Meningococcaemia

Have a low threshold to start treatment for a suspected meningitis.

If meningococcal disease is suspected and unless there is a history of anaphylaxis to penicillins, give preferentially intravenous Penicillin G (benzylpenicillin) or alternatively intramuscularly. Intramuscular antibiotic injections are given proximally, into a warm part of the limb.

Benzylpenicillin Dose Guide:

• Infant: 300 mg
• Child 1-9 years: 600 mg
• Adult: 1200 mg

For an undifferentiated meningitis, give a third generation cephalosporin, such as Ceftriaxone or Cefotaxime (below), preferably intravenously.

If practical, obtain blood cultures prior to giving the antibiotic. But don’t let this concern delay life-saving antibiotic treatment—you can always collect 2-5 mL blood (EDTA tube) after treatment for PCR testing.

EMERGENT DRUG TREATMENT

1. 50 mg/kg Ceftriaxone or Cefotaxime
2. 20 mL/kg Normal Saline — if shocked (otherwise, care with fluids as children often have increased ADH secretion)
3. 0.15 mg/kg Dexamethasone (for undifferentiated meningitis) — within an hour of first antibiotics
4. Arrange for immediate transfer to hospital

Alternative antibiotics (IDSA Guidelines):

• Ampicillin
• Chloramphenicol 50 mg/kg/day (in two divided doses)
• Aztreonam
• Ciprofloxacin (a 500 mg single oral dose is usually reserved for chemoprophylaxis)

Note: rapid deterioration, without prompt treatment, is the rule

POST-EMERGENT CARE

1.  Isolate cases (if possible) until they have had > 12 hours of antibiotic treatment
2.  Notifiable disease — in Aus., contact Department of Human Services (DHS) Infectious —Disease Unit: Nurse 03 9637 4124, Medical Officer 03 9637 4127
3.  Contact chemoprophylaxis within 24 hours — usually arranged and supplied by DHS: household, daycare, and intimate contacts exposed to index case within 7 days of onset; any person who gave mouth-to-mouth resuscitation to the index case; index case should also receive prophylaxis if penicillin only was used.

• Infants and children > 1 month of age: Rifampicin 10 mg/kg PO 12 hourly (max 600 mg) for 2 days
• Adults: Rifampicin 600 mg 12 hourly for 2 days
• Infants < 1 month of age: Rifampicin 5 mg/kg PO 12 hourly for 2 days
• Pregnancy: rifampicin contraindicated; give Ceftriaxone 250 mg STATIM

Other empirical therapy for an undifferentiated meningitis may include vancomycin and acyclovir. A 7-day course of intravenous ceftriaxone or penicillin is adequate for uncomplicated meningococcal meningitis. 

The course of benzylpenicillin therapy is 200,000-300,000 U/kg/day, divided q2-4hr, x 24 doses.

---

References

The Royal Children’s Hospital Melbourne: Clinical Practice Guidelines. Acute Meningococcal Disease. Available at http://www.rch.org.au/clinicalguide/guideline_index/Acute_Meningococcal_Disease/ as at 10 June 2016

Gondim F, Singh M, Reynolds N — Medscape. Meningococcal Meningitis. Available at http://emedicine.medscape.com/article/1165557-overview as at 10th June 2016

Meningitis Research Foundation. Meningococcal Meningitis and Septicaemia — Guidance Notes: Diagnosis and Treatment in General Practice. Available at http://www.meningitis.org/assets/x/50631 as at 10 June, 2016.