• It is usually found in the mucous membrane of the nose and throat of humans⁴ (no known animal reservoir) with carriage rates varying from 2% in the those aged under 5 to a peak of 25% in 15-19 year-olds (in unimmunised populations).⁵
• Carriage rates are greater in smokers, overcrowded households and military recruits.
• Asymptomatic nasopharyngeal carriage is transient and eventually resolves (after a period ranging from days to many months), leaving protective immunity against the organism.¹
• Infection is transmitted from person to person by droplets or secretions from the upper respiratory tract. The most likely source of infection of virulent strains appears to be household members or close friends who are asymptomatic carriers.
• Meningococcal disease usually occurs within 1-14 days of acquisition.¹
• Most cases of meningococcal disease occur sporadically, with <5% of cases occurring in clusters.

Pathogenic forms possess a capsule that prevents phagocytosis:

• These are divided into 13 serogroups, of which 9 cause invasive disease (A, B, C (C1, C1-), X, Y, W135, Z, and L).
• 4 serotypes are known to cause epidemics: A, B, C and W135.
• In the UK in 1996-2000, group B accounted for 59% of all infections, and group C 36% (now greatly reduced by vaccination).
• Colonisation with nonpathogenic Neisseria lactamica (common in preschool children) may confer protection against meningococcal disease.

Epidemiology

The epidemiology of bacterial meningitis in the UK has changed dramatically in the past two decades following the introduction of vaccines to control Haemophilus influenzae type b, serogroup C meningococcus and pneumococcal disease. There is currently no licensed vaccine against serogroup B meningococcus, which is now the most common cause of bacterial meningitis (and septicaemia) in children and young people aged 3 months or older.³

Meningococcal disease is the most common infectious cause of death in childhood in developed countries.
• UK rates of invasive disease are 2-6 per 100,000 with approximately 10% fatality.
• Large-scale epidemics can occur in the developing world, mainly in sub-Saharan Africa but also in Russia and China, due mainly to group A.¹
• Most infections occur during winter and early spring.^4,6
• Most cases occur below age 5 years and particularly during the first year of life. There is also a smaller peak at age 14-19 years. However, about one third of the cases of meningococcal disease occurs in adults.⁷
• Most cases are sporadic, although outbreaks do occur, especially in adolescents.⁶
• Most cases of invasive infection occur 2-4 days after acquiring the virulent strain, with invasion of the submucosa to reach capillaries and start the bacteraemia.
• Influenza A, asplenia and complement deficiencies predispose to infection.

Presentation³

• Features of bacterial meningitis include:
  • Fever, headache.
  • Stiff neck, back rigidity, bulging fontanelle (in infants), photophobia.
  • Altered mental state, unconsciousness, toxic/moribund state.
  • Shock; signs of shock include:
    • Toxic/moribund state; altered mental state/decreased conscious level.
    • Unusual skin colour, capillary refill time more than 2 seconds; cold hands/feet.
    • Tachycardia and/or hypotension; respiratory symptoms or breathing difficulty.
    • Leg pain.
    • Poor urine output.
  • Kernig's sign (pain and resistance on passive knee extension with hips fully flexed).
  • Brudziñski's sign (hips flex on bending the head forward).
  • Paresis, focal neurological deficits (including cranial nerve involvement and abnormal pupils).
  • Seizures.
• Meningococcal meningitis and/or septicaemia may, in addition, present with capillary refill time more than 2 seconds, unusual skin colour, hypotension, leg pain and cold hands/feet.
• Meningococcal septicaemia without meningitis does not tend to present with stiff neck, back rigidity, bulging fontanelle, photophobia, Kernig's sign, Brudziñski's sign, paresis, focal neurological deficits or seizures.
• Some children and young people will present with mostly nonspecific symptoms or signs and the conditions may be difficult to distinguish from other less important (viral) infections presenting in this way
• Children and young people with the more specific symptoms and signs are more likely to have bacterial meningitis or meningococcal septicaemia and the symptoms and signs may become more severe and more specific over time.

Transient meningococcaemia¹

• Causes fever and a nonspecific viral rash, which can both disappear within 2-5 days without treatment.

Chronic meningococcaemia¹

• Rare but can last for weeks or months.
• Causes intermittent fever, arthralgia and a nonspecific maculopapular rash.
• Symptoms may disappear for days before causing fever, joint pains and signs of vasculitis.

Prehospital management

• Transfer any patient with suspected bacterial meningitis or suspected meningococcal septicaemia to secondary care as an emergency by telephoning 999.³
• Give benzylpenicillin whilst waiting for the ambulance unless there is history of immediate penicillin allergy after previous penicillin administration (e.g. difficulty in breathing, collapse, generalised itchy rash). Benzylpenicillin dose is 1,200 mg for adults, 600 mg if aged 1-9 years, 300 mg if aged <1 year.^4,9
• Cefotaxime may be used as an alternative.
• Antibiotics should be injected intravenously (IV) or intramuscularly (IM) in adults and IM in children. The recommended site of IM injection is the quadriceps muscle.¹
• Warn close family contacts that chemoprophylaxis may be required if meningococcal disease is confirmed (see 'Chemoprophylaxis for contacts', below).

