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Bacterial meningitis and meningococcal septicaemia overview

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Bacterial meningitis and meningococcal septicaemia

About

What is covered

This pathway covers diagnosis and management of bacterial meningitis and meningococcal septicaemia in children and young people (under 16 years) in primary and secondary care.
Meningococcal disease is the leading infectious cause of death in early childhood. It most commonly presents as bacterial meningitis (15% of cases of N meningitidis) or septicaemia (25% of cases), or as a combination of the two presentations (60% of cases).
The epidemiology of bacterial meningitis in the UK has changed dramatically in the past two decades following the introduction of vaccines to control H influenzae type b, serogroup C meningococcus and pneumococcal disease. However, no vaccine is currently licensed against serogroup B meningococcus, and this pathogen is now the most common cause of bacterial meningitis (and septicaemia) in children and young people aged 3 months or older.
The control of meningococcal disease is therefore a priority for clinical management (as well as public health surveillance and control).
Bacterial meningitis and meningococcal septicaemia are managed in different ways, therefore it is important that healthcare professionals are able to recognise them and manage them accordingly.

Updates

Updates to this pathway

11 May 2016 Pathway restructured and summarised recommendations replaced with full recommendations.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on managing bacterial meningitis and meningococcal septicaemia in children and young people in an interactive flowchart.

What is covered

This pathway covers diagnosis and management of bacterial meningitis and meningococcal septicaemia in children and young people (under 16 years) in primary and secondary care.
Meningococcal disease is the leading infectious cause of death in early childhood. It most commonly presents as bacterial meningitis (15% of cases of N meningitidis) or septicaemia (25% of cases), or as a combination of the two presentations (60% of cases).
The epidemiology of bacterial meningitis in the UK has changed dramatically in the past two decades following the introduction of vaccines to control H influenzae type b, serogroup C meningococcus and pneumococcal disease. However, no vaccine is currently licensed against serogroup B meningococcus, and this pathogen is now the most common cause of bacterial meningitis (and septicaemia) in children and young people aged 3 months or older.
The control of meningococcal disease is therefore a priority for clinical management (as well as public health surveillance and control).
Bacterial meningitis and meningococcal septicaemia are managed in different ways, therefore it is important that healthcare professionals are able to recognise them and manage them accordingly.

Updates

Updates to this pathway

11 May 2016 Pathway restructured and summarised recommendations replaced with full recommendations.

Sources

NICE guidance and other sources used to create this pathway.

Quality standards

Quality statements

‘Safety netting’ information

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Parents and carers of children and young people presenting with non-specific symptoms and signs are given ‘safety netting’ information that includes information on bacterial meningitis and meningococcal septicaemia.

Quality measure

Structure: Evidence of local arrangements for parents and carers of children and young people presenting with non-specific symptoms and signs to be given ‘safety netting’ information that includes information on bacterial meningitis and meningococcal septicaemia.
Process: Proportion of parents or carers of children and young people presenting with non-specific symptoms and signs who are given ‘safety netting’ information that includes information on bacterial meningitis and meningococcal septicaemia.
Numerator – the number of people in the denominator who are given ‘safety netting’ information that includes information on bacterial meningitis and meningococcal septicaemia.
Denominator – the number of parents or carers of children and young people presenting with non-specific symptoms and signs.
Outcome: Parent/carer satisfaction with information received.

What the quality statement means for each audience

Service providers ensure systems are in place for parents and carers of children and young people presenting with non-specific symptoms and signs to be given ‘safety netting’ information that includes information on bacterial meningitis and meningococcal septicaemia.
Healthcare professionals give ‘safety netting’ information to parents and carers of children and young people presenting with non-specific symptoms and signs, including information on bacterial meningitis and meningococcal septicaemia.
Commissioners ensure they commission services that enable parents and carers of children and young people presenting with non-specific symptoms and signs to be given ‘safety netting’ information that includes information on bacterial meningitis and meningococcal septicaemia.
Parents and carers of children and young people with general symptoms are given ‘safety netting’ information (for example, advice on what symptoms to look out for and how and when to seek further care) that includes information on bacterial meningitis and meningococcal septicaemia (blood poisoning).

