Quality of in-hospital care for adults with acute bacterial
meningitis: a national retrospective survey
Indicators for assessing standards into diagnosis and management of
acute meningitis and meningococcal septicaemia
1. OUTSIDE HOSPITAL MANAGEMENT
Treatment: Parenteral benzylpenicillin (1200 mg). IV or IM route
Contraindication - anaphylaxis
1. a) Percentage of those seen by GP and diagnosis suspected, who were given
parenteral benzylpenicillin (1200 mg) IV or IM route*.
*Excluding those with recorded anaphylaxis.
2. EARLY HOSPITAL MANAGEMENT
Assessment of severity of illness: Severely ill patients managed in ICU/HDU
2. a) Percentage of all patients, where differential diagnosis includes
meningitis/meningosepticaemia, assessed by ICU team.
2. b) Percentage of severity of illness assessed/recorded.
2. c) Percentage of severely ill* patients managed or referred to ICU/HDU.
*Severely ill patient: patient presenting with signs of meningeal irritation and
impaired conscious level and/or petechial rash.
Investigations: CT or MRI to all patients with papilloedema or focal neurological
signs.
2. e) Percentage of patients with papilloedema or focal neurological signs who had
CT or MRI scan.
Investigations: appropriate blood and CSF diagnostic investigations in all suspected
cases.
2. f) Percentage with Blood for Meningococcal culture
2. g)
If predominantly septicaemia suspected
If predominantly meningitis suspected
% of Heart rate
% of Heart rate
% of Respiratory rate
% of Respiratory rate
% of Peripheral perfusion
% of Blood pressure
% of Blood pressure
% of Mental status (coma scale)
% of Urine output
% of Focal neurology
% of Mental status
% of Frequent seizures
% of Papilloedema
2. h) Percentage meningococcal PCR
2. i) Percentage throat swab for meningococcal culture,
2. j) Percentage blood for meningococcal serology.
2. k) Percentage CSF for meningococcal culture,
2. l) Percentage CSF for meningococcal PCR.
Lumbar puncture: to all adult meningitis patients except when a contraindication
Contraindications: Clinical diagnosis of meningitis (raised intracranial pressure,
ICP)*, focal neurological signs, severe shock, impaired conscious level, coagulation
disorder, respiratory comprise or clinical diagnosis of meningococcal sepsis.
*Includes raised ICP at Computer Tomography (CT or MRI).
2. m) Percentage of meningitis patients who had LP
2. n) Percentage who had LP in presence of contraindications.
Treatment/management: IV antibiotics within 1 h of admission* at hospital
*Time of the first assessment by medical staff (JHO, SHO, Registrar, etc.) at the
hospital.
2. o) Percentage of patients given IV antibiotics within 1 h of diagnosis*.
*Where diagnosis at arrival includes meningitis/meningococcal septicaemia.
3. HOSPITAL MANAGEMENT
Diagnosis: The differential diagnosis should include meningitis/ meningococcal
septicaemia at first assessment (<12 h).
Management: Patient should be assessed by the consultant within 24 h.
3. a) Percentage with differential diagnosis of meningitis/ meningococcal septicaemia
at first assessment (<12 h).
3. b) Percentage of patients assessed by consultant within 24 h.
Treatment of suspected meningitis or meningococcal septicaemia:
Meningitis patients
Meningococcal patients
3. c) Percentage of cases with
typical meningococcal (purpuric)
rash given 1.2 g benzylpenicillin IV
or ceftriaxone or cefotaxime
3. d) Percentage of cases without typical purpuric rash
given 2 g ceftriaxone or cefotaxime IV
3.e) Percentage of suspected penicillin-resistant pneumococcal meningitis* given 2g
ceftriaxone or cefotaxime regimen + 1g vancomycin or 600 mg rifampicin IV.
*If has visited a country with a high prevalence of penicillin resistance within the last
two months.
3. f) Percentage of all case antibiotics administered intravenously throughout the
treatment course.
4. NOTIFICATION AND PROPHYLAXIS
Notification: report to CCDC all clinically suspected cases
4.a) Percentage of cases reported to CCDC
4.b) Percentage of cases reported within 24 h of diagnosis, where diagnosis
suspected.
Chemoprophylaxis to eliminate carriage: Index cases should be given
chemoprophylaxis before discharge from hospital
4.c) Percentage of cases given chemoprophylaxis (rifampicin or ciprofloxacin orally),
or ceftriaxone for eliminating carriage.
5. RECORDS
Records: All essential information* about the management of the case should be
recorded.
5. a) Percentage of essential information recorded.
5. b) Percentage of results recorded from the investigations required.
*Essential information:: Assessment of vital signs (pulse, temp, blood pressure, rash,
respiratory comprise); Assessment of meningeal signs (neck stiffness, papilloedema,
neurological examination, conscious level, capillary refill time) at first assessment.
CSF investigations (opening pressure, WCC, WC differential, RBC, Gram stain,
proteins, sugar, culture, meningococcal PCR); blood investigations [FBC (Hb, WCC,
RCC, platelet count), CRP, PCR-meningococcal, sugar, clotting screen].
6/06/02
On behalf of the Expert Panel for the study
Dr Ardiana Gjini
Clinical Research Fellow
University of Bristol
________________
REFERENCES
1. Begg, N., K. A. Cartwright, J. Cohen, et al. (1999). "Consensus statement on
diagnosis, investigation, treatment and prevention of acute bacterial meningitis in
immunocompetent adults. British Infection Society Working Party." J Infect 39(1): 115.
2. Expert opinion, panel including: J. Stuart, K. Cartwright, J. Cohen, S Granier, R.
Heyderman, M. Jacobs, T Nichols, N. Ninis, H. Prempeh, A. Whitehouse.