Meningococcal disease remains an important cause of mortality in children in the UK. Two UK studies have found that aggressive treatment of severe cases can lead to an improvement in outcome1, 2 and the 2003 American College of Critical Care Medicine consensus paper on paediatric and neonatal septic shock reported that intensive care management had reduced mortality due to septic shock in children from 97% in the 1960s to 9% 30 years later3.
Recent research by the Royal College of Paediatrics and Child Health and the meningococcal group at St Mary's Hospital, London funded by Meningitis Research Foundation, looked at health care delivery for almost 500 children with MD. During this study it was seen that a few clinical errors repeatedly led to delayed or inadequate treatment of cases with MD. Complications of meningococcal disease such as shock or raised intra-cranial pressure were often not recognised when they were present. There was also frequently a failure to appreciate how ill children were. Management of cases was often not aggressive enough given the severity of the illness and did not follow the protocol 'Early management of meningococcal disease'. This was first published in 19984, the fourth edition was published in Archives of Disease in Childhood 20035, and the current fifth edition is due to be published in Archives in spring 2007.
The study was published in the British Medical Journal in June 20056 - 'The role of healthcare delivery in the outcome of meningococcal disease in children: case-control study of fatal and non-fatal cases'. Multivariate analysis revealed three specific management failures were independently associated with an increased risk of death. These were 1) children being managed by unsupervised junior doctors 2) children being managed by non-paediatric trained staff and 3) a failure to use enough inotropes in septicaemic patients (this is a marker of aggressive management).
The symptoms displayed by the children in the study prior to their admission to hospital have also been analysed in collaboration with the MRC-funded Department of Primary Health Care at Oxford University, and published7. These data shed new light on the symptoms of meningococcal septicaemia. The data are available in this learning tool in the section Development of Symptoms in Meningococcal Disease and should make doctors aware of the importance of early signs of septicaemia and help them to make an earlier diagnosis.
The importance of this research into the management of meningococcal disease lies not only in its relevance to the correct management of meningococcal disease. The complications of MD, shock and raised intracranial pressure, are also seen in other life-threatening conditions, so it is extremely important for doctors in training to be aware of the early signs as prompt action saves lives.
The aims of this learning tool are...
- To use clinical examples to teach about the signs of septicaemia and meningitis
- To clarify the important differences between meningococcal meningitis and septicaemia
- To outline the basic management of meningococcal septicaemia and meningitis in line with the protocol 'Early management of meningococcal disease in children'
- To describe the clinical pathophysiology of meningococcal disease.
The Clinical Case Histories section of the learning tool presents cases of MD from the study, which illustrate how the early signs of meningococcal disease can be missed, and critical points in managing a case where lack of information (i.e. not measuring or monitoring vital signs), or not acting appropriately on the information available can adversely affect the outcome of the case. Each case illustrates a different learning point. Examples are taken from a range of settings to accurately reflect where children presenting with this disease were looked after. Not all children were managed by paediatricians. Non-clinically relevant details have been changed in order to preserve the anonymity of children and doctors without obscuring the clinical teaching points these cases bring to light.
Each case is presented together with relevant questions. The answers and explanations to the questions can be found by following the links to the relevant information. In these supporting sections are film clips and photographs to illustrate the explanations. We hope that the nature of the questions and the order in which they are asked will help doctors to structure their thoughts when they are seeing acutely sick children in their daily work.
