Early clinical and public health management of meningococcal disease in Australia HNELHD CG
12_TBA
Clinical Guideline
Early clinical and public health management of meningococcal
disease in Australia
Document Registration Number: Insert
Sites where Guideline applies
All HNE Health sites
This Guideline applies to:
1. Adults
Yes
2. Children up to 16 years
Yes
3. Neonates – less than 29 days
Yes
Target audience
All clinical staff involved in the management of
meningococcal disease
Description
These guidelines are provided to assist primary care
practitioners with the emergency management of cases of
suspected meningococcal disease and public health
practitioners with the prevention of further cases after a
case of invasive meningococcal disease has been
reported.
Keywords
Meningococcal, meningitis, septicaemia, public, health
Replaces Existing Guideline?
No
Related documents (Policies, Australian Standards, Codes of Conduct, legislation etc)

Guidelines for the early clinical and public health management of meningococcal disease in Australia
at: http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-other-mening-2007.htm

NSW Health PD2006_014 Notification of Infectious Diseases under the Public Health Act 1991

NSW Health PD2005_383 Children and Infants with Bacterial Meningitis - Acute Management

HNE Health Clinical Guideline HNELHN CG 11_02 Area Antimicrobial Guideline

- HNE Health Policy Compliance Procedures PD2005_383: PCP1-7 Management of Acute Bacterial
Meningitis in infants and children
Position responsible for Guideline
Governance
Dr Cameron Dart, Clinical Leader, Emergency Stream
Guideline Contact Officer
Diana Williamson, CNC Emergency
Contact Details
Ph: 55554
Email: Diana.williamson@hnehealth.nsw.gov.au
Date authorised
February 2012
Authorising body
Emergency Clinical Stream Leadership
This Guideline contains advice on
therapeutics
Yes
Issue Date
February 2012
Date for review
February 2013
TRIM number
Early clinical and public health management of meningococcal disease in Australia HNELHD
CG 12_TBA
Note: Over time links in this document may cease working. Where this occurs please source the
document in the PPG Directory at: http://ppg.hne.health.nsw.gov.au/
GUIDELINE SUMMARY
This document establishes best practice for HNE Health. While not requiring mandatory compliance,
staff must have sound reasons for not implementing standards or practices set out within the
guideline, or for measuring consistent variance in practice.
Introduction
This document provides clinicians with a useful integrated document to help guide and inform their
practice, and enhances the early and consistent approach to the management of meningococcal
disease.
This guideline has been developed by the District Meningococcal Review Committee and approved for
use by the Emergency Clinical Stream.
Situation
The Communicable Disease Network Australia (CDNA) and Australian Government of Health and Aging
have developed clinical guidelines for the early clinical and public health management of meningococcal
disease in Australia. Topics covered in the Guidelines include:

Emergency management of suspected invasive meningococcal disease in general practice ;(
Chapter 2)

Early (emergency department) hospital management of suspected invasive meningococcal disease;
(Chapter 3)

Laboratory tests and their use; (Chapter 4)

Public health management of sporadic cases of invasive meningococcal disease; (Chapter 8)

Public health management of outbreaks of cases of invasive meningococcal disease; Chapter 9)

Reporting and public health surveillance of meningococcal disease. (Chapter 6)
Background
This guideline seeks to ensure a standard approach to monitoring, notifying and managing
Meningococcal disease supported by the District Meningococcal Review Committee as acceptable
practice.
Assessment
Clinicians treating patients with suspected meningococcal disease also consider the application of the
following documents:

NSW Health PD2006_014 Notification of Infectious Diseases under the Public Health Act 1991

NSW Health PD2005_383 Children and Infants with Bacterial Meningitis – Acute Management

HNE Health PD2005_383 PCPs from one to seven Management of Acute Bacterial Meningitis in
Infants and Children

HNE Health CG 11_02 Area Antimicrobial Guideline
Recommendation
Along with the above documents, clinicians also refer to the Guidelines for the early clinical and public
health management of meningococcal disease in Australia from the CDNA.
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February 2012
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Early clinical and public health management of meningococcal disease in Australia HNELHD
CG 12_TBA
GUIDELINE
This document reflects what is currently regarded as safe and appropriate practice. Staff must be
aware, however, that in any clinical situation there may be many factors that cannot be covered by a
single document and therefore does not replace the need for the application of clinical judgment in
respect to each individual patient.
All clinical staff in HNE Health are to be familiar with the Guidelines for the early clinical and public
health management of meningococcal disease in Australia at:
http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-other-mening-2007.htm
The following documents also apply:
1. For children refer to HNE Health Policy Compliance Procedures PD2005_383: PCP 1 to 7
Management of Acute Bacterial Meningitis in infants and children
2. Notifiable diseases must be reported as described in PD2006_014 Notification of Infectious
Diseases under the Public Health Act 1991
3. NSW Health PD2005_383 Children and Infants with Bacterial Meningitis – Acute Management
4. HNE Health CG 11_02 Area Antimicrobial Guideline
Key points for pre-hospital care

Meningococcal septicaemia has considerably greater mortality than meningococcal meningitis and
is often characterised by a rapidly evolving petechial or purpuric rash that does not blanch under
pressure. In the early stages of the disease, the rash may not be present or may be atypical. If
present it may consist only of a few haemorrhagic spots located in a place such as the groin or
feet (see Section 2.2).

