Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management—summary of updated NICE guidance

Recognition

In these new recommendations, most of the symptoms and signs identified were at least moderately (≥50%) or highly (≥90%) sensitive or specific for a diagnosis of bacterial meningitis or meningococcal disease (infographic and tables 1-3). However, the evidence appraised was mostly based on individual symptoms and signs, as limited data were available for the diagnostic accuracy of combinations, and from adult populations. The presence of these individual symptoms or signs alone may not be sufficient to make a diagnosis because of the substantial overlap with other conditions that present similarly.

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Therefore, the Guideline Committee considered the evidence along with their clinical knowledge and experience to identify combinations of symptoms and signs (red flag combinations) that should raise the index of suspicion or prompt an assessor to strongly suspect bacterial meningitis or meningococcal disease. Recommendations were classified as “strongly suspect” if there were the red flag combinations. However, they should not be used in isolation, and the guideline contains further information about when to suspect bacterial meningitis and meningococcal disease in the absence of these red flag symptoms and signs.

Evidence on risk factors that increase the likelihood of an individual having bacterial meningitis or meningococcal disease was also evaluated. Recommendations were classified as “be on heightened alert to the possibility of” if a risk ratio of >1.25 (moderate association) or >2.00 (strong association) was found between a risk factor and bacterial meningitis or meningococcal disease, or based on the Guideline Committee’s experience. Being on heightened alert may prompt strong suspicions for bacterial meningitis or meningococcal disease in the absence of red flag combinations.

• Strongly suspect bacterial meningitis in people with all the symptoms in the red flag combination:

  • Fever

  • Headache

  • Neck stiffness

  • Altered level of consciousness or cognition (including confusion or delirium).

• Be on heightened alert to the possibility of bacterial meningitis (including meningococcal meningitis) in people with any of these risk factors:

  • Missed relevant immunisations, such as meningococcal, Haemophilus influenzae type b (Hib), or pneumococcal vaccines

  • Reduced or absent spleen function

  • Congenital complement deficiency or acquired inhibition

  • A student in further or higher education, particularly if they are in large shared accommodation (such as halls of residence)

  • A family history of meningococcal disease

  • Have been in contact with someone with Hib disease or meningococcal disease, or have been in an area with an outbreak of meningococcal disease

  • A previous episode of bacterial meningitis or meningococcal disease

  • A cerebrospinal fluid leak

  • A cochlear implant.

• Strongly suspect meningococcal disease in people with any of these red flag symptoms:

  • Haemorrhagic, non-blanching rash with lesions larger than 2 mm (purpura)

  • Rapidly progressive and/or spreading non-blanching petechial or purpuric rash

  • Any symptoms and signs of bacterial meningitis (see tables 1 and 2), when combined with a non-blanching petechial or purpuric rash.

• Be on heightened alert to the possibility of meningococcal disease in people with any of these risk factors:

  • Missed meningococcal vaccinations

  • Reduced or absent spleen function

  • Complement deficiency or inhibition

  • A student in further or higher education, particularly if they are in large shared accommodation (such as halls of residence)

  • A family history of meningococcal disease

  • Have been in contact with someone with meningococcal disease, or have been in an area with an outbreak

  • A previous episode of meningococcal disease.

• If you send a person home after clinical assessment for bacterial meningitis and meningococcal disease:

  • Give safety netting advice (see recommendation 1.3.2 of full guideline)

  • Ask them to return for further assessment if they develop new symptoms, if a rash changes from blanching to non-blanching, or if existing symptoms get worse.

  [Based on very low to high quality evidence and the experience and opinion of the Guideline Committee (GC)]

Antibiotic therapy pre-hospital

These recommendations were updated, now including or amending suggestions of recommended antibiotic therapy pre-hospital. Following evidence review, administration of pre-hospital antibiotic therapy was not associated with improved clinical outcomes in patients with suspected bacterial meningitis and meningococcal disease.56 However, in the real world setting, it remains difficult to distinguish bacterial meningitis from other conditions that do not require antibiotic therapy, patients who have meningococcal disease deteriorate rapidly, and there can be substantial delay in transferring patients to hospital. Therefore, pre-hospital antibiotic therapy should be given where meningococcal disease is strongly suspected unless it will delay transfer to hospital, or where transfer to hospital is likely to be significantly delayed for people with strongly suspected bacterial meningitis.

