What is the management and treatment of meningococcal disease?

Management and Treatment of Meningococcal Disease

Immediate administration of parenteral antibiotics as soon as meningococcal disease is suspected is the cornerstone of management, along with urgent referral to secondary care to reduce mortality and morbidity. 1

Initial Assessment and Stabilization

Primary Care Assessment

• Evaluate for fever, non-specific symptoms, headache, neck stiffness, photophobia, and petechial or purpuric rash
• Consider caregiver's concerns and comparison with usual behavior
• Perform full clinical examination
• Document Glasgow Coma Scale (GCS) score for prognostic value and monitoring

Immediate Hospital Management

1. Stabilize airway, breathing, and circulation as immediate priority 1
2. Make decision regarding senior review and/or intensive care within the first hour
3. Take blood cultures immediately (within 1 hour of arrival)
4. Determine management pathway based on presentation:

For Suspected Meningitis (without shock/severe sepsis):

• Perform lumbar puncture (LP) within 1 hour if safe to do so
• Start antibiotics immediately after LP
• If LP cannot be performed within 1 hour, start antibiotics after blood cultures

For Septicemia or Rapidly Evolving Rash:

• Give antibiotics immediately after blood cultures
• Begin fluid resuscitation with initial 500 ml crystalloid bolus
• Follow sepsis guidelines
• Defer LP until patient is stabilized

Antibiotic Therapy

Pre-hospital Antibiotics

• For suspected meningococcal disease in community: administer benzylpenicillin, cefotaxime, or ceftriaxone 1
• This should not delay transfer to hospital

Empiric Hospital Antibiotics

• Adults <60 years: Cefotaxime 2g IV q6h OR Ceftriaxone 2g IV q12h
• Adults ≥60 years: Add Amoxicillin 2g IV q4h to cover Listeria
• Children: Cefotaxime or Ceftriaxone at age-appropriate dosing 1

Definitive Therapy (once organism identified)

• Neisseria meningitidis: Continue cefotaxime or ceftriaxone; alternatively, benzylpenicillin 2.4g IV q4h
• Duration: 5 days if good clinical response 1

Supportive Care

Fluid Management

• For shock: administer rapid infusion of isotonic crystalloid/colloid up to 60 ml/kg (three boluses of 20 ml/kg with reassessment after each) 1
• Fluid resuscitation exceeding 60 ml/kg plus inotropic support is often required
• Early consultation with intensive care for circulatory failure requiring repeated fluid boluses

Intensive Care Considerations

• Consider early ventilatory support after starting inotropes for fluid-resistant shock
• For inotrope-resistant shock, consider vasopressin and steroid dose titration
• For complex fluid balance issues or renal failure, consider continuous venovenous hemofiltration 1

Corticosteroid Therapy

• Not recommended for meningococcal septicemia except in inotrope-resistant shock 1
• For bacterial meningitis of unknown etiology or confirmed meningococcal meningitis: dexamethasone 0.15 mg/kg q6h for 4 days, starting with or within 24 hours of first antibiotic dose 1

Prevention of Secondary Transmission

Chemoprophylaxis

• Liaise with local public health department for appropriate public health actions
• Offer prophylaxis to close contacts who had prolonged contact in household setting within 7 days before onset of illness 1
• Close contacts include:
  • Those living/sleeping in same household
  • Pupils in same dormitory
  • Intimate contacts (boyfriends/girlfriends)
  • University students sharing kitchen in residence hall

Effective Prophylactic Antibiotics

• Ciprofloxacin (most effective)
• Rifampin/rifampicin
• Ceftriaxone
• Minocycline 2

Follow-up Care

Potential Complications to Monitor

• Hearing loss
• Neurological complications
• Psychiatric and psychosocial problems
• Bone and joint complications (may not appear for years)
• Post-necrotic scarring (possible amputations/skin grafting)
• Renal impairment
• Post-traumatic stress disorder (both patients and families) 1

Vaccination

• Before hospital discharge, offer meningococcal C vaccine to unvaccinated patients 1

Common Pitfalls and Caveats

1. Delayed recognition: The classic triad of fever, neck stiffness, and altered mental status is often absent, especially in children. Non-specific symptoms may predominate.

2. Waiting for rash: Not all patients develop the characteristic non-blanching rash. Treatment should not be delayed if meningococcal disease is suspected.

3. Delaying antibiotics: Do not delay antibiotics for diagnostic procedures if the patient appears seriously ill.

4. Inadequate fluid resuscitation: Aggressive fluid therapy is often required, with careful monitoring for response.

5. Failure to involve senior clinicians early: Early senior review is essential for patients with suspected meningococcal disease.

6. Overlooking close contacts: Ensure all close contacts receive appropriate prophylaxis to prevent secondary cases.