Source guidance

Feverish illness in children NICE guideline CG160, recommendations 1.4.2.3 (key priority for implementation), 1.5.8.2 and 1.7.2.1.

Data source

Structure: Local data collection.
Process: Local data collection.
Outcome: Local data collection.

Definitions

Non-specific symptoms and signs are detailed in table 1 of NICE guideline CG102.
‘Safety netting’ information comprises oral and/or written information on what symptoms to look out for, how to access further care, likely time course of expected illness and, if appropriate, the uncertainty of the diagnosis.
Information on warning symptoms should include a specific instruction for parents and carers looking after a feverish child to seek further advice if any of the following occur:
  • The child develops a non-blanching rash.
  • The parent or carer feels that the child is less well than when they previously sought advice.
  • The parent or carer is more worried than when they previously sought advice.
  • The fever lasts longer than 5 days.
  • The parent or carer is distressed, or concerned that they are unable to look after the child.
  • The child is lethargic or irritable.
  • The child stops feeding (infants only).
  • The child has a fit.

Monitoring

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

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.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia to have their temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition monitored at least hourly until stable.
Process: Proportion of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia who have their temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition monitored at least hourly until stable.
Numerator – the number of people in the denominator who have their temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition monitored at least hourly until stable.
Denominator – the number of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia to have their temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition monitored at least hourly until stable.
Healthcare professionals monitor the temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia at least hourly until stable.
Commissioners ensure they commission services for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia to have their temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition monitored at least hourly until stable.
Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia (blood poisoning) have their temperature, breathing, pulse, blood pressure, urine production, blood oxygen levels and level of consciousness monitored at least every hour until they are stable.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.1.6 and 1.4.47.
Feverish illness in children NICE guideline CG160, recommendation 1.2.1.1.

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (clinical and organisational criteria), criterion 1.

Definitions

Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia have the physiological observations described in the statement assessed regularly throughout their care pathway, whether presenting in primary care or after they have been admitted to hospital.
Neurological condition is assessed using observations that include pupillary reactions, motor function and levels of consciousness (Glasgow Coma Scale or AVPU [Alert, Voice, Pain, Unresponsive]).

Management of petechial rash

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people presenting with a petechial rash receive antibiotics in accordance with NICE guidance.

Quality measure

Structure: Evidence of local arrangements for children and young people presenting with a petechial rash to receive antibiotics in accordance with NICE guidance.
Process: Proportion of children and young people presenting with a petechial rash who receive antibiotics in accordance with NICE guidance.
Numerator – the number of people in the denominator who receive antibiotics in accordance with NICE guidance.
Denominator – the number of children and young people presenting with a petechial rash.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people presenting with a petechial rash to receive antibiotics in accordance with NICE guidance.
Healthcare professionals give antibiotics to children and young people presenting with a petechial rash in accordance with NICE guidance.
Commissioners ensure they commission services that ensure children and young people presenting with a petechial rash receive antibiotics in accordance with NICE guidance.
Children and young people with a rash of small red or purple spots that doesn’t fade when a glass is pressed firmly against the skin (a non-blanching rash) have appropriate investigations and receive antibiotics if their healthcare professional considers them at risk of bacterial meningitis or meningococcal septicaemia (blood poisoning).

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.3.2 (key priority for implementation) and 1.3.3–1.3.6.

Data source

Structure: Local data collection.
Process: Local data collection.

Definitions

NICE guideline CG102 provides information on the correct prescribing of antibiotics for children and young people presenting with a petechial rash.
NICE guidance on the management of petechial rash is also available in diagrammatical form in the NICE pathway on bacterial meningitis and meningococcal septicaemia.

