients who may have invasive meningococcal infection should be transferred urgently to hospital by ambulance.

Antibiotic therapy in hospital

Benzylpenicillin 2.4 g (children: 60 mg/kg up to 2.4 g) IV every 4 hours plus either

• Ceftriaxone 2 g (children: 50 mg/kg up to 2 g) IV every 12 hours or
• Cefotaxime 2 g (children 50 mg/kg up to 2 g) IV every 6 hours

Laboratory testing

Antibiotics should not be delayed while initiating or awaiting results of diagnostic tests.

Tests you need to take include:

• blood cultures (2 sets – 4 bottles); blood for PCR (EDTA tube)
• CSF for microscopy, culture and PCR (if possible meningitis)

Infection control

Droplet precautions (in addition to standard precautions) should be used until the completion of 24 hours of appropriate systematic antibiotics.

Notification

The Communicable Disease Control Branch, South Australia, should be notified on suspicion of invasive meningococcal disease on 1300 232 272 (24 hours, 7 days) to enable prompt public health follow up of close contacts for prophylactic antibiotics and information.

Vaccination

Meningococcal ACWY vaccine is available and is on the National Immunisation Program.

A vaccine against serogroup B is registered in Australia.

Support services

In some cases meningococcal infection has serious long term sequelae or is fatal. Doctors are urged to provide appropriate counselling or refer people to suitably qualified counsellors.

Resources

Emergency Department staff be alert for meningococcal disease!

A poster for use in emergency departments (PDF 449KB) that provides information on the clinical presentation, treatment, laboratory tests, infection control and notification of invasive meningococcal infection.

Be alert for meningococcal disease!

A desktop card for use in general practice surgeries (PDF 455KB) that provides information on the clinical presentation, treatment, laboratory tests, infection control and notification of invasive meningococcal infection.

Meningococcal infection - symptoms, treatment and prevention

An information resource for patients about invasive meningococcal infection detailing the clinical presentation, incubation period, infectious period, treatment and control of spread.