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ACUTE BACTERIAL MENINGITIS MANAGEMENT IN ADULTS IS INADEQUATE: A MULTI–CENTRE AUDIT AND SURVEY
  1. Edward J Needham,
  2. J William Brown,
  3. Dhaneesha NS Senaratne,
  4. A Mariam Karimi,
  5. Thomas A Gibson,
  6. Emily E Brown,
  7. Sooha Kim,
  8. John W Thorpe,
  9. Adrian Boyle,
  10. Alasdair J Coles
  1. Norfolk and Norwich University Hospital; Addenbrooke's Hospital; University of Cambridge

    Abstract

    Acute bacterial meningitis (ABM) carries a 20–50% mortality rate with significant morbidity in survivors. Appropriate investigations and expeditious treatment (particularly antibiotics and often steroids) significantly improve outcomes. The National Institute for Clinical and Health Excellence (NICE) has not published guidance directing management in adults despite robust evidence informing treatment. We aimed to evaluate the investigation and initial management of suspected ABM against a European guideline1 in five East Anglian hospitals. We subsequently explored whether the results reflected insufficient knowledge by inviting all doctors in these emergency and acute medical departments to complete a survey.

    Audit Clinical coding searches over 12 months at 5 hospitals for any type of meningitis identified 32 patients with proven ABM (bacteria in cerebrospinal fluid or typical composition) or those treated as ABM if lumbar puncture (LP) was omitted. 28 patients (88%) survived to discharge. Blood culture collection preceded antibiotics in 28 patients (88%). LP was attempted in 26 patients (81%), all undergoing prior head imaging; 19 patients (73%) merited this scan suggesting that LP (and subsequent antibiotics) were unnecessarily delayed in 7 patients (27%). LP was performed within the recommended 4 hours in 17 patients (65%); the median time to LP was 218 minutes (range: 5–1235).

    Median time to antibiotic administration from first documented suspicion of ABM was 72 minutes (range: 0–4740); 9 patients (28%) were treated within the recommended 30 minutes. 29 patients (94%) were treated according to local antibiotic policy (or had valid reasoning for deviation).

    High dose corticosteroids, recommended for non–meningococcal ABM before or with the first antibiotic dose, were given to 11 patients (34%); the remainder had no documented contraindication although 2 patients (6%) later cultured meningococcus. Median time to steroid administration was 17 hours, 16 hours after antibiotics.

    25 patients (78%) had seizures or reduced conscious level at presentation; 12 of these (48%) received acyclovir.

    Survey: 101 doctors (22 consultants, 41 registrars and 38 junior doctors; response rate 62%) completed an online questionnaire addressing ABM management in adults against European guidance.1

    18 doctors (18%) correctly identified the indications for head imaging before LP; 1% identified all contraindications to LP. 32% selected the correct indications and 1% the correct contraindications to high–dose corticosteroids.

    62% referred to (non–existent) NICE guidelines; none were aware of the European guidelines.1 The majority felt their undergraduate and postgraduate training in managing ABM sufficient and reported a median confidence of 7/10 (where 10=fully confident) in it's management.

    Conclusions Unjustified variance from European guidelines occurred in one or more aspect of every patient's management. Significant deficits in knowledge, particularly regarding expeditious antibiotic and steroid therapy, appear to be contributory despite reasonable self–reported confidence. Beyond local education we recommend development of a NICE guideline for managing ABM in adults.

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