Initiation of antibiotics

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people with suspected bacterial meningitis or meningococcal septicaemia receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected bacterial meningitis or meningococcal septicaemia to receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Process: Proportion of children and young people with suspected bacterial meningitis or meningococcal septicaemia who receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Numerator – the number of people in the denominator who receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Denominator – the number of children and young people with suspected bacterial meningitis or meningococcal septicaemia arriving in hospital.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected bacterial meningitis or meningococcal septicaemia to receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Healthcare professionals give children and young people with suspected bacterial meningitis or meningococcal septicaemia intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Commissioners ensure they commission services for children and young people with suspected bacterial meningitis or meningococcal septicaemia to receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Children and young people with suspected bacterial meningitis or meningococcal septicaemia (blood poisoning) are given antibiotics intravenously (directly into a vein through a needle or thin tube) or intraosseously (directly into the bone through a needle or thin tube) within an hour of arrival at hospital.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.2.4 and 1.4.1–1.4.3.

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (pharmacological interventions), criteria 2–4.

Definitions

Antibiotics should be administered for children and young people with suspected bacterial meningitis or meningococcal septicaemia as soon as possible in order to optimise chances of recovery, and within an hour of arrival in secondary care.
While antibiotics should be given at the earliest opportunity, either in primary or secondary care (without delaying urgent transfer to hospital to do so), this statement concerns children and young people with suspected bacterial meningitis or meningococcal septicaemia for whom there has been no delay in their transfer to hospital, either from their GP or through attendance at an accident and emergency department.
For children and young people for whom urgent transfer to hospital is not possible (for example, in remote locations or adverse weather conditions), antibiotics may be given in primary or community care (see NICE guideline CG102 recommendations 1.2.3 and 1.2.4).

Lumbar puncture for suspected bacterial meningitis

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people with suspected bacterial meningitis have a lumbar puncture.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected bacterial meningitis to have a lumbar puncture.
Process: Proportion of children and young people with suspected bacterial meningitis who have a lumbar puncture.
Numerator – the number of people in the denominator who have a lumbar puncture.
Denominator – the number of children and young people with suspected bacterial meningitis.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected bacterial meningitis to have a lumbar puncture.
Healthcare professionals perform a lumbar puncture for children and young people with suspected bacterial meningitis.
Commissioners ensure they commission services for children and young people with suspected bacterial meningitis to have a lumbar puncture.
Children and young people with suspected bacterial meningitis have a procedure called a lumbar puncture, in which a sample of the fluid surrounding the brain and spinal cord is taken using a hollow needle inserted into the lower part of the back.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.3.18 (key priority for implementation) and 1.3.19.

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (clinical and organisational criteria), criterion 7.

Definitions

It is important that children and young people with suspected bacterial meningitis have a lumbar puncture as soon as possible, but only when it is safe to do so. Contraindications to lumbar puncture include:
  • signs suggesting raised intracranial pressure:
    • reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more)
    • age-relative bradycardia and hypertension
    • focal neurological signs
    • abnormal posture or posturing
    • unequal, dilated or poorly responsive pupils
    • papilloedema
    • abnormal ‘doll’s eye’ movements
    • tense, bulging fontanelle
  • shock
  • extensive or spreading purpura
  • convulsions until stabilised
  • coagulation abnormalities:
    • coagulation results (if obtained) outside the normal range
    • platelet count below 100 x 109/litre
    • receiving anticoagulant therapy
  • superficial infection at the lumbar puncture site
  • respiratory insufficiency (lumbar puncture is considered to have a high risk of precipitating respiratory failure in the presence of respiratory insufficiency).

CSF microscopy for suspected bacterial meningitis

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people with suspected bacterial meningitis have their cerebrospinal fluid (CSF) microscopy result available within 4 hours of lumbar puncture.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected bacterial meningitis to have their CSF microscopy result available within 4 hours of lumbar puncture.
Process: Proportion of children and young people with suspected bacterial meningitis who have their CSF microscopy result available within 4 hours of lumbar puncture.
Numerator – the number of people in the denominator who have their CSF microscopy result available within 4 hours of lumbar puncture.
Denominator – the number of children and young people with suspected bacterial meningitis who have had a lumbar puncture.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected bacterial meningitis to have their CSF microscopy result available within 4 hours of lumbar puncture.
Healthcare professionals ensure children and young people with suspected bacterial meningitis have their CSF microscopy result available within 4 hours of lumbar puncture.
Commissioners ensure they commission services for children and young people with suspected bacterial meningitis to have their CSF microscopy result available within 4 hours of lumbar puncture.
Children and young people with suspected bacterial meningitis have the results of their lumbar puncture within 4 hours of the procedure being done.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendation 1.3.20.