Meningococcal disease may have clinical features not normally expected in children with acute
systemic illnesses (see Section 2.2).

Practitioners should ensure that a patient with a systemic febrile illness, particularly a child, can be
promptly reassessed should the need arise within 4-6 hours (see Section 2.2).

All general practitioners should have benzylpenicillin in their surgeries and emergency bags, and
should be ready to administer it immediately to patients with a systemic febrile illness and a
petechial or purpuric rash (see Section 2.3). The doses are:
-
children aged < 1 year — 300 mg;
-
children aged 1–9 years — 600 mg;
-
adults or children aged 10 years or over — 1200 mg. ( this can be administered Intravenous or
intramuscular)

The early administration of benzylpenicillin on suspicion of meningococcal disease, followed by
urgent transfer to hospital, can be life saving. Ceftriaxone is a suitable alternative if available.

If clinical suspicion exists to warrant a referral for admission to hospital the patient should receive
benzylpenicillin prior to transfer.

A history of a rash following penicillin is not a contraindication for benzylpenicillin. If definite
contraindications to Penicillin refer to the infectious disease Physician on call.

The local public health unit should be notified immediately to enable an appropriate public health
response
Prior to transfer to an Emergency Department , advise the receiving hospital of patients condition or
referral
Classic signs

Haemorrhagic rash, meningism, impaired consciousness

Median onset 13–22 hours
Newly identified signs and symptoms in children under 16 years of age

Leg pain, cold extremities, abnormal skin colour

Median onset 7–12 hours
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Early clinical and public health management of meningococcal disease in Australia HNELHD
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Important Points for Consideration in Hospital Care
If a patient has clinical signs or symptoms suggestive of invasive meningococcal disease (meningitis
or septicaemia) they should be given parenteral antibiotics immediately (see Section 3.3) and triaged
appropriately to expediate care

Deferral of lumbar puncture may be appropriate (see Section 3.5.1).

Therapy should not be delayed while awaiting results of diagnostic tests, such as a lumbar
puncture or computed tomography (CT) scan.

All patients with suspected meningococcal infection should have blood collected as soon as
possible for Polymerase chain reaction (PCR) and culture, and blood for neutrophil and
platelet counts. If petechiae are present or if frank bleeding is evident, formal coagulation
studies should be undertaken.
Treatment should be guided by the latest version of the Antibiotic Guidelines. These may be
accessed through the link provided. http://proxy9.use.hcn.com.au For many patients, the severe
sepsis guidelines need to be followed rather than the meningitis.
Specimens used for the diagnosis of meningococcal infection

Blood for culture and PCR

Aspirate from sterile sites for microscopy, culture, PCR as appropriate

Aspirate from skin lesions for microscopy, culture and PCR (though this is not validated)

CSF for microscopy, culture, PCR

Meningococcal septicaemia often occurs without meningitis. In these cases the cerebrospinal
fluid (CSF) may be normal.
Where evidence exists for increased intracranial pressure (e.g. clouded or impaired consciousness,
papilloedema, focal neurological signs or vomiting), lumbar puncture should be deferred until therapy
and supportive measures have been established and investigations, such as a CT scan, undertaken to
define existing intracranial lesions.

Negative findings on initial microscopy and biochemical examination of CSF do not exclude
meningococcal meningitis. Positive cultures may be obtained in the following days.

Culture of Neisseria meningitidis from a normally sterile site confirms the diagnosis. However,
with early use of antibiotics and the likelihood of a negative culture, non-culture methods for
diagnosis become more important.

PCR tests to detect meningococcal DNA can be per formed on blood and CSF, and have high
sensitivity and specificity, even when prior antibiotics have been given (see Section 4.4).

Complications of meningococcal disease require appropriate discharge planning and
specialised follow-up arrangements.

Counselling and support for the patient, family members and health professionals involved in
the care of the patient should be considered.
IMPLEMENTATION PLAN
Responsibility for promoting adherence to these guidelines rests with:
• Area Quality Use of Medicines Committee
• Clinical Directors across HNE, all Clinical Streams
• Directors of Physician Training
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Early clinical and public health management of meningococcal disease in Australia HNELHD
CG 12_TBA
• Director of JMO Training
• Area Infection Prevention and Control Unit
Communication Plan
This will include distribution to
• HNE Acute Networks and Cluster Managers: thence to heads of Clinical Units
• Chair of Area Quality Use of Medicines Committee and thence to other QUM/Drug Committees
EVALUATION PLAN
The HNELHD Meningococcal Review Committee reviews all meningococcal cases across the district
for clinical compliance to the guideline which is considered current best practice. A letter is sent to the
key clinicians involved in each case which highlights the key findings of the review to improve
compliance to the guideline..
CONSULTATION WITH KEY STAKEHOLDERS

Infectious Diseases Physicians

Clinical Microbiologists, HAPS

Emergency Medicine, Clinical Stream

Population Health

Clinical Governance
REFERENCES
Guidelines for the early clinical and public health management of meningococcal disease in Australia
Australian Government Department of Health and Ageing October 2007. May be accessed
electronically:
http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-other-mening-2007.htm
eTG complete antibiotic guidelines can be accessed at: http://proxy9.use.hcn.com.au
Version One
February 2012
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