Recognising meningococcal disease in primary care: qualitative study of how general practitioners process clinical and contextual information
BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7127.276 (Published 24 January 1998) Cite this as: BMJ 1998;316:276
- Stephen Granier, research fellowa,
- Penny Owen, general practitionerb,
- Roisin Pill, professorc,
- Lionel Jacobson, research fellowc
- 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
- Accepted 28 September 1997
Abstract
Objectives: To describe the presentation of meningococcal disease in primary care; to explore how general practitioners process clinical and contextual information in children with meningococcal disease; 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 1994 and December 1996 admitted 31 children (under 16 years of age) in whom meningococcal disease was diagnosed.
Main outcome measures: Categories of clinical rules and techniques used by general practitioners in processing each case.
Results: 22 children had rashes; in 16 of them the rashes were non-blanching. When present, a haemorrhagic rash was the most important factor in the doctor's decision to admit a child. 22 children had clinical features not normally expected in children with acute self limiting illnesses—for example, lethargy, poor eye contact, altered mental states, pallor with a high temperature, and an abnormal cry. Contextual information, such as knowledge of parents' consultation patterns and their normal degree of anxiety, played an important part in the management decisions in 15 cases. Use of penicillin was associated with the certainty of diagnosis and the presence and type of haemorrhagic rash.
Conclusion: The key clinical feature of meningococcal disease—a haemorrhagic rash—was present in only half of the study children. The general practitioners specifically hunted for the rash in some ill children, but doctors should not be deterred from diagnosing meningococcal disease and starting antibiotic treatment if the child is otherwise well, if the rash has an unusual 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
Footnotes
- Accepted 28 September 1997