meningococcal septicaemia

see also:

• meningitis
• meningococcus
• meningococcal chemoprophylaxis
• RCH guidline - acute meningococcal disease
• AFTB lectures - meningococcaemia

• often presents with acute onset fever, severe muscle pains, vomiting and then drowsiness, confusion, hypotensive septicaemic shock as the petechial rash develops and rapidly becomes purpuric over minutes to hours.
• if not treated early with appropriate iv antibiotics, fluid +/- inotrope resuscitation, death is likely within hours of onset of the fever.
• even with treatment there is a significant mortality rate and high risk of long term morbidity due to limb necrosis.
• some patients may have co-existing meningococcal meningitis
• there is often a prodrome of URTI symptoms
• other severe complications include Waterhouse-Friderichsen syndrome (a massive, usually bilateral, hemorrhage into the adrenal glands caused by fulminant meningococcemia), adrenal insufficiency, and disseminated intravascular coagulation (DIC)

• call ambulance for emergency transfer
• give initial dose of parenteral antibiotic as soon as possible:
  • benzylpenicillin IV or IM:
    • iv use:
      • mix 600 mg vial with 1.6 mL water for injection to give 300 mg/mL (ie 600 mg/2 mL) or mix 1.2 g vial with 3.2 mL water for injection to give 300 mg/mL (ie 1.2 g/4 mL).
      • max. rate 300mg/min
    • child < 1 year: 300mg
    • child 1-9 years: 600mg
    • adult or child 10 years or more: 1.2g
  • if allergic to penicillin but not an immediate hypersensitivity:
    • iv or im ceftriaxone 50mg/kg to 2g max.
  • if immediate hypersensitivity to penicillin, avoid cephalosporins and give:
    • iv ciprofloxacin 10mg/kg to max. 400mg 12hrly
  • if delay in further iv antibiotic dosing of > 6hrs (eg. remote areas), then also give
    • iv or im ceftriaxone 50mg/kg to 2g max.

• triage 1 for patients with fever and petechial or purpuric rash as this may be life threatening within hours
• rapid clinical assessment
• A,B,C's as usual
• 100% oxygen eg. 15L/min unless chronic CO₂ retainer, in which case aim for SaO₂ 90-92%
• iv access (preferably 2 lines)
• FBE, U&E, clotting profile, 2 sets of blood cultures, meningococcal PCR
• no lumbar puncture (LP) as will delay Rx and there is likely to be coagulopathy
• check BSL
• careful but aggressive iv fluid resuscitation if hypotense as high risk of delayed APO - see sepsis / septicaemia
  • iv NSaline (aiming for a CVP of 8-12mmHg):
    • if systolic BP < 90 or lactate > 4 then
      • give 20ml/kg stat then boluses of 200-500ml NSaline if systolic BP falls below 90 again.
    • otherwise, give 500-1000ml NSaline over 30-60min
• iv dexamethasone 0.15mg/kg to max 10mg qid for 4 days start before or at 1st dose antibiotics
• iv ceftriaxone 50mg/kg to max 2g bd for 3-5 days ¹⁾
• iv benzyl penicillin 60mg/kg to max 2.4g 4hrly for 3-5 days
• if immediate hypersentivity to penicillins, instead of ceftriaxone or penicillin, give
  • iv ciprofloxacin 10mg/kg to max. 400mg 12hrly for 3-5 days
• consider arterial line and IDC if hypotense
• consider central venous line and early inotrope support if refractory shock despite initial crystalloid Rx
• infectious disease isolation measures
• nurse patient at 30deg head up if altered mental state
• arrange transfer to an ICU as soon as possible
• contact inpatient unit as soon as possible (eg. infectious diseases)
• meningococcal disease is a notifiable disease and will need contact tracing and chemoprophylaxis for contacts.