On the spot treatment needed

BMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6969.1661a (Published 17 December 1994) Cite this as: BMJ 1994;309:1661
  1. F A I Riordan,
  2. O Marzouk,
  3. A P J Thomson,
  4. J A Sills,
  5. C A Hart
  1. Johanne Holly research fellow, Lecturer, Honorary consultant paediatrician, Consultant paediatrician, Professor of medical microbiology, Institute of Child Health, Royal Liverpool Children's Hospital (Alder Hey), Liverpool L12 2AP.

    EDITOR,—C S Nanayakkara and R Cox's letter highlights the confusion that exists between meningococcal meningitis and meningococcal septicaemia.1 Life threatening meningococcal disease presents not as meningitis but as septicaemia, often with a rash.2 Giving penicillin before admission to hospital may decrease the mortality from meningococcal disease3; penicillin should therefore be given to those most at risk of dying—that is, those with septicaemia characterised by a purpuric rash. Information and publicity about meningococcal disease should focus on septicaemia, characterised by a petechial or purpuric rash, rather than on meningitis.2

    In a recent prospective study in Merseyside the most important factor affecting whether children with meningococcal disease received penicillin before admission was the admitting doctor's diagnosis. When meningococcal disease was diagnosed 26 (84%) of 31 children were given penicillin. Of the 19 children diagnosed as having meningitis, however, only three (16%) were given penicillin (P<0.0001, Fisher's exact test). To increase the numbers of children given penicillin before admission, attention should focus on meningococcal disease and not meningitis.

    There is little evidence that children with bacterial meningitis benefit from antibiotics before admission,4 although they may benefit from dexamethasone given with, or before, the first dose of antibiotic.5 There is no evidence supporting the use of dexamethasone in meningococcal septicaemia, and antibiotics should not therefore be withheld before admission from those with a purpuric rash because steroids are unavailable.

    The rapid progression of meningococcal septicaemia requires immediate antibiotic treatment to be given by the first doctor to see the patient. Penicillin should thus be recommended before admission for patients with meningococcal disease presenting with a petechial or purpuric rash. Such on the spot treatment might help reduce the mortality from this devastating infection.


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