Meningitis (management in primary care)

When patients present to a first-contact setting (e.g. general practice, out-of-hours or walk-in centres, emergency departments etc), health professionals should:

• identify any immediately life-threatening features
• assess the likelihood of serious illness or self-limiting illness, without necessarily diagnosing a particular condition
• determine a source of the illness to direct specific treatment
• make appropriate management decisions based on the results of assessment (1).

If a patient with suspected bacterial meningitis or meningococcal disease is identified in the pre-hospital setting, they should be transferred to secondary care urgently.

• if meningococcal meningitis or haemophilus influenzae meningitis is suspected then a single STAT dose of benzylpenicillin should be administered by the general practitioner before transfer to hospital
• the benefit to the patient of early treatment outweighs the chance of isolating the organism

Transfer all patients to hospital immediately

If time before hospital admission, and if suspected meningococcal septicaemia or non-blanching rash, give IV benzylpenicillin as soon as possible

Recommended doses are (2):

• in adults and children of 10 years or more: IV or IM benzylpenicillin 1.2 g
• for children 1 to 9 years: IV or IM benzylpenicillin 600 mg
• for children less than 1 year: IV or IM benzylpenicillin 300 mg

The dose should be given as soon as possible - ideally, administration should be intravenous. Intramuscular administration is less likely to be effective in shocked patients as a result of reduced tissue perfusion. However intramuscular administration should be used if a venous access cannot be found.

Note that benzylpenicillin should be withheld if there is a known history of anaphylaxis following penicillin administration. Cefotaxime is an alternative in this case.

Note:

• STAT indicates that intervention is emergent
• a critical review of early management of meningitis has suggested that supportive care such as oxygen and intravenous fluids is as important as early antibacterial therapy (2)
  
• NICE suggest regarding pre-hospital management of suspected bacterial meningitis and meningococcal septicaemia (1)
  • transfer people with suspected bacterial meningitis or meningococcal disease to hospital as an emergency
  • tell the hospital that a person with suspected bacterial meningitis or meningococcal disease is being transferred and that they will need assessment by a senior clinical decision-maker
  • do not delay transfer to hospital to give antibiotics to people with suspected or strongly suspected bacterial meningitis or meningococcal disease
  • if there is likely to be a clinically significant delay in transfer to hospital for people with strongly suspected bacterial meningitis, give intravenous or intramuscular ceftriaxone or benzylpenicillin outside of hospital
  • for people with strongly suspected meningococcal disease, give intravenous or intramuscular ceftriaxone or benzylpenicillin as soon as possible outside of hospital, unless this will delay transfer to hospital
  • do not give antibiotics outside of hospital if the person has severe antibiotic allergy to either ceftriaxone or benzylpenicillin

Reference:

1. NICE (March 2024). Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management
2. Meningitis Research Foundation 2018. Meningococcal Meningitis and Sepsis. Guidance notes. Diagnosis and treatment in general practice