Recognising meningococcal disease in primary care: qualitative study of how general practitioners process clinical and contextual information

BMJ 1998;316:276-279 (24 January)

General practice

Recognising meningococcal disease in primary care: qualitative study of how general practitioners process clinical and contextual information

Stephen Granier, research fellow,^a Penny Owen, general practitioner,^b Roisin Pill, professor,^c Lionel Jacobson, research fellow ^c

^a Department of General Practice and Primary Care, King's College School of Medicine and Dentistry, London SE5 9PJ, ^b Llanedeyrn Health Centre, Cardiff CF3 7PN, ^c Department of General Practice, University of Wales College of Medicine, Cardiff CF3 7PN

Correspondence to: Dr Granier

Objectives: To describe the presentation of meningococcal diseasein primary care; to explore how general practitioners processclinical and contextual information in children with meningococcaldisease; and to describe how this information affects management.
Design: Qualitative analysis of semistructured interviews.
Setting: General practices in South Glamorgan.
Subjects: 26 general practitioners who between January 1994and December 1996 admitted 31 children (under 16 years of age)in whom meningococcal disease was diagnosed.
Main outcome measures: Categories of clinical rules and techniquesused by general practitioners in processing each case.
Results: 22 children had rashes; in 16 of them the rashes werenon-blanching. When present, a haemorrhagic rash was the mostimportant factor in the doctor's decision to admit a child.22 children had clinical features not normally expected in childrenwith acute self limiting illnesses—for example, lethargy,poor eye contact, altered mental states, pallor with a hightemperature, and an abnormal cry. Contextual information, suchas knowledge of parents' consultation patterns and their normaldegree of anxiety, played an important part in the managementdecisions in 15 cases. Use of penicillin was associated withthe certainty of diagnosis and the presence and type of haemorrhagicrash.
Conclusion: The key clinical feature of meningococcal disease—ahaemorrhagic rash—was present in only half of the studychildren. The general practitioners specifically hunted forthe rash in some ill children, but doctors should not be deterredfrom diagnosing meningococcal disease and starting antibiotictreatment if the child is otherwise well, if the rash has anunusual or scanty distribution, or if the rash is non-haemorrhagic.

Key messages

In primary care the main emphasis in managing meningococcal disease in children is early recognition and initiation of antibiotic treatment
In this study of 26 general practitioners admitting 31 children with meningococcal disease, a haemorrhagic rash was the most important single factor leading to admission but was present in only half of the children
When a haemorrhagic rash is present general practitioners should not be deterred from diagnosing meningococcal disease and starting antibiotic treatment if the child is otherwise well or if the rash is scanty or has an unusual distribution
The general practitioners noted abnormal illnesses with features different from those of acute self limiting illnesses, including unwillingness to interact or make eye contact, altered mental states, and pallor with a high temperature
Knowledge of parents and their help-seeking behaviour were important in making management decisions
General practitioners were prepared to discount potentially misleading information

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