Investigations in hospital

Meningococci are fastidious and samples require careful handling. Close liaison with a microbiologist is required.

• Blood cultures.
• FBC, U&Es, renal function tests, liver function tests.
• Investigations for disseminated intravascular coagulation (prothrombin time is elevated, activated partial thromboplastin time (aPTT) is elevated, platelet count is reduced and the fibrinogen level is low).
• Blood test for polymerase chain reaction (PCR); this is increasingly used for diagnosis, serogrouping and multilocus sequence typing.¹ Perform whole blood real-time PCR testing - (EDTA sample) - for N. meningitidis to confirm a diagnosis of meningococcal disease.³
• Pharyngeal swab (per-nasal if the patient is unable to co-operate).
• Lumbar puncture - once the patient is stable, and an assessment made to rule out raised intracranial pressure (may need a CT scan). Send cerebrospinal fluid for microscopy, culture, glucose and PCR.
• Aspirate from other sterile sites suspected of being infected (e.g. joints) for microscopy, culture and PCR.

Hospital management¹

• Antibiotics:
  • Do not delay treatment in acutely ill patients - start antibiotics and supportive therapy as soon as possible (may require ITU) and investigate afterwards.
  • Give IV ceftriaxone immediately to children and young people with a petechial rash if any of the following occur at any point during the assessment (these children are at high risk of having meningococcal disease):
    • Petechiae start to spread.
    • The rash becomes purpuric.
    • There are signs of bacterial meningitis or meningococcal septicaemia.
    • The child or young person appears ill.
  • Choice of antibiotics in hospital should be guided by local protocols but the following are usually used:
  • Benzylpenicillin, cefotaxime, ceftriaxone, and chloramphenicol are effective antibiotics.
  • Patients are usually initially given cefotaxime or ceftriaxone, often combined with vancomycin until the causative agent has been identified.
  • When N. meningitidis is identified, antibiotic treatment should be continued with benzylpenicillin alone or a third-generation cephalosporin.
  • Traditionally, patients are treated for 7 days, but 3 or 4 days of IV treatment have proved to be curative.
  • Chemoprophylaxis (see 'Chemoprophylaxis for contacts', below) is sometimes recommended for patients given penicillin or chloramphenicol for treatment, as pharyngeal carriage may not be eliminated with these antibiotics.
• Aggressive management of raised intracranial pressure reduces mortality.
• Fluids:
  • Do not restrict fluids unless there is evidence of raised intracranial pressure or increased antidiuretic hormone secretion.³
  • Aggressive fluid treatment is often required but requires very careful monitoring and care, as excessive volume treatment may cause fatal brain oedema and herniation.
  • If there are signs of shock, give an immediate fluid bolus of 20 ml/kg sodium chloride 0.9% over 5-10 minutes. Give the fluid IV or via an intraosseous route and reassess the child or young person immediately afterwards; if the signs of shock persist, immediately give a second bolus of 20 ml/kg of IV or intraosseous sodium chloride 0.9% or human albumin 4.5% solution over 5-10 minutes
  • If the signs of shock still persist after the first 40 ml/kg: immediately give a third bolus of 20 ml/kg of IV or intraosseous sodium chloride 0.9% or human albumin 4.5% solution over 5-10 minutes; call for anaesthetic assistance for urgent tracheal intubation and mechanical ventilation; start treatment with vasoactive drugs. Some children and young people may require large volumes of fluid over a short period of time to restore their circulating volume
  • Consider giving further fluid boluses at 20 ml/kg of IV or intraosseous sodium chloride 0.9% or human albumin 4.5% solution over 5-10 minutes based on clinical signs and appropriate laboratory investigations, including U&Es.
• Most patients with fulminant meningococcal sepsis require dialysis; haemofiltration has been used to reduce oedema.
• Anticoagulants are frequently given for patients with disseminated intravascular coagulation but has not been shown to improve outcome.
• Corticosteroids given to patients of all ages with bacterial meningitis significantly reduce hearing loss and neurological sequelae, but there is no evidence that they reduce overall mortality.¹⁰

Children and young people should be reviewed by a paediatrician, with the results of their hearing test 4-6 weeks after discharge from hospital, to discuss morbidities associated with their condition and to be offered referral to the appropriate services.³