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (clinical and organisational criteria), criterion 8.

Definitions

CSF microscopy provides the CSF white blood cell count, which is the most important investigation for a diagnosis of meningitis. Samples should also be routinely processed for total protein and glucose concentrations.
It is important that samples are processed rapidly given that white cell counts decrease significantly with time.

Blood tests

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people with suspected bacterial meningitis or meningococcal septicaemia have whole blood meningococcal polymerase chain reaction (PCR) testing.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected bacterial meningitis or meningococcal septicaemia to have whole blood meningococcal PCR testing.
Process: Proportion of children and young people with suspected bacterial meningitis or meningococcal septicaemia who have whole blood meningococcal PCR testing.
Numerator – the number of people in the denominator who have whole blood meningococcal PCR testing.
Denominator – the number of children and young people with suspected bacterial meningitis or meningococcal septicaemia.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected bacterial meningitis or meningococcal septicaemia to have whole blood meningococcal PCR testing.
Healthcare professionals carry out whole blood meningococcal PCR testing for children and young people with suspected bacterial meningitis or meningococcal septicaemia.
Commissioners ensure they commission services for children and young people with suspected bacterial meningitis or meningococcal septicaemia to have whole blood meningococcal PCR testing.
Children and young people with suspected bacterial meningitis or meningococcal septicaemia (blood poisoning) have a blood sample taken for a type of DNA laboratory test called PCR that will help confirm the diagnosis.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendation 1.3.8 (key priority for implementation).

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (clinical and organisational criteria), criterion 3.

Definitions

PCR is a DNA-based diagnostic test.
PCR testing may not always be appropriate (for example, if the diagnosis has been confirmed by positive blood or cerebrospinal fluid cultures).
:title Access to specialists

Access to specialists

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

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.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia who have signs of shock or raised intracranial pressure to be assessed by a consultant paediatrician.
Process: Proportion of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia who have signs of shock or raised intracranial pressure that are assessed by a consultant paediatrician.
Numerator – the number of people in the denominator who are assessed by a consultant paediatrician.
Denominator – the number of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia who have signs of shock or raised intracranial pressure.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia who have signs of shock or raised intracranial pressure to be assessed by a consultant paediatrician.
Healthcare professionals ensure that 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.
Commissioners ensure they commission services for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia who have signs of shock or raised intracranial pressure to be assessed by a consultant paediatrician.
Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia (blood poisoning) who have signs of shock (for example unusual skin colour or breathing difficulty) or raised pressure in the brain are assessed by a consultant paediatrician.

Source guidance

Feverish illness in children NICE guideline CG160, recommendation 1.5.9.1.

Data source

Structure: Local data collection.
Process: Local data collection.

Transfer within and between hospitals

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

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.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals to be escorted by a healthcare professional trained in advanced paediatric life support.
Process: Proportion of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals who are escorted by a healthcare professional trained in advanced paediatric life support.
Numerator – the number of people in the denominator who are escorted by a healthcare professional trained in advanced paediatric life support.
Denominator – the number of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals to be escorted by a healthcare professional trained in advanced paediatric life support.
Healthcare professionals ensure 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.
Commissioners ensure they commission services for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals to be escorted by a healthcare professional trained in advanced paediatric life support.
Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia (blood poisoning) being transferred within or between hospitals are escorted by a healthcare professional trained in life saving treatment for children (advanced paediatric life support).

Source guidance

Topic Expert Group consensus.

Data source

Structure: Local data collection.
Process: Local data collection.

