Dr Fiona McGill @ MRF's Meningitis & Septicaemia in Children & Adults 2015
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The UK Joint Specialist Societies' Guideline on Acute Meningitis and Meningococcal Sepsis in Adults http://www.meningitis.org/conference2015
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Dr Fiona McGill @ MRF's Meningitis & Septicaemia in Children & Adults 2015
- 1. The UK Joint Specialist Societies Guideline on the Diagnosis and Management of Acute Meningitis and Meningococcal sepsis in immunocompetent adults. Fiona McGill, RS Heyderman, BD Michael, S Defres, NJ Beeching, R Borrow, A Miller, L Glennie, O Gaillemin, D Wyncoll, E Kaczmarski, S Nadel, G Thwaites, J Cohen, NWS Davies, A Rhodes, R Read, T Solomon British Infection Association Public Health England Intensive Care Society Association of British Neurologists Society for Acute Medicine Meningitis Research Foundation
- 2. Outline • Background • Recommendations • Implementation
- 3. Background
- 5. Why do we need a guideline? The management of meningitis in the UK is sub- optimal • Published UK based audits: – Specific diagnostic tests (beyond culture) often omitted e.g. molecular tests – Considerable variability in dosage of antibiotics prescribed – Delays in antibiotics and investigations – Inappropriate tests e.g. CT scans Cullen; Journal of Infection 2005 Stockdale; Quarterly Medical Journal 2011
- 6. Guidelines may improve outcomes – Swedish national review after guideline revision • Treatment started earlier • Mortality reduced – US study comparing 3 time periods • Mortality decreased • “associated with the introduction of recommendations for use of adjunctive dexamethasone for pneumococcal meningitis” – Dutch historical cohort comparison • Improved outcome and mortality • Follows recommendations for steroids Glimaker; Clinical Infectious Diseases 2015 Castelblanco; Lancet Infectious Diseases 2014 Brouwer; Neurology 2010
- 7. Our aims: • to create user-friendly, comprehensive, evidence-based guidelines primarily for hospital-based clinicians in the UK with auditable outcomes. • Scope: – Adults – suspected and proven acute meningitis and meningococcal sepsis – pre-hospital care to post-discharge support
- 8. Fiona: “when will the meningitis guidelines be revised?” BIA guidelines secretary “Would you like to do it?” 1999 2003 2012
- 9. Methods • Working party formed • Identified questions • Literature search • 2-3 authors wrote each section • Whole guideline assimilated and edited • Consultation with stakeholders – Revision and editing
- 10. Methods • Working party formed • Identified questions • Literature search • 2-3 authors wrote the relevant section • Whole guideline assimilated and edited • Consultation with stakeholders – Revision and editing
- 11. Recommendations
- 12. Key Recommendations • Pre-hospital management • Indications for hospital admission • Clinical signs • Pre admission antibiotics • Initial hospital assessment • Neuroimaging and lumbar punctures • Bleeding risks and lumbar punctures • Diagnostic Scoring systems • Investigations • Treatment • Empirical • Definitive • Adjunctive • Outpatient treatment • Critical Care • Which patients should be referred to critical care • Other critical care management issues • Prophylaxis • Prevention of secondary cases • Screening for predispositions • Infection control measures • Follow Up/Sequelae • Viral Meningitis • Audit Tool
- 13. Key Recommendations • Pre-hospital management • Indications for hospital admission • Clinical signs • Pre admission antibiotics • Initial hospital assessment • Neuroimaging and lumbar punctures • Bleeding risks and lumbar punctures • Diagnostic Scoring systems • Investigations • Treatment • Empirical • Definitive • Adjunctive • Outpatient treatment • Critical Care • Which patients should be referred to critical care • Other critical care management issues • Prophylaxis • Prevention of secondary cases • Screening for predispositions • Infection control measures • Follow Up/Sequelae • Viral Meningitis • Audit Tool
- 14. Antibiotics in the community • Give to those who have signs of meningococcal disease, severe sepsis or where there might be a delay in getting to hospital • Patients with known anaphylaxis should not receive antibiotics in the community
- 15. Initial hospital assessment • Action to be taken within the first hour of arriving in hospital – Stabilisation of patient – Blood cultures taken – Lumbar puncture if safe (patients with meningitis) – Treatment commenced – Fluid resuscitation (if signs of sepsis) – Document decision regarding senior review and need for critical care input
- 16. Medical training • All clinicians managing patients should have training on the initial management of acute bacterial meningitis and meningococcal sepsis • Patients should be cared for with the input of an infection specialist
- 17. Neuroimaging and Lumbar Puncture Image courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 32383 Image courtesy of Dr Benedict Michael.
