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Bacterial meningitis and meningococcal septicaemia overview

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Bacterial meningitis and meningococcal septicaemia HAI

About

What is covered

This pathway covers diagnosis and management of bacterial meningitis and menigococcal 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

26 August 2014 Minor maintenance updates.
17 September 2013 Minor maintenance updates.
24 May 2013 Update to change clinical guideline 47 links to Feverish illness in children pathway
26 February 2013 Minor maintenance updates.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care

What is covered

This pathway covers diagnosis and management of bacterial meningitis and menigococcal 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

26 August 2014 Minor maintenance updates.
17 September 2013 Minor maintenance updates.
24 May 2013 Update to change clinical guideline 47 links to Feverish illness in children pathway
26 February 2013 Minor maintenance updates.

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Bacterial meningitis and meningococcal septicaemia. NICE clinical guideline 102 (2010)

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.

Description of 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 clinical guideline references

NICE clinical guideline 47 recommendations 1.4.1.4 (key priority for implementation), 1.5.6.2 and 1.7.2.1.

Data source

Structure
Local data collection.
Process
Local data collection.
Outcomes
Local data collection.

Definitions

Non-specific symptoms and signs are detailed in table 1 of NICE clinical guideline 102.
‘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.

Description of 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 clinical guideline references

NICE clinical guideline 102 recommendations 1.1.6 and 1.4.47.
NICE clinical guideline 47 recommendation 1.2.1.1.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 102 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.

Description of 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 clinical guideline references

NICE clinical guideline 102 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 clinical guideline 102 provides information on the correct prescribing of antibiotics for children and young people presenting with a petechial rash.
See also management of petechial rash in this pathway.

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 practicefor 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.

Description of 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 clinical guideline references

NICE clinical guideline 102 recommendations 1.2.4 and 1.4.1–1.4.3.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 102 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 clinical guideline 102 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.

Description of 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 clinical guideline references

NICE clinical guideline 102 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 clinical guideline 102 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.

Description of 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 clinical guideline references

NICE clinical guideline 102 recommendation 1.3.20.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 102 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.

Description of 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 clinical guideline references

NICE clinical guideline 102 recommendation 1.3.8 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 102 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).

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.

Description of 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 clinical guideline references

NICE clinical guideline 47 recommendation 1.5.7.1.

Data source

Structure
Local data collection.
Process
Local data collection.

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 practicefor 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.

Description of 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 clinical guideline references

NICE clinical guideline 102 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 clinical guideline 102 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:
    • 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.

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.

Description of 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 reference

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.

Description of 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 clinical guideline references

NICE clinical guideline 102 recommendation 1.4.50.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 102 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.

Description of 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 clinical guideline references

NICE clinical guideline 102 recommendations 1.5.1 and 1.5.2.

Data source

Structure
Local data collection.
Process
Local data collection.
Outcomes
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.

Description of 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 clinical guideline references

NICE clinical guideline 102 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.

Description of 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 clinical guideline references

NICE clinical guideline 102 recommendations 1.5.5 (key priority for implementation) and 1.5.7.
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 clinical guideline 102 audit support (clinical and organisational criteria), criterion 15.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Non-specific symptoms/signs

Common non-specific symptoms/signs:
  • fever
  • vomiting/nausea
  • lethargy
  • irritable/unsettled
  • ill appearance
  • respiratory symptoms/signs or breathing difficulty
  • refusing food/drink
  • headache
  • muscle ache/joint pain.
Less common non-specific symptoms/signs:
  • chills/shivering
  • diarrhoea, abdominal pain/distension
  • sore throat/coryza or other ear, nose and throat symptoms/signs.

More specific symptoms/signs

More specific symptoms/signs:
  • shock
  • hypotension
  • toxic/moribund state
  • non-blanching rash
  • capillary refill time more than 2 seconds
  • unusual skin colour
  • cold hands/feet
  • leg pain
  • back rigidity
  • stiff neck
  • bulging fontanelle
  • Kernig's sign
  • Brudzinski's sign
  • photophobia
  • altered mental state
  • focal neurological deficit including cranial nerve involvement and abnormal pupils
  • seizures
  • unconsciousness
  • paresis.
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.
If there is a raised CRP and/or white blood cell count and an abnormal CSF, treat as bacterial meningitis.
Do not rule out bacterial meningitis if CRP and white blood cell count are normal.
If no CSF is available or the CSF findings are uninterpretable, manage as confirmed meningitis.
Symptoms and signs of bacterial meningitis and meningococcal septicaemia
Symptom / sign
Bacterial meningitis (meningococcal meningitis and meningitis caused by other bacteria)
Meningococcal disease (meningococcal meningitis and/or meningococcal septicaemia)
Meningococcal septicaemia
Common non-specific symptoms / signs (not always present, especially in neonates)
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
Chills / shivering
Y
Y
Y
Diarrhoea, abdominal pain / distension
Y
Y
NK
Sore throat / coryza or other ear, nose and throat symptoms / signs
Y
Y
NK
More specific symptoms / signs
Non-blanching rasha
Y
Y
Y
Stiff neck
Y
Y
NK
Altered mental stateb
Y
Y
Y
Capillary refill time more than 2 seconds
NK
Y
Y
Unusual skin colour
NK
Y
Y
Shock
Y
Y
Y
Hypotension
NK
Y
Y
Leg pain
NK
Y
Y
Cold hands / feet
NK
Y
Y
Back rigidity
Y
Y
NK
Bulging fontanellec
Y
Y
NK
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; NK: not known if present (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.
Perform whole blood real-time PCR testing (EDTA sample) for N meningitidis to confirm a diagnosis of meningococcal disease.
Take the PCR blood sample as soon as possible.
Use PCR testing of blood samples from other hospital laboratories if available, to avoid repeating the test.
Do not rule out meningococcal disease if a blood PCR test result for N meningitidis is negative.
Perform a lumbar puncture as a primary investigation unless this is contraindicated.
If there are contraindications (see below), consider delaying lumbar puncture until there are no longer contraindications.
Do not allow lumbar puncture to delay the administration of parenteral antibiotics.
Submit CSF to the laboratory to hold for PCR testing for N meningitidis and S pneumoniae, but only perform the PCR testing if the CSF culture is negative.
Be aware that CSF samples taken up to 96 hours after admission to hospital may give useful PCR results.
CSF examination should include white blood cell count and examination, total protein and glucose concentrations, Gram stain and microbiological culture. A corresponding laboratory-determined blood glucose concentration should be measured.
CSF white blood cell counts, total protein and glucose concentrations should be made available within 4 hours to support the decision regarding adjunctive steroid therapy.
In suspected bacterial meningitis, consider alternative diagnoses if the child or young person is significantly ill and has CSF variables within the accepted normal ranges.
Consider herpes simplex encephalitis as an alternative diagnosis.

