May 2013 | Volume 21 | Number 2EMERGENCY NURSE
Art & science | care of children
InvasIve menIngococcal disease (ImD),
which includes meningococcal septicaemia and
meningococcal meningitis, is caused by the
bacterium Neisseria meningitidis. Historically, the
organisms responsible for most cases of ImD have
been the meningococcal serogroups B and c.
In the UK, ImD is a leading infectious cause of
death in children and young people (Paul et al 2011,
stanton et al 2011), although incidence of ImD
caused by serogroup c has fallen by 95 per cent
since 1999, when meningococcal c vaccine was
introduced (stanton et al 2011, Joint committee on
vaccination and Immunisation (JcvI) 2012).
no meningococcal B vaccine is available in the UK,
where infection with serogroup B meningococcus
accounts for 88 per cent of ImD cases (JcvI 2012,
Hicks et al 2013), and is responsible for most cases
of bacterial meningitis and septicaemia (Wilcox 2012).
Invasive meningococcal disease is associated
with a mortality rate of between of 5 and 8 per cent
in the UK (Thorburn et al 2001, ninis et al 2005).
mortality rates are particularly high during the first
few hours of rapidly progressive, or fulminant,
meningococcal septicaemia. severe short- and
long-term complications, such as hearing loss, and
damage to bones and joints, are also associated
with this form of the disease (national Institute for
Health and care excellence (nIce) 2010, Paul et al
2011, Wilcox 2012).
Rapid recognition and assessment of ImD is
essential, especially by healthcare professionals who
work in emergency departments (eDs) (ninis et al
2010). If such professionals suspect patients have
ImD, they should initiate fluid resuscitation and
administration of intravenous antibiotics, and alert
the appropriate clinical teams (Paul et al 2011).
This article discusses the results of a
retrospective clinical audit in which clinical
management of ImD in the first six hours of care in
the eD was compared with recommendations from
the scottish Intercollegiate guidelines network
(sIgn) (2008) and nIce (2010). The article also
discusses strategies for the early recognition and
management of ImD in eDs.
Methodology Yeovil District Hospital serves about
180,000 people, of whom about 28,000 are aged
under 17 years. about 2,600 people in this age range
are admitted to the hospital and about 14,000 attend
the hospital’s eD each year each year.
In 2012, the authors conducted a retrospective
audit involving all patients aged under 17 years who
had been diagnosed with ImD at the eD between
January 2005 and December 2010.
Camelia Laura Vaina and colleagues discuss a clinical
audit of emergency practitioners’ adherence to guidelines
for the treatment of this serious bacterial condition
Diagnosing and managing invasive
meningococcal disease in children
Camelia Laura Vaina is
a specialty doctor in paediatrics
at Yeovil District Hospital
NHS Foundation Trust, Somerset
Siba Prosad Paul is specialty
trainee, year 6, in paediatric
gastroenterology at Bristol
Royal Hospital for Children
Paul Anthony Heaton is
a consultant paediatrician
Christine Routley is a matron
Huma Mazhar is a specialty
trainee, year 6, in paediatrics
All at Yeovil District Hospital
NHS Foundation Trust, Somerset
Date of submission
March 1 2012
Date of acceptance
April 15 2013
This article has been subject
to double-blind review and
has been checked using
In developed countries, invasive meningococcal
disease (IMD) is a leading infectious cause of death
among children. In the UK, Neisseria meningitidis
serogroup B is the most frequently identified cause
of IMD. This article describes a clinical audit in
which early management of IMD is compared
with recommendations in the relevant guidelines.
It confirms the importance of early recognition of IMD
and the need to review previous, less serious diagnoses
in ill children. Emergency department nurses play a
vital role in the early recognition and management of
IMD. Introduction of a meningococcal B vaccine is
likely to benefit children in the UK.
Invasive meningococcal disease, recognition, audit
EMERGENCY NURSE May 2013 | Volume 21 | Number 2 25
Patients were included in the audit if their
blood or cerebrospinal fluid (csF) culture, or
polymerase chain reaction, results were positive
for serogroup B meningococcus. Using the local
microbiology record system, the authors identified
20 such patients. They then studied the patients’
clinical notes to gather further information about:
■■ signs or symptoms recognised by the patients’
parents or gPs, or by eD doctors.