- 18. Associations between performing CT scans and: • delays in antibiotics and LP, • worse outcome, • decreased chance of identifying organism Proulx; Quaterly Journal of Medicine 2005 Michael; Emergency Medical Journal 2010 Glimaker; Clinical Infectious Diseases 2015 All (n=1117) Had CT (n=901) Did not have CT (n=216) P value Time from admission to LP, median hours (IQR) 16 (6.75,28) 18 (8,29) 10 (4,22) <0.001 Time from admission to antibiotics, median hours (IQR) 3 (1,11) 3 (1,11) 2 (0,10) 0.002 McGill et al, unpublished, UK Meningitis Study
- 19. Which patients need a CT scan? Indications for neuroimaging prior to LP in suspected meningitis* Focal neurological signs Presence of papilloedema** Continuous or uncontrolled seizures GCS ≤12*** *to exclude significant brain swelling and shift that may predispose to cerebral herniation post LP **inability to view the fundus is not a contraindication to LP, especially in patients who have had a short duration of symptoms *** LP may be safe at levels below this
- 20. Bleeding risk and LPs • Delay LMWH until after LP is performed • INR<=1.4 • Platelets >40 • LP should not be delayed for the results of blood tests unless a high clinical suspicion of a bleeding diathesis • Other reasons to delay LP: • Infection at site of LP • Unstable patient • Haemodynamic/respiratory compromise
- 21. Meningitis Suspected Meningococcal Sepsis Bloods Blood Cultures FBC, Urea, creatinine and electrolytes, LFT’s, clotting screen, Lactate Procalcitonin (or CRP if unavailable) Meningococcal and Pneumococcal PCR Serology sample Glucose HIV Ab/Ag test CSF Cell Count Opening Pressure Microscopy, Culture and Sensitivity Meningococcal and Pneumococcal PCR Protein, Glucose, Lactate Throat swab Bacterial CultureBacterial Culture Further tests (if no aetiology identified on first panel) If bacterial meningitis seems likely: 16S rRNA PCR on CSF If viral meningitis seems likely: CSF PCR for: HSV 1, HSV 2, VZV and Enterovirus. Stool for Enterovirus PCR Throat swab for Enterovirus PCR Blood Cultures FBC, Urea, creatinine and electrolytes, LFT’s, clotting screen, Lactate Procalcitonin (or CRP if unavailable) Meningococcal and Pneumococcal PCR Serology sample Glucose HIV Ab/Ag test Investigations
- 22. Empirical Treatment – Ceftriaxone/Cefotaxime – Think about penicillin resistance if recent travel – add in IV Vancomycin or Rifampicin – Add in Amoxicillin if >60 or immunocompromised – Chloramphenicol if anaphylaxis to penicillins/cephalosporins
- 23. Definitive treatment • Guided by microbiological results – Continue cephalosporin or de-escalate to Benzylpenicillin • Consider outpatient therapy • Aciclovir/valaciclovir not recommended in herpes meningitis Duration of treatment Pneumococcal Meningitis Good Recovery 10 days Delayed Recovery 14 days Meningococcal Meningitis/Sepsis Good recovery 5 days Delayed Recovery 7 days No identified pathogen Good recovery 10 days Delayed recovery 14 days
- 24. Adjunctive treatment • Dexamethasone 10mg IV 6 hourly – can be given up to 12 hours after antibiotics • No role for glycerol or therapeutic hypothermia
- 25. Critical Care • Involve early • Refer – Those with rapidly evolving rash – Those with GCS of 12 or less – Those requiring monitoring or organ support – Those with uncontrolled seizures • Intubation strongly considered in those with GCS of 12 or less • Anyone with severe sepsis should be managed in a critical care setting
- 26. Prophylaxis/screening • All patients with meningitis or meningococcal sepsis should have an HIV test • Patients with 2 or more episodes (or family history of > 1) should have immunological investigations • Trauma, neurosurgery or rhino/otorrhoea – investigations for a CSF leak
- 27. Follow up/sequelae • Follow up appointments • Hearing tests within 4 weeks of being well enough to test • Fast track assessment for cochlear implant • Support organisations
- 28. Implementation
- 29. Implementation • How do we actually get people to use the guideline? • How do we assess the effectiveness or otherwise of the guideline? • Implementation best achieved with a multifaceted approach actively engaging clinicians (Prior; J Eval Clin Pract, 2008) More effective interventions Less effective interventions Multifaceted interventions Didactic education Interactive education Passive dissemination strategies Clinical reminder systems
- 30. Many doctors unaware of the existence of the guidelines “I know there are guidelines, but and I know that you could probably just Google them and they would probably just be there erm... It is ringing some bells but I couldn't tell you what was on it ((laughs)).” ST3 elderly care “Erm... there must be some national guidelines, and I do actually need to read them, I have not read any recently erm...“ ST3 gasteroenterology “Erm… well I know there are some but I don’t, I have never used them.” CT1 Acute Medicine/ A and E “Yes, I mean I… I have done you know I have done a fair amount of emergency medicine and acute medicine and it [the use of steroids in the management of meningitis] is not something I have really come across, but then how many actual proper bacterial meningitises have I seen.” CT1 Acute Medicine/A and E
- 31. How do we actually get people to use the guideline? • They need to have heard about it – National launch • Federation of Infection Societies Conference – Involvement of several societies • Presentations at Intensive Care Society meeting in December • Write up in the Society for Acute Medicine’s journal – Algorithm – Audit Tool
- 32. How do we actually get people to use the guideline? • Some other suggestions (for discussion…) – National audit – Press release – Editorial – Apps/easy to navigate ‘clickable’ electronic versions – Learning modules - BMJ learning
- 33. How do we assess the effectiveness or otherwise of the guideline? • Audit Tool – National audit • Historical cohort studies • Other suggestions welcome
- 34. Acknowledgements • All authors • All members of the partner organisations for comments in the consultation period • Dr Huw Cooper and Professor C H Raine for advice regarding audiological follow up
Editor's Notes
- Probably don’t need to tell this audience about the cases of poor management of meningitis that make the news. And although these extreme cases are thankfully rare there is definitely room for improvement across the board in the management of meningitis.
