MENINGITIS FACTSHEET

Statistics

Acute meningitis, whether bacterial or viral, is a notifiable disease. Meningococcal septicaemia is also notifiable. After reaching a peak in 1988, notifications of acute meningitis in England and Wales have remained at a fairly high level, with 1,823 cases in 1994 (source: OPCS). In the same year there were 126 cases of bacterial meningitis in Northern Ireland (source: DHSS for N. Ireland), and 90 cases in Scotland of meningococcal, pneumococcal and Hib meningitis (source: SCIEH Weekly Reports). The successful introduction of Hib vaccine into the UK infant immunisation schedule in 1992 has almost eliminated Hib meningitis.

Clinical presentation of meningitis and/or septicaemia
Infants

Non-specific symptoms are:

• drowsiness
• irritability
• lack of appetite
• distress on handling
• vomiting or diarrhoea
• fever

More specific symptoms are:

• neck stiffness
• tense or bulging fontanelle
• purpuric or petechial rash that does not blanch under pressure

Late symptoms are:

• high-pitched or moaning cry
• coma
• neck retraction
• shock
• widespread haemorrhagic rash

Older children and adults

Non-specific symptoms are:

• vomiting
• fever
• back or joint pains
• headache

More specific symptoms are:

• neck stiffness
• photophobia
• confusion
• purpuric or petechial rash that does not blanch under pressure

Late symptoms are:

• coma
• shock
• widespread haemorrhagic rash

Consider a diagnosis of meningitis or septicaemia in any child with an unexplained illness or fever. Meningism may be absent, so look carefully for any sign of a petechial or purpuric rash. The combination of fever with a petechial or purpuric rash constitutes a medical emergency. Such a patient may deteriorate rapidly, and should be given penicillin and transferred immediately to hospital.

Penicillin

An injection of benzylpenicillin (Crystapen) is recommended immediately if a diagnosis of meningitis or septicaemia is suspected. Two studies (BMJ 1992; 305:141-7) indicate that this can significantly reduce case fatality rates. Current fatality rates range from around 7% for meningococcal meningitis, to 20% for pneumococcal meningitis and meningococcal septicaemia.

Give intravenously if possible, otherwise by intramuscular injection. Suggested doses are:

• 1,200 mg (2 mega-units) for adults and children over ten-years-old
• 600 mg (1 mega-unit) for 1 to 10 year olds
• 300 mg (0.5 mega-unit) for children under one-year-old

For patients with a history of anaphylaxis to penicillin, chloramphenicol or a parenieral cephalosporin can be given instead. If these antibiotics are not available, take the patient directly to hospital with minimum delay.

Crystapen has a shelf life of three years at 25°C. A single injection may be life-saving and will make little difference to diagnosis.

Prophylaxis

Prophylactic antibiotics (often rifampicin) are recommended for intimate contacts of meningococcal disease. This may reduce the risk of secondary cases, but there is still a 1% chance of secondary cases in the family during subsequent months. With other causes of meningitis, chemoprophylaxis is not indicated.

Meningococcal vaccine should be offered to intimate contacts of cases of meningococcal disease, due to group A or C strains ("Immunisation Against Infectious Disease", Department of Health 1992). For details of local policy, contact the consultant in communicable disease control at your health authority.