■■ The management strategies initiated in primary
care and the eD.
■■ The treatments the patients received from their
times of arrival at the eD.
Findings Twenty patients with ImD were identified.
of these, nine (45 per cent) had meningococcal
septicaemia and 11 (55 per cent) had meningococcal
meningitis. eight (40 per cent) of the children
were under one year old at presentation and
11 (55 per cent) were male.
The signs and symptoms most often cited by
parents had been fever, lethargy and irritability, and
an ill appearance. The parents of nine (45 per cent)
children had also reported the presence of petechial
rash, which they had confirmed to be non-blanching
by use of the glass test.
Thirteen (65 per cent) children had been assessed
by gPs, five (25 per cent) had been brought by
their parents directly to the eD and the parents
of two (10 per cent) children had received advice
from the nurse-led telephone helpline, nHs Direct.
of the 13 children who had been assessed by gPs,
five (38 per cent) had non-blanching rash. of these,
three (23 per cent) had received intramuscular
penicillin and two (15 per cent) had received no
antibiotics, possibly to ensure their transfers would
not be delayed. In line with sIgn (2008) and nIce
(2010) recommendations, the eight (62 per cent)
children without rash had received no antibiotics in
signs and symptoms observed in the 20 patients
during initial assessments and documented by eD
healthcare professionals are shown in Figure 1.
Investigations had been undertaken in all
20 patients. Delayed lumbar puncture had been
performed in six (30 per cent) children after they
had been judged physiologically stable enough to
undergo the procedure.
contraindications for lumbar puncture include
coagulation abnormalities, extensive or spreading
purpuric rash, a glasgow coma scale score of less
than 9, shock and signs of raised intracranial
pressure, as well as focal neurological signs, such
as unsteadiness and impairment of tactile sensation
(nIce 2010, Wilcox 2012).
Outcomes seven (35 per cent) patients had
been severely ill on arrival at the eD. of these,
two (29 per cent) were to die of ImD and the
other five (71 per cent) were to experience
short- or long-term complications, including learning
disabilities, hearing loss, seizures, cerebral sinus
thrombosis and sixth-nerve palsy.
Presentation to the eD of the two children
who were to die had been delayed significantly.
one of the children, a girl aged four years, had
purpura fulminans, a haemorrhagic condition
associated with sepsis. The other child, a girl
aged seven years, had been ill with fever, rigors,
headache, vomiting, abdominal pain and lethargy,
all of which suggests ImD, for more than 12 hours
before she had presented to the eD (Paul et al
2011). This patient had first become ill during
the influenza H1n1, or swine-flu, epidemic, in
2009/10. Her parents had contacted nHs Direct and
swine flu had been diagnosed by telephone. nHs
Direct staff had advised that the girl be prescribed
oseltamivir, as recommended in the current relevant
Department of Health guideline. Her condition had
deteriorated, however, and she had been brought
to the eD, where staff had noted she was moribund
and lethargic, with a rapidly spreading petechial
rash and high temperature.
In both children, aggressive and prolonged
resuscitation attempts, during which the children
were intubated, proved to be unsuccessful.
of the other five children with severe ImD, one
(20 per cent) had been diagnosed with chicken pox
by a gP and given intramuscular benzylpenicillin,
which may have delayed the child’s presentation
to the eD. There had been no delays in the
Number of children with different signs and symptoms of invasive
Observations documented at triage in emergency department
Signs of shock
Pain in joints
Number of patients
May 2013 | Volume 21 | Number 2 EMERGENCY NURSE
Art & science | care of children
management of the other four (80 per cent) children,
although one had been admitted with a provisional
diagnosis of an unspecified viral illness before being
diagnosed with meningitis 24 hours later.
Three (60 per cent) of the five children had
needed intensive care, one had needed neurosurgical
treatment and the other had remained under
observation in a ward. These cases highlight the
need for review of less-serious diagnoses in children
who are becoming progressively ill (Knight and
Table 1 shows how the management of the
patients compared with recommendations made
in sIgn (2008) and nIce (2010) guidelines.
