Paediatric Meningococcal Disease

Overview

Meningococcal disease may present with a clinical spectrum ranging from acute bacterial meningitis to rapidly progressive meningococcal septicaemia. Although bacterial meningitis can affect all ages, incidence of bacterial meningitis and meningococcal disease is highest in children aged under 2 years and declines during childhood.

Definitions

Transmission and Microbiology

Microbiology

• Neisseria meningitidis is a gram-negative, aerobic, encapsulated diplococcus
• Capsular group B (MenB) is the most common cause in people aged under 25 years

Transmission

• Transmitted by aerosol, droplets, or direct contact with secretions from the upper respiratory tract
• Usually commensal in nasopharynx
• Prevalence increases through childhood (5% in infants to 24% in 19 year olds)
• Incubation period is usually 3–5 days

Clinical Features

Consider bacterial meningitis and meningococcal septicaemia in children and young people who present with the symptoms and signs below. Be aware that some children will present with mostly non-specific symptoms, while others will have more specific features.

Differential Diagnosis

Investigation and Management of Petechial Rash

Investigations for Unexplained Petechial Rash with Fever

• Full blood count
• C-reactive protein (CRP)
• Coagulation screen
• Blood culture
• Whole-blood PCR for N. meningitidis
• Blood glucose
• Blood gas

Management Based on Test Results

• Treat with IV ceftriaxone if CRP and/or WBC count is raised
• Normal CRP and WBC do not rule out meningococcal disease
• If discharged, advise parents to return if child appears ill

Investigation and Management of Suspected Bacterial Meningitis

Initial Investigations

• CRP and white blood cell count
• Blood culture
• Whole blood PCR for N. meningitidis
• CSF PCR if culture negative

Lumbar Puncture

• Perform unless contraindicated
• Do not delay antibiotics for LP
• CSF examination: WBC count, protein, glucose, Gram stain, culture

CSF Interpretation

• Neonates: ≥20 cells/μL (consider even if fewer)
• Older children: >5 cells/μL or >1 neutrophil/μL

Management

Empirical Antibiotics

• ≥3 months: IV ceftriaxone
• <3 months: IV cefotaxime + amoxicillin/ampicillin
• Add vancomycin for recent travel/antibiotic exposure

Definitive Treatment

• Meningococcal disease: IV ceftriaxone for 7 days
• H. influenzae: IV ceftriaxone for 10 days
• S. pneumoniae: IV ceftriaxone for 14 days
• Group B streptococcus: IV cefotaxime for ≥14 days
• Listeria: IV amoxicillin/ampicillin for 21 days + gentamicin

Corticosteroids

• Do not use in children <3 months
• Dexamethasone for suspected/confirmed bacterial meningitis with:
  • Purulent CSF
  • CSF WBC >1000/μL
  • Raised WBC with protein >1 g/L
  • Bacteria on Gram stain
• Administer within 4 hours of antibiotics (max 12 hours)
• Do not use high-dose steroids for meningococcal septicaemia

Supportive Management

Fluid Management

• Assess for shock, raised ICP, and dehydration
• Use isotonic fluids for maintenance
• Monitor electrolytes and blood glucose regularly

Fluid Resuscitation in Septicaemia

• Immediate bolus of 20 ml/kg NaCl 0.9% over 5-10 min
• Second bolus if signs of shock persist
• Third bolus if still in shock after 40 ml/kg
• Call for anaesthetic assistance for intubation
• Start vasoactive drugs

Other Aspects

• Monitor and correct metabolic disturbances
• Manage seizures per local protocols
• Treat raised intracranial pressure
• Respiratory support as needed

Prophylaxis

Close Contacts

• Risk is highest in first 7 days after diagnosis
• Prophylaxis for:
  • Household-type contacts
  • Those with direct exposure to respiratory secretions
• Antibiotic prophylaxis within 24 hours

Complications