Transfer to intensive care

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

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.

Quality measure

Structure: Evidence of local arrangements for 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 to be transferred by a specialist paediatric retrieval team.
Process: Proportion of 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 who are transferred by a specialist paediatric retrieval team.
Numerator – the number of people in the denominator who are transferred by a specialist paediatric retrieval team.
Denominator – the number of 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.

What the quality statement means for each audience

Service providers ensure systems are in place for 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 to be transferred by a specialist paediatric retrieval team.
Healthcare professionals ensure 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.
Commissioners ensure they commission services for 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 to be transferred by a specialist paediatric retrieval team.
Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia (blood poisoning) who need to be transferred to a paediatric intensive care unit or high dependency unit in another hospital are taken by a team of healthcare professionals that specialises in caring for and transporting seriously ill children (a paediatric retrieval team).

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendation 1.4.50.

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (clinical and organisational criteria), criterion 24.

Definitions

A specialist paediatric retrieval team comprises medical and nursing staff with specialist training in the transfer of sick children and young people from hospitals to paediatric intensive care or high dependency units.

Information provision

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people who have had bacterial meningitis or meningococcal septicaemia, and/or their parents and carers, are given information before discharge about the disease, its potential long-term effects and how to access further support.

Quality measure

Structure: Evidence of local arrangements for children and young people who have had bacterial meningitis or meningococcal septicaemia, or their parents and carers, to be given information before discharge about the disease, its potential long-term effects and how to access further support.
Process: Proportion of children and young people who have had bacterial meningitis or meningococcal septicaemia, or their parents or carers, who receive information before discharge about the disease, its potential long-term effects and how to access further support.
Numerator – the number of people in the denominator or their parents or carers who receive information before discharge about the disease, its potential long-term effects and how to access further support.
Denominator – the number of children and young people who have had bacterial meningitis or meningococcal septicaemia.
Outcome: Patient and/or parent or carer satisfaction with information received before discharge.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people who have had bacterial meningitis or meningococcal septicaemia, and/or their parents and carers, to be given information before discharge about the disease, its potential long-term effects and how to access further support.
Healthcare professionals give information before discharge to children and young people who have had bacterial meningitis or meningococcal septicaemia and/or their parents and carers about the disease, its potential long-term effects and how to access further support.
Commissioners ensure they commission services for children and young people who have had bacterial meningitis or meningococcal septicaemia, and/or their parents and carers, to be given information before discharge about the disease, its potential long-term effects and how to access further support.
Children and young people who have had bacterial meningitis or meningococcal septicaemia (blood poisoning), and/or their parents and carers, are given information before leaving hospital about the disease, its potential long-term effects and how to access further support.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.5.1 and 1.5.2.

Data source

Structure: Local data collection.
Process: Local data collection.
Outcome: Local data collection.

Definitions

Further support can be provided for children and young people who have had bacterial meningitis or meningococcal septicaemia, and their parents or carers by the GP, or hospital paediatrician and by patient support organisations, including meningitis charities that can offer support, befriending, in-depth information, advocacy, counselling, and written information to signpost families to further help.

Audiological assessment

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people who have had bacterial meningitis or meningococcal septicaemia have an audiological assessment before discharge.

Quality measure

Structure: Evidence of local arrangements for children and young people who have had bacterial meningitis or meningococcal septicaemia to have an audiological assessment before discharge.
Process: Proportion of children and young people who have had bacterial meningitis or meningococcal septicaemia who have an audiological assessment before discharge.
Numerator – the number of people in the denominator who have an audiological assessment before discharge.
Denominator – the number of children and young people who have had bacterial meningitis or meningococcal septicaemia.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people who have had bacterial meningitis or meningococcal septicaemia to have an audiological assessment before discharge.
Healthcare professionals ensure children and young people who have had bacterial meningitis or meningococcal septicaemia have an audiological assessment before discharge.
Commissioners ensure they commission services for children and young people who have had bacterial meningitis or meningococcal septicaemia to have an audiological assessment before discharge.
Children and young people who have had bacterial meningitis or meningococcal septicaemia (blood poisoning) have a hearing test before they leave hospital.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendation 1.5.3.

