Prehospital parenteral penicillin for meningitis: Trial in children with suspected meningococcal disease would be useful

BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7555.1451-a (Published 15 June 2006) Cite this as: BMJ 2006;332:1451
  1. D Graham Mackenzie, specialist registrar in public health (gm{at}nhs.net),
  2. Charles J P Saunders, consultant in public health medicine,
  3. Diptendu N Bhattacharyya, infectious disease consultant,
  4. Chris R Steer, consultant paediatrician
  1. Cameron House, Windygates, Leven, Fife KY8 5RG
  2. Hayfield House, Kirkcaldy, Fife KY2 5AH

    EDITOR—Harnden et al's study raises important questions about the role of prehospital parenteral penicillin in children with meningococcal disease.1 Their paper and accompanying statistical comment have shown the potential importance of excluding patients who would never have been considered for treatment. However, their study design is likely to have excluded a group of children with suspected meningococcal disease who were given prehospital parenteral penicillin.

    Public health guidelines recommend that general administer prehospital parenteral penicillin to patients with suspected meningococcal disease, though the guidelines do not make specific recommendations about the clinical criteria on which general practitioners should base their decision.2 Recent research shows that clinical features other than haemorrhagic rash can be important in identifying meningococcal disease,3 reinforcing how difficult clinical decisions can be when treating an acutely unwell child.

    In contrast, the formal case definition for meningococcal disease is decided after consultation between hospital clinician, microbiologist, and consultant in meningococcal disease in public health medicine, usually hours or days after hospital admission.2 According to the methods section in an earlier paper,4 this appears to have been the starting point for Harnden et al's study. Not all children treated with prehospital antibiotics for suspected meningococcal disease would meet the formal case definition, partly because of incomplete application of microbiological tests. For example, when we conducted an audit of such cases notified to public health in our region between 2000 and 2001, only 18 out of 36 cases (50%) had undergone adequate microbiological testing to confirm meningococcal disease.

    A randomised controlled trial of prehospital parenteral penicillin in children with suspected meningococcal disease would be a useful next step and would address concerns about confounding. However, as demonstrated above, the inclusion criteria for such a study would need to be considered carefully for the findings to be relevant to general practitioners making decisions about acutely ill children in the community.


    • Competing interests None declared.


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