Ceftriaxone is the preferred option because it is a broad spectrum antibiotic, but it is less commonly available outside of hospital than benzylpenicillin. Administering the antibiotic intramuscularly, rather than intravenously, is more practical.

• If there is likely to be a clinically significant delay in transfer to hospital for people with strongly suspected bacterial meningitis, give intravenous or intramuscular ceftriaxone or benzylpenicillin outside of hospital.

• For people with strongly suspected meningococcal disease, give intravenous or intramuscular ceftriaxone or benzylpenicillin as soon as possible outside of hospital, unless this will delay transfer to hospital.

• Do not give antibiotics outside of hospital if the person has severe antibiotic allergy to either ceftriaxone or benzylpenicillin.

  [Based on very low to low quality evidence from observational studies and the experience and opinion of the GC]

Timing of investigations and antibiotic therapy in-hospital

Initiation of antibiotic therapy for suspected bacterial meningitis or meningococcal disease before investigations may hinder diagnosis or lead to unnecessary antibiotic use if patients have a non-bacterial illness. Previous NICE guidance recommended giving antibiotics without delay and what investigations to perform, but did not comment on timeframes or sequencing.

Following evidence review, early (0 to 3 hours) compared with later (≥2 to >3 hours) in-hospital antibiotic administration for bacterial meningitis is associated with lower rates of mortality in adults,78 but there is limited evidence to inform a specific timeframe. For suspected meningococcal disease, there is no evidence comparing different timings of in-hospital antibiotic administration. The hour after arrival in hospital is widely regarded as the “golden hour” for people with life-threatening conditions and was considered enough time to stabilise a patient, take blood samples, and administer antibiotic therapy. When bacterial meningitis is suspected, it may not always be possible to perform a lumbar puncture, but doing so before starting antibiotic therapy should be the goal when this can be done within one hour.

• A senior clinical decision maker should perform an initial assessment and ensure that:

  • Antibiotics start within one hour of the person with suspected bacterial meningitis arriving at hospital, and in line with the section on antibiotics for bacterial meningitis in hospital [in the full guideline]

  • Blood tests and lumbar puncture are performed before starting antibiotics (if it is safe to do so and will not cause a clinically significant delay to starting antibiotics), and in line with the sections on blood tests and lumbar puncture [in the full guideline].

• A senior clinical decision maker should perform an initial assessment and ensure that:

  • Antibiotics start within one hour of the person with suspected meningococcal disease arriving at hospital, and in line with the section on antibiotics for meningococcal disease in hospital [in the full guideline]

  • Blood tests are performed before starting antibiotics, and in line with the section on blood tests [in the full guideline].

  [Based on low quality evidence from observational studies and the experience and opinion of the GC]

Hospital discharge and post-discharge care

A wide range of long term complications are associated with bacterial meningitis and meningococcal disease, some of which may not be evident for several months or years.910 Do not discharge people with bacterial meningitis and meningococcal disease from hospital until relevant assessments have taken place and an appropriate follow-up plan has been arranged.

The updated recommendations comment on timing of follow-up visits, how long people should be followed up for, and which assessments should be undertaken. Patients prefer written information, such as a detailed discharge summary, and think that it is helpful and informative.11 A review at four to six weeks after discharge is newly recommended for all adults, in line with the existing recommendation for babies, children, and young people, to discuss any known complications and ensure any delayed complications are not missed. The Guideline Committee did not specify who should undertake this review because there could be variation in practice locally but acknowledged that such assessments are usually performed in secondary care.

• For people who are taking antiepileptic drugs, refer for a medicines review three months after hospital discharge with a clinician with an interest in epilepsy, an epilepsy specialist nurse, or a neurologist.

• Document the follow-up plan for managing complications in the discharge summary.

• For adults who have had bacterial meningitis or meningococcal disease, arrange for a review with a hospital doctor at four to six weeks after discharge from hospital. As part of this review, cover:

  • The results of their audiological assessment (if available at this time) and whether cochlear implants are needed

  • Damage to bones and joints

  • Skin complications (including scarring from necrosis)

  • Psychosocial problems

  • Neurological problems

  • Care needs.

• For babies under 12 months old who have had meningitis or meningococcal disease, arrange a review with a paediatrician for one year after discharge. At this review, assess for possible late-onset neurodevelopmental, orthopaedic, sensory, and psychosocial complications.

• For babies, children, and young people, community child development services should follow up and assess the risk of long term neurodevelopmental complications for at least two years after discharge.

  [Based on very low to moderate quality evidence and the experience and opinion of the GC]