Data source

Structure: Local data collection.
Process: Local data collection.

Definitions

It may not be possible to arrange an audiological assessment before discharge in all circumstances. Where this is the case the assessment should be undertaken within 4 weeks of the child or young person being fit to undergo testing (that is, once they are no longer critically ill).

Follow-up

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people who have had bacterial meningitis or meningococcal septicaemia have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.

Quality measure

Structure: Evidence of local arrangements for children and young people who have had bacterial meningitis or meningococcal septicaemia to have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.
Process: Proportion of children and young people who have had bacterial meningitis or meningococcal septicaemia who have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.
Numerator – the number of people in the denominator who have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.
Denominator – the number of children and young people who are discharged after having had bacterial meningitis or meningococcal septicaemia.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people who have had bacterial meningitis or meningococcal septicaemia to have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.
Healthcare professionals ensure that children and young people who have had bacterial meningitis or meningococcal septicaemia have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.
Commissioners ensure they commission services for children and young people who have had bacterial meningitis or meningococcal septicaemia to have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.
Children and young people who have had bacterial meningitis or meningococcal septicaemia (blood poisoning) have an appointment with a specialist (a consultant paediatrician) within 6 weeks of leaving hospital.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.5.5 (key priority for implementation) and 1.5.7.
Management of invasive meningococcal disease in children and young people SIGN clinical guideline 102, recommendation 9.1.7.

Data source

Structure: Local data collection.
Process: Hospital Episode Statistics contain the data necessary for the monitoring of outpatient follow-up.
Also contained within NICE guideline CG102 audit support (clinical and organisational criteria), criterion 15.

Tracheal intubation and mechanical ventilation in meningococcal septicaemia

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

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.

Quality measure

Structure: Evidence of local arrangements for children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation to have the procedure undertaken by an anaesthetist experienced in paediatric airway management.
Process: Proportion of children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation who have the procedure undertaken by an anaesthetist experienced in paediatric airway management.
Numerator – the number of people in the denominator who have the tracheal intubation and mechanical ventilation procedure undertaken by an anaesthetist experienced in paediatric airway management.
Denominator – the number of children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation to have the procedure undertaken by an anaesthetist experienced in paediatric airway management.
Healthcare professionals ensure that 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.
Commissioners ensure they commission services for children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation to have the procedure undertaken by an anaesthetist experienced in paediatric airway management.
Children and young people with meningococcal septicaemia (blood poisoning) receiving help to breathe using a tube inserted into their windpipe (tracheal intubation) through which air is pushed into the lungs via a ventilator machine (ventilation), have the procedure undertaken by an experienced specialist (an anaesthetist experienced in paediatric airway management).

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.4.30 (key priority for implementation) and 1.4.35.

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (pharmacological criteria), criterion 16.

Definitions

Tracheal intubation with mechanical ventilation is required for the following indications.
  • Threatened (for example, loss of gag reflex) or actual loss of airway patency.
  • The need for any form of assisted ventilation, for example bag–mask ventilation.
  • Clinical observation of increasingly laboured breathing.
  • Hypoventilation or apnoea.
  • Features of respiratory failure, including:
    • reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more)
    • irregular respiration (for example, Cheyne–Stokes breathing)
    • hypoxia (PaO2 less than 13 kPa or 97.5 mmHg) or decreased - oxygen saturations in air
    • hypercapnia (PaCO2 greater than 6 kPa or 45 mmHg).
  • Continuing shock following infusion of a total of 40 ml/kg of resuscitation fluid.
  • Signs of raised intracranial pressure.
  • Impaired mental status, including:
    • reduced or fluctuating level of consciousness (Glasgow Coma - Scale score less than 9 or a drop of 3 or more)
    • moribund state.
  • Control of intractable seizures.
  • Need for stabilisation and management to allow brain imaging or transfer to the paediatric intensive care unit or another hospital. An anaesthetist experienced in paediatric airway management is an anaesthetist who has maintained their skills in paediatric resuscitation to the level of advanced paediatric life support or equivalent (for example by undertaking regular supernumerary attachments to paediatric lists or secondments to specialist centres/paediatric simulator work).
In the absence of an anaesthetist, another clinician experienced in paediatric airway management may undertake tracheal intubation and mechanical ventilation for children and young people with meningococcal septicaemia.
A paediatric intensivist should be consulted by the clinician undertaking tracheal intubation and mechanical ventilation.