Education after the authors had completed the
audit, they introduced education sessions in their
unit to emphasise the need for eD practitioners to
adhere to sIgn (2008) and nIce (2010) guidelines
for the management of children with ImD. These
education sessions focused on the need to:
■■ administer antibiotics early.
■■ Undertake clotting screens in children with
fever and non-blanching rash.
■■ Review less serious diagnoses made in
The audit shows that early recognition and
management of ImD are associated with better
outcomes. The initial presentations to the eD of
two children with ImD who were to die had been
delayed considerably, and they may have lived if the
correct diagnoses had been made earlier. similarly,
in a case-control retrospective study of 143 children
with ImD, ninis et al (2005) show that deviation
from optimal management had been more frequent
among patients with ImD who subsequently died
than among those who lived.
In the authors’ study, the death rate, at
10 per cent, was slightly higher than those of
between 5 and 8 per cent reported by Thorburn et al
(2001) and ninis et al (2005). This finding may be
anomalous, however, because of the relatively small
size of the authors’ study group. such anomalies
were found by Riordan (2001) in a similarly
early recognition by parents and carers of signs
and symptoms of ImD, including petechial rash and
high fever, may lead to better outcomes, therefore,
while the time between first manifestation and first
examination may be a better indicator of prognosis
than the time between first presentation and first
examination (nishioka 2002).
administration of antibiotics at the earliest
opportunity, preferably within one hour of
presentation, is generally considered necessary
(Riordan 2001), but evidence for decreasing this time
further is weak (nishioka 2002).
early signs and symptoms of ImD, such as mild
fever or flu-like illness, are similar to those for a
wide range of mainly infectious conditions, which
can make diagnosis of ImD difficult.
This point should is significant when one of
the fatal cases in the authors’ audit is considered.
The case coincided with the influenza epidemic of
2009/10 and, because the child concerned had been
diagnosed with swine flu, her presentation to the eD
had been delayed. similar delays in ImD diagnosis
due to the implementation of swine-flu management
pathways have been reported elsewhere (Knight
and glennie 2010).
Table 1 Comparison of practice of emergency care staff with appropriate recommendations
Recommendations from guidelines (Scottish Intercollegiate Guidelines
Network 2008, National Institute for Health and Care Excellence 2010)
Number of times practitioners
adhered to recommendations
rate (per cent)
Perform a full blood count and test for C-reactive protein 20/20100
Test for meningococcus using blood culture and polymerase chain reaction16/2080*
Undertake a clotting screen 7/978
Undertake fluid resuscitation with 20mL/kg of 0.9 per cent sodium chloride7/7100
Administer antibiotics, cefotaxime or ceftriaxone20/20100
Administer antibiotics within one hour of presentation15/20 75
* All 20 children had at least one or the other test, which equates, from a clinical perspective, to 100 per cent adherence
EMERGENCY NURSE May 2013 | Volume 21 | Number 2 27
clinical outcomes for children with ImD are likely
to improve if front line staff:
■■ adhere to published protocols (ninis et al 2005).
■■ Receive better training in typical and atypical
signs and symptoms of ImD, including abdominal
pain and distension, sore throat and cough, chills
and rigors (nIce 2010, Paul et al 2011).
■■ Receive the support of more experienced
professional colleagues (ninis et al 2005).
In a study by Wells et al (2001), non-blanching
rash was found to be present in only 11 per cent
of patients with ImD, while in a more recent audit
involving 99 children with non-blanching rash by
Hicks et al (2013), only 2 per cent of such children
were found to have had ImD.
It follows that emergency nurses should not base
their assessments of the presence of ImD solely
on the presence or absence of non-blanching rash.
The authors’ clinical audit has similar results to
other studies, and it shows that good outcomes
depend on early recognition and prompt initiation
of fluid resuscitation and antibiotic therapy.
It also shows that non-specific signs and
symptoms of ImD can pose a diagnostic challenge
to healthcare professionals and there is a
need in the UK for routine vaccination against
meningococcus B to reduce incidence of ImD in
children (ladhani et al 2012). meanwhile, increased
awareness of the signs and symptoms of ImD
among parents and healthcare professionals
should improve its detection, diagnosis and
management, and lead to more timely interventions
with better outcomes.