- Couple of published audits in the UK 354 minutes = almost 6 hours Over 3 hours
- At least 3 large nationwide studies claiming improvements following changes in guideline recommendations Numerous biases, not least we don’t know how well the guidelines were adhered to, but there is a suggestion of improvement…. Glimaker attributes the changes to the removal of reduced conscious level as a contraindication to LP’; castelblanco and brouwer suggest recommendations regarding steroids are responsible for the changes seen
- including clinical features, investigations, treatment, follow-up and prevention. Not TB, neurosurgical, paedicatric
- Many people/doctors are aware of the algorithm – few are aware of the original consensus statement. Possible over the last 15 years clinical guidelines have become much more commonplace and one reason for updating the guidelines would be to make them more user friendly and more widely known. In 2011 I started work at the LBIG on a study, funded by the MRF, looking at outcomes and epidemiology of menignitis – mainly viral but hey. I was also on the council for the British Infection Association. Those two things conspired and an innocent question at a steering committee about when the meningitis guidelines would be revised resulted in this mammoth task ahead of us – 3 years later this is what we have……
- BIA, SAM, ICS, MRF, ABN, PHE
- BIA, SAM, ICS, MRF, ABN, PHE
- Not going to go through all 121 recommendations………some where there are changes Grading is given in the guideline Minimal RCT evidence, much of it is based on observational studies, if not even observational studies some things are graded ‘author recommendation’.
- Not going to go through all 121 recommendations… Going to go through the ones that are new, have changed or might be contraversial
- More in line with the paediatric guidance, Minimal evidence regarding abx in community Not recommended in other forms of infection/sepsis
- Focus on early senior review/critical care involvement Focus on the first hour – compromise between what is good practice and what is practically achievable. Changing cultures.
- Hopefully a call for hospitals to ensure meningitis is part of compulsory teaching programmes A couple of studies showing patients that are looked after on an ID ward do better plus lots of anecdotal evidence….
- Concern regarding the risk of cerebral herniation The risk attributable to LP is not clear Bacterial meningitis itself causes herniation (even in the absence of LP) Risk is probably higher if there is evidence of ‘brain shift’, often associated with space occupying lesion Benefits of LP – establishing a diagnosis, antimicrobial sensitivities –need to be weighed against the potential risks CT head is NOT performed to identify raised intracranial pressure An LP is NOT contraindicated in the presence of raised intracranial pressure – in fact is often used therapeutically in those situations (e.g. cryptococcal meningitis)
- Glimaker – compared with CT before LP
- Only 5 of these patients had proven bacterial meningitis (out of 301)
- In an attempt to reduce the number of unnecessary CT scans and potentially improve the measures quoted before we have rationalised the recommendations for CT scanning to those that might indicate a space occupying lesion. There are other contraindications to immediate LP. Removal of immunocompromise, stress it is the presence of papilloedema and not the inability to see the fundus that is a contraindication, GCS - ? Still quite high but this was a compromise between what would clinicians would be comfortable with.
- Limited data in meninigitis, extrapolated from data in anaesthetics, obstetrics and oncology with caveats that these do not necessarily have the same risks.
- Not much too different, stressed the possibility of pen resistance and inserted a couple of websites regarding european and global risks of PRP. Age cut off for listeria is slightly higher and added in other risk factors such as DM, alcohol excess etc…
- Attempted to make this section flow as you would get the results so what to do if the gram film shows something, culture or PCR etc….. Durations have been reduced slightly and made more definitive – it was felt that 10-14 days was not helpful. 10 days if doing well or 14 if not. 5 and 7 for meningococcal. OPAT – this is new, increasing reports of treating meningitis as an outpatient – especially uncomplicated meningococcal or the end of a course for oneumococcal.
- More pragmatic recommendation for Dex – dose as per the original de Gans Dutch trial. In practice steroids are rarely given with or before abx and so it was felt necessary to allow a period of time after the abx had been given. A sub group analysis of the most recent cochrane review showed that there was no difference beween patients who received steroids after abx compared with those who received them before or with. Exact timings of when steroids were given varied between studies and so 12 hours was chosen as a pragmatic time point.
- again, emphasis on early referral
- Meningitis = CSF pleocytosis Institgated by an immunologist/infection specialist
- Not all sequelae will be apparent on discharge Follow up for all patients with bacterial meningitis recognising that not all sequelae will be apparent on discharge If hearing loss reported rapid hearing assessment If documentation of significant hearing loss – fast track for cochlear implant
- Synthesis of systematic reviews
- People need to have heard of it
- People need to have heard of it