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Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

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Supporting information

Table 1 Symptoms and signs of bacterial meningitis and meningococcal septicaemia

Common non-specific symptoms / signs (not always present, especially in neonates)
Symptom / sign
Bacterial meningitis (meningococcal meningitis and meningitis caused by other bacteria)
Meningococcal disease (meningococcal meningitis and/or meningococcal septicaemia)
Meningococcal septicaemia
Fever
Y
Y
Y
Vomiting / nausea
Y
Y
Y
Lethargy
Y
Y
Y
Irritable / unsettled
Y
Y
Y
Ill appearance
Y
Y
Y
Refusing food / drink
Y
Y
Y
Headache
Y
Y
Y
Muscle ache / joint pain
Y
Y
Y
Respiratory symptoms / signs or breathing difficulty
Y
Y
Y
Less common non-specific symptoms / signs
Symptom / sign
Bacterial meningitis (meningococcal meningitis and meningitis caused by other bacteria)
Meningococcal disease (meningococcal meningitis and/or meningococcal septicaemia)
Meningococcal septicaemia
Chills / shivering
Y
Y
Y
Diarrhoea, abdominal pain / distension
Y
Y
Not known
Sore throat / coryza or other ear, nose and throat symptoms / signs
Y
Y
Not known
More specific symptoms / signs
Symptom / sign
Bacterial meningitis (meningococcal meningitis and meningitis caused by other bacteria)
Meningococcal disease (meningococcal meningitis and/or meningococcal septicaemia)
Meningococcal septicaemia
Non-blanching rasha
Y
Y
Y
Stiff neck
Y
Y
Not known
Altered mental stateb
Y
Y
Y
Capillary refill time more than 2 seconds
Not known
Y
Y
Unusual skin colour
Not known
Y
Y
Shock
Y
Y
Y
Hypotension
Not known
Y
Y
Leg pain
Not known
Y
Y
Cold hands / feet
Not known
Y
Y
Back rigidity
Y
Y
Not known
Bulging fontanellec
Y
Y
Not known
Photophobia
Y
Y
N
Kernig's sign
Y
Y
N
Brudzinski's sign
Y
Y
N
Unconsciousness
Y
Y
Y
Toxic / moribund state
Y
Y
Y
Paresis
Y
Y
N
Focal neurological deficit including cranial nerve involvement and abnormal pupils
Y
Y
N
Seizures
Y
Y
N
Y: symptom or sign present;
N: symptom or sign not present;
Not known: not reported in the evidence.
a Be aware that a rash may be less visible in darker skin tones – check soles of feet, palms or hands and conjunctivae;
b Includes confusion, delirium and drowsiness, and impaired consciousness;
c Only relevant in children under 2 years.

Table 2 Signs of shock

Signs of shock include:
  • capillary refill time more than 2 seconds
  • unusual skin colour
  • tachycardia and/or hypotension
  • respiratory symptoms or breathing difficulty
  • leg pain
  • cold hands/feet
  • toxic/moribund state
  • altered mental state/decreased conscious level
  • poor urine output

Glossary

Alert, voice, pain, unresponsive.
C-reactive protein
Cerebrospinal fluid
Computed tomography
ethylenediaminetetraacetic acid
Haemophilus influenzae
Listeria monocytogenes
Neisseria meningitidis
polymerase chain reaction
summary of product characteristics
Streptococcus pneumoniae
white blood cell

Paths in this pathway

Pathway created: July 2012 Last updated: June 2016

© NICE 2016

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