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Growth of Neisseria meningitidis from blood cultures, or a positive PCR for meningococcus on blood sample (EDTA or APD tube).
In the Auckland population, a child who presents with fever and a petechial rash (in the absence of a clear alternative explanation for the petechiae) should be presumed to have meningococcaemia until proven otherwise.
Meningococcaemia may occur as an unexpected finding in children who present to CED with a fever but seem otherwise well. More commonly, it occurs in the context of a sick child with fever, chills, malaise, prostration and a rash that initially may be urticarial, maculo-papular or petechial. In fulminant cases, purpura, disseminated intravascular coagulation, shock, coma and death can ensue within several hours despite appropriate therapy. Meningococcaemia may also present as clinical meningitis whose signs are indistinguishable from those of acute meningitis caused by Haemophilus influenzae and 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.
Emergency Treatment in Primary Care
If the referring doctor strongly suspects meningococcaemia, parenteral antibiotics should be given immediately. Preferred antibiotics are Amoxycillin or Penicillin G.
The doses cited here are those recommended by the Ministry of Health in October 1995 (Dr Diana Lennon, Dr Rod Ellis-Pegler):
|Drug||Dose (IV, IM)||Usual brand||Vial||Water to add||Concentration|
(max 2000 mg)
(max 2000 mg)
|Sandoz brand||600 mg =
1 mega unit
|4.6 ml||120 mg/ml|
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.
Antibiotics in Hospital (before culture result is available)
- Age Less than One Month
Amoxycillin and Cefotaxime 50mg/kg/dose
Birthweight Antibiotic Age (days) Dose frequency < 2000g Amoxycillin + Cefotaxime 0 - 7 12 hourly 8 - 28 6 hourly > 2000g Amoxycillin 0 - 7 8 hourly 8 - 28 6 hourly + Cefotaxime 0 - 7 12 hourly 8 - 28 6 hourly
- Age One to Three Months
Amoxycillin - 75mg/kg/dose 6 hourly
+ Cefotaxime - Load 100mg/kg then 50mg/kg/dose 6 hourly
- Age Greater than Three Months
Cefotaxime - Load 100mg/kg then 50mg/kg/dose (max 2000mg/dose) 6 hourly
Use Ceftriaxone in in-patients only if there is a problem
with IV access.
(The dose is a load of 80-100mg/kg (max 2000mg/dose), followed by 80-100mg/kg/dose max 2000mg/dose) every 24 hours starting 12 hours after the load).
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 days.
Well children may be treated as outpatients with Ceftriaxone for a total of 4 days at the dose described above, but require a minimum of 6 hours initial assessment in short stay/ward with consultant review. If consultant review unavailable, admit.
Antibiotic therapy should not be discontinued if fever persists, and the child should be discussed with the Paediatric Infectious Diseases Consultant.
Notification to the Auckland Regional Public Health Protection Service
See guidelines on meningitis.
Prophylaxis for Contacts
See guidelines on meningitis.
Information for Families
2009 Red Book - 28th Edition (Report of the Committee on Infectious Diseases of the AAP)
2009 Pocket Book of Pediatric Antimicrobial Therapy. JD Nelson
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- Date last published: 01 March 2010
- Document type: Clinical Guideline
- Services responsible: General Paediatrics, Paediatric Infectious Diseases
- Author(s): Lesley Voss
- Editor: Greg Williams
- Review frequency: 2 years
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