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Definition for acute management
- Growth of Neisseria meningitidis from blood cultures, or a positive PCR for meningococcus on blood sample (EDTA or APD tube).
- Clinical consistent presentation such as unwell child with fever, chills, malaise, prostration and rash (initially may be urticarial, maculo-papular), evolving into petechiae or purpura. In fulminant cases: purpura, disseminated intravascular coagulation, shock, coma
- Meningococcaemia may also present as clinical meningitis whose signs are indistinguishable from those of acute meningitis caused by other bacterial pathogens eg Streptococcus pneumoniae
Principles of management
A febrile illness in a child who presents with a petechial rash must be taken very seriously. Unless there is a definite alternative explanation for the petechiae, the child should be treated with parenteral antibiotics until blood cultures return as negative at 48 hours (it is important to establish whether the child has already been on oral antibiotics). Have a low threshold for discussing these children with a consultant.
If the child is sick or less than 3 months old, or if you are in doubt, admit.
Children who present as clinical meningitis, or in shock, should be managed according to the appropriate guidelines.
Emergency treatment in primary care
If the referring doctor strongly suspects meningococcaemia, parenteral antibiotics should be given immediately.
This is in line with current recommendations from the Ministry of Health in advice November 2018:
|Drug||Children (<30kg)||Max dose (adults)|
|Ceftriaxone (first line treatment)||50 mg/kg IV or IM up to 2g as a single dose||2g IV or IM|
|Benzylpenicillin (second choice)||50 mg/kg IV or IM to maximum of 2g||2.4g IV or IM|
- Ceftriaxone is the preferred first-line treatment for both adults and children presenting in primary care
- If ceftriaxone is not available, benzylpenicillin can be used in primary care
- Patients allergic to penicillin who do not have a documented history of anaphylaxis to penicillin can be given ceftriaxone.
- There is no routine community treatment recommendation for patients with a documented history of anaphylaxis to penicillin. These patients must be transferred immediately by ambulance to the closest hospital. This hospital should be made aware of the patient transfer. If in remote location or at a significant distance from secondary care, or if there is any delay, you should seek urgent advice from an Infectious Disease Physician regarding treatment options prior to transfer to hospital. In some circumstances following advice, ceftriaxone may be considered warranted, if the expected benefit outweighs risk, as the incidence of ceftriaxone allergy in those with a history of penicillin anaphylaxis is very low (<1%).
- IV administration is preferred to IM (where available and not leading to delays). IM dosing can be administered in two divided doses and with lignocaine to reduce pain. The recommended paediatric IM dose takes into account the administration volume required.
Antibiotic treatment of suspected meningococcal infections presenting to Emergency Departments
|Ceftriaxone*||100mg/kg IV up to maximum of 2g|
- *Cefotaxime may be used in place of Ceftriaxone in children (for cefotaxime dosing refer NZFC or Starship Meningitis guideline.
- Note: if pre-hospital antibiotics have been given,top-up doses of Ceftriaxone or Cefotaxime may be required as per the Starship Meningitis guideline.
- Penicillin G is no longer recommended as empirical treatment of meningococcal infection in the Emergency Department, due to the increased incidence of Neisseria meningitidis resistant to penicillin in-vitro.
- Patients allergic to penicillin who do not have a documented history of anaphylaxis to penicillin can be given ceftriaxone
- In patients with a history of anaphylaxis or severe allergic reactions to cephalosporins, Infectious Diseases advice should be sought.
Lumbar puncture is not required if there is no clinical sign of meningitis in a child over the age of 18 months, and is contraindicated in a sick child or a child with a rapidly evolving rash.
Steroids do not change outcome in children with meningococcaemia without meningitis. They should not be given to a child who is not in shock and has no evidence of meningitis.
The total duration of antibiotic therapy in a child > 3 months of age with uncomplicated meningoccaemia (with normal CSF) is 4-5 days.
For duration in definite or presumed meningococcal meningitis, see Starship Meningitis guideline.
Antibiotic therapy should not be discontinued if fever persists, and the child should be discussed with the Paediatric Infectious Diseases Consultant.
Ceftriaxone/Cefotaxime antibiotic may be able to be rationalised based on susceptibility testing results when available.
Notification to the Auckland Regional Public Health Protection Service
See guidelines on meningitis.
Prophylaxis for contacts
See guidelines on meningitis.
See Immunisation Advisory Centre information sheets on available meningococcal vaccines at http://www.immune.org.nz/meningococcal-disease-information-health-professionals
Information for families
- 2018 Red Book (Report of the Committee on Infectious Diseases of the AAP)
- 2012 Pocket Book of Pediatric Antimicrobial Therapy. JD Nelson
- Bradley JD Nelson
Did you find this information helpful?
- Date last published: 03 December 2018
- Document type: Clinical Guideline
- Services responsible: General Paediatrics, Paediatric Infectious Diseases, Children’s Emergency Department
- Owner: Emma Best
- Editor: Greg Williams
- Review frequency: 2 years
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