Repeat lumbar puncture in neonates

Perform a repeat lumbar puncture in neonates with:
  • persistent or re-emergent fever
  • deterioration in clinical condition
  • new clinical findings (especially neurological findings) or
  • persistently abnormal inflammatory markers.
Do not perform a repeat lumbar puncture in neonates:
  • who are receiving the antibiotic treatment appropriate to the causative organism and are making a good clinical recovery
  • before stopping antibiotic therapy if they are clinically well.
Perform a lumbar puncture unless any of the following contraindications are present:
  • signs suggesting raised intracranial pressure
  • shock
  • extensive or spreading purpura
  • after convulsions until stabilised
  • coagulation abnormalities
    • coagulation results (if obtained) outside the normal range
    • platelet count below 100 x 109/litre
    • receiving anticoagulant therapy
  • local 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)
  • radiological evidence of raised intracranial pressure.
Signs suggesting raised intracranial pressure:
  • reduced or fluctuating level of consciousness
  • relative bradycardia and hypertension
  • focal neurological signs
  • abnormal posture or posturing
  • unequal, dilated or poorly responsive pupils
  • papilloedema
  • abnormal 'doll's eye' movements.

Non-specific symptoms/signs

Common non-specific symptoms/signs:
  • fever
  • vomiting/nausea
  • lethargy
  • irritable/unsettled
  • ill appearance
  • respiratory symptoms/signs or breathing difficulty
  • refusing food/drink
  • headache
  • muscle ache/joint pain.
Less common non-specific symptoms/signs:
  • chills/shivering
  • diarrhoea, abdominal pain/distension
  • sore throat/coryza or other ear, nose and throat symptoms/signs.

More specific symptoms/signs

More specific symptoms/signs:
  • stiff neck
  • altered mental state
  • back rigidity
  • bulging fontanelle
  • photophobia
  • Kernig's sign
  • Brudzinski's sign
  • unconsciousness
  • toxic/moribund state
  • paresis
  • focal neurological deficit including cranial nerve involvement and abnormal pupils
  • seizures
  • shock.
Do not perform a lumbar puncture.
Nil by mouth.
Check airway and breathing.
Give oxygen by face mask.
Give an immediate fluid bolus of intravenous or intraosseous 20 ml/kg sodium chloride 0.9% over 5–10 minutes.
Reassess immediately.
If signs of shock persist, immediately give a second bolus of intravenous or intraosseous 20 ml/kg sodium chloride 0.9% or human albumin 4.5% solution over 5–10 minutes.
If signs of shock remain after a total of 40 ml/kg fluid:
  • immediately give a third bolus of intravenous or intraosseous 20 ml/kg sodium chloride 0.9% or human albumin 4.5% solution over 5–10 minutes
  • call for anaesthetic assistance for urgent tracheal intubation and mechanical ventilation (use local or national protocols for intubation)
  • start treatment with vasoactive drugs (use local or national protocols)
  • consult with paediatric intensivist
  • anticipate aspiration and pulmonary oedema.
Anticipate, monitor and correct glucose, acid/base and electrolyte disturbances, and anaemia and coagulopathy using local or national protocols.
In children and young people with shock that is unresponsive to vasoactive agents, steroid replacement therapy using low-dose corticosteroids (hydrocortisone 25 mg/m2 four times daily) should be used only when directed by a paediatric intensivist.
Do not treat meningococcal septicaemia with high-dose corticosteroids (defined as dexamethasone 0.6 mg/kg/day or an equivalent dose of other corticosteroids).
Do not use activated protein C or recombinant bacterial permeability-increasing protein in children and young people with meningococcal septicaemia.

Glossary

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: August 2014

© NICE 2014

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