Ep 210 – Bacterial meningitis and meningococcal disease

In this episode, Dr Hannah Rosa discusses bacterial meningitis and meningococcal disease, with a focus on the NICE guideline that was published in 2024. She reviews how to recognise bacterial meningitis and meningococcal disease and answers the key question: when to give antibiotics outside of hospital? At the end of this episode, there is a chance to put the learning into a clinical context with some clinical scenarios.

Key take-home points

• Bacterial meningitis includes meningococcal meningitis without meningococcal sepsis and meningitis caused by other bacteria.
• Meningococcal disease includes meningococcal sepsis with or without meningococcal meningitis.
• A fever is less common in babies and in older adults; ask when antipyretics were last given.
• Bacterial meningitis may be missed in older adults with delirium.
• In young people and young adults, an altered level of consciousness or altered behaviour may be incorrectly assumed to be caused by alcohol or substance use and bacterial meningitis may be missed.
• If a patient has any symptoms or signs of bacterial meningitis with a non-blanching petechial or purpuric rash, then this needs to be regarded as meningococcal disease until proven otherwise.
• If a patient has a haemorrhagic, non-blanching rash with lesions over 2 mm, or a rapidly progressing or spreading non-blanching petechial or purpuric rash, then this also needs to be regarded as a red flag for meningococcal disease.
• It is possible to have meningococcal disease without meningitis, and a patient may present with just the rash and without a headache or neck stiffness.
• It is key to check all over the body for a rash, including in the nappy area and to look for petechiae in the conjunctivae. A rash may be more difficult to see on brown, black or tanned skin.
• People with suspected bacterial meningitis or meningococcal disease should be transferred to hospital as an emergency.
• If there is likely to be a clinically significant delay in transfer to hospital for people with strongly suspected bacterial meningitis, we should give intravenous or intramuscular ceftriaxone or benzylpenicillin outside of hospital.
• For people with strongly suspected meningococcal disease, we should give intravenous or intramuscular ceftriaxone or benzylpenicillin as soon as possible outside of hospital, unless this will delay their transfer to hospital.
• Ceftriaxone is the preferred option because it is a broad-spectrum antibiotic, but it is less commonly available outside of hospital than benzylpenicillin.
• Do not give antibiotics outside of hospital if the person has a severe antibiotic allergy to either ceftriaxone or benzylpenicillin.
• If a patient is unlikely to have bacterial meningitis or meningococcal disease and goes home with an unconfirmed diagnosis, provide good safety-netting advice.

Key reference

1. NICE. 2024. https://www.nice.org.uk/guidance/ng240.

Useful resource

1. NHS. https://www.healthiertogether.nhs.uk/.