Complications

• Early complications - seizures, raised intracranial pressure, cerebral venous or sagittal sinus thrombosis, and hydrocephalus.
• In severe fulminant meningococcaemia - disseminated intravascular coagulation, adrenal haemorrhage and adrenal failure (Waterhouse-Friderichsen syndrome). Circulatory collapse and impaired renal and pulmonary function also occur.
• Late complications: communicating hydrocephalus (walking difficulty, cognitive impairment, incontinence), deafness (1-10% cases) which is usually irreversible. Children and young people with a severe or profound deafness should be assessed for cochlear implants as soon as they are fit to undergo testing.³
• Amputations and abnormal bone growth due to necrosis have been increasingly seen recently as a result of meningococcal disease.²
• Skin complications (including scarring from necrosis).
• Psychosocial problems.
• Neurological and developmental problems.
• Renal failure.
• Septic complications: septic arthritis, purulent pericarditis, endophthalmitis, pneumonia.
• Immune-complex complications, e.g. arthritis and pericarditis, tend to present several days after the onset of illness, when the patient is otherwise improving.¹
• 5-8% of cases show persistent problems such as headache, tiredness, sleeplessness, poor concentration problems and irritability, arthritis (10%), and cutaneous vasculitis.

Prognosis

• Mortality is now about 10%. Circulatory collapse is the primary cause of death in the developed world.¹
• Meningococcaemia is the more dangerous presentation, especially when leading to septic shock; however, meningitis is more likely to lead to neurodevelopmental complications.
• 15% of patients with meningococcal disease have long-term complications, including deafness and both major and minor neurodevelopmental impairments.²

Chemoprophylaxis for contacts

This should be offered as soon as possible after case is confirmed:⁴

• To close contacts of cases, irrespective of vaccination status - for example, those who have had prolonged close contact with the case in a household-type setting during the seven days before onset of illness (i.e. living and/or sleeping in the same household, pupils in the same dormitory, boy/girlfriends, or university students sharing a kitchen in a hall of residence).
• Those who have had transient close contact with a case and have been directly exposed to large particle droplets/secretions from the respiratory tract of a case around the time of admission to hospital.
• Rifampicin is the drug of choice (but is contra-indicated if jaundice is present or there has been previous sensitivity):
  • Adults and children aged >12 years - 600 mg orally twice daily for 2 days.
  • Children aged 1-12 years - 10 mg/kg dose orally twice daily for 2 days.
  • Children aged <1 year - 5 mg/kg orally twice daily for 2 days.
• Rifampicin can be used in pregnancy (although caution is advised and ceftriaxone is preferred). The dose for ceftriaxone is 250 mg IM/IV for an adult or 125 mg for a child aged <12 yrs.
• Ciprofloxacin is a useful when large numbers of contacts need prophylaxis - and can be used aged 5 (single dose of 500 mg orally if aged >12, 250 mg if aged 5-12).
• If serotype of case is identified as type A or C, contacts should also have subsequent meningococcal vaccine in addition to immediate chemoprophylaxis.

Prevention

• Vaccination with serogroup C conjugate vaccine, part of the UK vaccination programme for infants and 15-17 year olds since 1999 (extended to 20-24 year-olds in 2002).¹¹ Also given with pneumococcal, Hib, and influenza vaccines for asplenic patients.
• Vaccines are available against group A and C serotypes for patients travelling to Africa and the Middle East.
• Pilgrims going to the Hajj and Umra require vaccine against groups A, C, W135 and Y.⁶
• Antibiotic prophylaxis in close contacts of index cases with rifampicin or ciprofloxacin (see above).

Document references

1. Stephens DS, Greenwood B, Brandtzaeg P; Epidemic meningitis, meningococcaemia, and Neisseria meningitidis. Lancet. 2007 Jun 30;369(9580):2196-210. [abstract]
2. Hart CA, Thomson AP; Meningococcal disease and its management in children. BMJ. 2006 Sep 30;333(7570):685-90.
3. Bacterial meningitis and meningococcal septicaemia, NICE Clinical Guideline (June 2010); The management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care
4. Meningococcal disease, Health Protection Agency
5. Cartwright KA, Stuart JM, Jones DM, et al; The Stonehouse survey: nasopharyngeal carriage of meningococci and Neisseria lactamica. Epidemiol Infect. 1987 Dec;99(3):591-601. [abstract]
6. Immunisation against infectious disease - 'The Green Book'; Dept of Health (various dates)
7. Smith DS et al; Meningococcal Infections, eMedicine, Mar 2009
8. Thompson MJ, Ninis N, Perera R, et al; Clinical recognition of meningococcal disease in children and adolescents. Lancet. 2006 Feb 4;367(9508):397-403. [abstract]
9. Cartwright K, Reilly S, White D, et al; Early treatment with parenteral penicillin in meningococcal disease. BMJ. 1992 Jul 18;305(6846):143-7. [abstract]
10. Brouwer MC, McIntyre P, de Gans J, et al; Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2010 Sep 8;9:CD004405. [abstract]
11. Ramsay ME, Andrews NJ, Trotter CL, et al; Herd immunity from meningococcal serogroup C conjugate vaccination in England: database analysis. BMJ. 2003 Feb 15;326(7385):365-6.

Acknowledgements