How to assess and treat suspected meningococcemia in a high-risk patient?

Assessment of Meningococcemia

In suspected meningococcemia, immediately assess airway, breathing, circulation, and Glasgow Coma Scale within the first hour, obtain blood cultures, and administer empiric antibiotics (ceftriaxone 2g IV) within 60 minutes—do NOT perform lumbar puncture if the patient has signs of shock, rapidly evolving rash, or sepsis. 1

Immediate Priority Assessment (First Hour)

Airway, Breathing, and Circulation

• Stabilize airway, breathing, and circulation as the immediate priority—this takes precedence over all diagnostic procedures 1
• Assess airway patency and consider intubation if GCS ≤12 2
• Evaluate respiratory adequacy: oxygen saturation, breathing pattern, need for supplemental oxygen or ventilatory support 2
• Check cardiovascular stability: blood pressure, heart rate, capillary refill time (target <2 seconds), and peripheral perfusion 1, 2
• Examine extremities for dusky or cold appearance indicating impaired perfusion—young patients with meningococcemia can maintain blood pressure until catastrophic late deterioration 2, 3

Neurological Assessment

• Document Glasgow Coma Scale score immediately—this is mandatory for prognostic value and monitoring changes 1, 2
• Assess for focal neurological signs: asymmetric weakness, cranial nerve palsies, visual field defects, or lateralizing signs 1, 2
• Evaluate pupillary examination: size, reactivity, and symmetry (abnormalities indicate increased intracranial pressure) 2
• Check for continuous or uncontrolled seizures 1, 2

Critical Rash Assessment

• Systematically examine the entire body for rash, including mucous membranes and conjunctivae—presence or absence must be documented for all patients 1, 2
• Characterize rash type: petechial, purpuric, maculopapular, or blanching 2, 3
• A rapidly evolving purpuric rash is pathognomonic for meningococcal sepsis and mandates immediate action 1, 3, 4

Sepsis Evaluation

• Calculate National Early Warning Score (NEWS): aggregate score ≥5-6 or single parameter score of 3 requires urgent senior review; score ≥7 requires critical care assessment 1, 2
• Do NOT be falsely reassured by low early warning scores—patients with meningococcemia can deteriorate rapidly despite initially reassuring vital signs 1, 2, 3
• Measure capillary refill time (target <2 seconds), assess skin temperature, color, and mottling 1, 2

Senior Clinician Review

• A senior clinician must review the patient within the first hour—most patients should be seen much earlier than the standard 14-hour consultant review time 1
• Decision regarding ICU admission should be made within the first hour 1

Laboratory Assessment

Blood Cultures

• Obtain blood cultures as soon as possible and within 1 hour of hospital arrival—this must occur before antibiotics are administered 1, 5
• Blood cultures remain positive for up to 9 days after antibiotics in meningococcal disease 1

When to Perform Lumbar Puncture

In patients with predominantly sepsis or rapidly evolving rash (meningococcemia):

• Do NOT perform lumbar puncture at this time 1
• Antibiotics should be given immediately after blood cultures 1
• Fluid resuscitation should commence immediately with initial bolus of 500 mL crystalloid 1

In patients with suspected meningitis without signs of shock:

• LP should be performed within 1 hour of arrival if safe to do so 1
• Neuroimaging required before LP if ANY of the following present: focal neurological signs, papilledema, continuous or uncontrolled seizures, GCS ≤12 1, 2
• If LP cannot be performed within 1 hour, commence antibiotics immediately after blood cultures 1

CSF Analysis (When LP Performed)

• Gram stain (97% specificity for bacterial meningitis) 5
• Cell count with differential (>2,000 leukocytes/mm³ or >1,180 neutrophils/mm³ suggests bacterial meningitis) 5
• CSF glucose and simultaneous serum glucose (CSF:serum glucose ratio <0.4 predicts bacterial meningitis with 99% certainty) 5
• PCR for Neisseria meningitidis (remains positive up to 9 days after antibiotics) 1, 5

Empiric Antibiotic Treatment

Administer within 1 hour of clinical suspicion:

• Ceftriaxone 2g IV every 12 hours (preferred) 5, 6, 3
• Alternative: Cefotaxime 2g IV every 6 hours 1, 5
• If beta-lactam anaphylaxis is documented, delay treatment until hospital admission when appropriate alternatives can be given 1

Pre-hospital antibiotics:

• Should be given if strong suspicion of meningococcal disease due to potential for rapid catastrophic deterioration 1, 3
• Benzylpenicillin, cefotaxime, or ceftriaxone have good CSF penetration and can be given intramuscularly 1
• Pre-hospital antibiotics must NOT delay hospital admission 1

Fluid Resuscitation in Meningococcemia with Shock

• Administer rapid infusion of 500 mL crystalloid bolus over 5-10 minutes 1
• Reassess after each bolus 1
• Fluid resuscitation up to 60 mL/kg may be required, given as three boluses of 20 mL/kg in children 1
• Target therapeutic endpoints: capillary refill <2 seconds, normal blood pressure (mean BP >65 mmHg in adults), warm extremities, urine output >0.5 mL/kg/hour, normal mental status, lactate <2 mmol/L 1
• Vasopressors may be necessary if shock does not respond to initial fluid challenges—this requires critical care setting 1

Isolation and Infection Control

• Implement respiratory isolation with droplet precautions immediately until meningococcal disease is excluded or 24 hours of effective antibiotics completed 1, 3
• Surgical masks required if in close contact (<3 feet) with respiratory secretions 1
• Antibiotic chemoprophylaxis for healthcare workers ONLY if exposed to respiratory secretions/droplets (e.g., during intubation without mask) 1

Critical Pitfalls to Avoid

• Never delay antibiotics waiting for LP or imaging—delays significantly increase mortality 1, 3, 4
• Never perform LP in presence of rapidly evolving rash, shock, or sepsis—this wastes critical time 1
• Never rely solely on early warning scores—meningococcemia patients maintain blood pressure until late catastrophic deterioration 1, 2, 3
• Never perform LP before neuroimaging if focal signs, papilledema, seizures, or GCS ≤12 present—this risks cerebral herniation 1, 2
• Never underestimate disease based on initial presentation—early symptoms may mimic benign viral illness 3, 4