Finally, introduction of a meningococcal B vaccine
in the UK is likely to be beneficial for children.
Health Protection Agency (2012) guidance for
public health management of meningococcal
disease in the UK. tinyurl.com/bm9x2jg
(last accessed: april 19 2013.)
Hicks SS, Paul SP, Zengeya ST et al (2013)
Invasive meningococcal disease: the need
for immunization in childhood. Indian
Journal of Pediatrics. ePub ahead of print.
Joint Committee on Vaccination and
Immunisation (2012) JCVI Statement on the
Use of Meningococcal C Vaccines in the Routine
Childhood Immunisation Programme. tinyurl.
com/cnglcyq (last accessed: april 19 2013.)
Knight C, Glennie L (2010) early recognition
of meningitis and septicaemia. Journal of
Family Health Care. 20, 1, 6-8.
Ladhani SN, Flood JS, Ramsay ME et al (2012)
Invasive meningococcal disease in england
and Wales: implications for the introduction
of new vaccines. Vaccine. 30, 24, 3710-3716.
National Institute for Health and Care
Excellence(2010) Bacterial Meningitis and
Meningococcal Septicaemia: Management
of Bacterial Meningitis and Meningococcal
Septicaemia in Children and Young People
Younger than 16 Years in Primary and
Secondary Care. CG102. tinyurl.com/cf659gg
(last accessed: april 19 2013.)
Nishioka SA (2002) Indicators of mortality
from meningococcal disease. Emergency
Medicine Journal. 19, 3, 281.
Ninis N, Phillips C, Bailey L et al (2005)
The role of healthcare delivery in the outcome
of meningococcal disease in children:
case-control study of fatal and non-fatal cases.
British Medical Journal. 330, 7506, 1475.
Ninis N, Nadel S, Glennie L (2010) Lessons
from Research for Doctors in Training:
Recognition and Early Management of
Meningococcal Disease in Children and Young
(last accessed: april 19 2013.)
Paul SP, Wellesley A, O’Callaghan C (2011)
meningococcal disease in children: case studies
and discussion. Emergency Nurse. 19, 4, 24-29.
Riordan FAI (2001) Improving promptness of
antibiotic treatment in meningococcal disease.
Emergency Medicine Journal. 18, 3, 162-163.
Scottish Intercollegiate Guidelines Network
(2008) Management of Invasive Meningococcal
Disease in Children and Young People.
Stanton MC, Taylor-Robinson D,
Harris D et al (2011) meningococcal disease
in children in merseyside, england: a 31 year
descriptive study. PLoS One. 6, 10, e25957.
Thorburn K, Baines B, Thomson A et al
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Implications for practice
Nurses in emergency departments are often the
first healthcare professionals to assess children and
they should be aware of the signs and symptoms of
IMD. They should also (Riordan 2001, Knight and
Glennie 2010, National Institute for Health and Care
Excellence 2010, Paul et al 2011, Wilcox 2012):
■■ Always review previous, apparently less-serious
diagnoses, such as gastroenteritis, viral illness or
swine flu, and assess whether patients have more
■■ Have a high index of suspicion about invasive
meningococcal disease (IMD) and observe, initally
every 15 minutes, and regularly and frequently
thereafter, patients’ blood pressure, respiratory and
heart rates, and consciousness.
■■ Request urgent medical reviews and appropriate
initiation of resuscitation of children in shock.
■■ Involve paediatric teams early if the child
concerned is haemodynamically unstable or in
shock, or has rapidly progressing non-blanching
rash, or if IMD is strongly suspected.
■■ Help with medicine and fluid management,
and ensure antibiotics are administered within
60 minutes of prescription.
■■ Support parents emotionally and keep them
updated about their children’s conditions.
■■ Check that children have been immunised against
meningococcus C and, if necessary, advise their
parents to organise it through their GPs.
■■ Arrange prophylactic antibiotics for close contacts,
in line with public health recommendations.
Ciprofloxacin is recommended as
chemoprophylaxis for children of all ages (Health
Protection Agency 2012).