A5V4d

Meningococcal disease
Narrative evidence and summary
Clinical assessment of the child with fever
Three EL 2+ prospective population-based studies 94,118,132 to determine the clinical predictors of
meningococcal disease in children with a haemorrhagic (non-blanching) rash with or without fever
were found. The children’s ages ranged from > 1 month 94,118,132 to < 16 years 132 and the population
varied from Denmark, 132 and the UK 118 to the USA. 94 The features that helped predict the presence of
meningococcal disease were:
distribution of rash below the superior vena cava distribution (OR 5.1 132 )
presence of purpura – lesions > 2 mm (OR 7.0 132 ; 37.2 118 )
neck stiffness (OR 6.9 132 )
capillary refill time > 2 seconds (OR 29.4 118 )
ill appearance (OR 16.7 118 )
CRP > 6 mg/litre. 118,132
One recent UK-based EL 3 retrospective study 133 was also found that aimed to determine the
frequency and time of onset of clinical features of meningococcal disease, to enable clinicians to
make an early diagnosis before the individual was admitted to hospital. The researchers found that
most children had only non-specific symptoms in the first 4–6 hours, but were close to death by
24 hours. The classic features of haemorrhagic rash, meningism and impaired consciousness
developed later (median onset 13–22 hours). In contrast, 72% of children had earlier symptoms (leg
pains, cold hands and feet, abnormal skin colour) that first developed at a median time of 8 hours.
GDG translation
The GDG considered a non-blanching rash (petechiae or purpura), neck stiffness and ill appearance
on clinical examination as being ‘red’ features.
The feature of rash below the nipple line was not included in the traffic light table. This is because the
sign is more useful in ruling out meningococcal disease if the rash is only found in the superior vena
cava distribution rather than ruling the diagnosis in.
The GDG decided that they could not make a recommendation based on the possible early features
of meningococcal disease 133 because of the retrospective nature of the study, the lack of controls and
the possibility of recollection bias. The GDG did appreciate the potential benefit of diagnosing
meningococcal disease at an early stage and called for further, prospective, research on this subject.
The updated review for capillary refill time was undertaken as part of the main symptoms and signs
review and can be found in section 5.4.
Recommendations
The recommendations covering meningococcal disease are presented at the end of section 5.5.
Non-meningococcal septicaemia
No prospective population studies were found which determined the clinical features of nonmeningococcal
sepsis. Papers on occult pneumococcal bacteraemia were excluded as they only
included laboratory screening test data. After searching for retrospective studies in the recent
10 years, there was no study judged to be of good enough quality to base recommendations upon
and therefore none have been made.
Bacterial meningitis
Two EL 2+ prospective population studies 134,135 and one EL 2- narrative review 136 on determining the
symptoms and signs of bacterial meningitis were found. Neck stiffness and a decreased conscious
level are the best predictors of bacterial meningitis. However, neck stiffness is absent in 25% of
infants under 12 months. 134 (EL 2+) Infants under 6 months of age have a bulging fontanelle in 55% of
bacterial meningitis cases. 134 (EL 2+)
131