Management of Bacterial Meningitis and Meningococcal Disease v11

Policy Title

Management Of Bacterial Meningitis And Meningococcal Disease

Policy Number

IC19

Version Number

11.0

Ratified By

Infection Prevention & Control Committee

Date Ratified

28/01/2019

Effective From

02/04/2019

Author(s) (name and designation)

Dr H Coutinho, Consultant Microbiologist

Sponsor

Dr H Lloyd, Joint DIPC/Director of Nursing, Midwifery & Quality

Expiry Date

01/01/2022

Withdrawn Date

Unless this copy has been taken directly from Pandora (the Trust’s Sharepoint document management system) there is no assurance that this is the most up to date version This policy supersedes all previous issues

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 2

Version Control

Version Release Author/Reviewer Ratified

by/Authorised by

Date Changes

(Please identify page no.)

6.0

January 2007

Dr G M Horne IPCC March 2007

7.0

January 2008

Dr G M Horne IPCC Jan 2008

8.0 December 2009

Dr G M Horne Mr M Young

IPCC October 2009

Page 8 – now use IV ceftriaxone

9.0 28/08/2012 Dr H Coutinho IPCC July 2012 See summary of changes

10.0 21/09/2015 Dr H Coutinho IPCC 15/09/2015 See summary of changes

11.0

02/04/2019 Dr H Coutinho IPCC 28/01/2019 Full review of policy

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 3

Contents Section Page 1 Introduction ...................................................................................................................... 4 2. Policy scope ....................................................................................................................... 4 3. Aim of policy...................................................................................................................... 5 4 Duties (roles and responsibilities) ..................................................................................... 5-6 5 Definitions ......................................................................................................................... 7 6 When A Case Occurs ......................................................................................................... 7

6.1 Statutory Notification ........................................................................................... 7 6.2 Notification of Cases and Treatment of Contacts ................................................. 8 6.3 IPC Precautions ..................................................................................................... 8-9 6.4 Prophylaxis contacts ............................................................................................. 9-10 6.5 Investigations ........................................................................................................ 12 6.6 Treatment ............................................................................................................. 12-13 6.7 Vaccination Against Meningococcal Disease ........................................................ 13-14 6.8 Care of the Deceased Patient Including Mortuary Procedure .............................. 14 6.9 Disseminating Information ................................................................................... 14-15 6.10 Information for Patients ....................................................................................... 15

7. Training ............................................................................................................................. 16 8. Equality and Diversity ....................................................................................................... 16 9. Monitoring compliance with the policy ............................................................................ 16 10. Consultation and review ................................................................................................... 16 11 Implementation of policy (including raising awareness) .................................................. 16 12 References......................................................................................................................... 17 13 Associated documentation (policies) ................................................................................ 17 Appendices Appendix 1 Ciprofloxacin Drug Information Leaflet ..................................................................... 18-19 Appendix 2 PHE North East Health Protection Team Meningococcal Infection.......................... 20-21

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 4

Management Of Bacterial Meningitis And Meningococcal Disease Policy 1 Introduction Bacterial meningitis is a life-threatening condition that can affect all ages, but is most common in babies and children. Meningitis is a potentially fatal condition, therefore optimal management requires early diagnosis and initiation of appropriate treatment 2 Policy scope

This policy covers care of patients with suspected/confirmed meningitis/meningococcal disease who come into hospital. It includes clinical management, infection control, control of infection spread (including pre-admission treatment), further investigation and treatment, prophylaxis and vaccination of cases and contacts, notification

Etiology

Many cases of meningitis are viral in aetiology which are usually mild and self-limiting. Bacterial meningitis is less common but is much more severe and life threatening. The causes include:

N.meningitidis (meningococcal) - Six meningococcal capsular groups (A, B, C, W, X and Y) distinguished by their polysaccharide capsule cause almost all invasive meningococcal infections in humans.

S.pneumoniae (pneumococcal).

H.influenza type b.

Hemolytic streptococci – Group B streptococci (neonatal),Group A streptococci.

Listeria (neonates, pregnancy and immunosuppressed patients).

E.coli (neonates).

Tuberculosis (rare).

Clinical features of acute bacterial meningitis include:

Non-specific symptoms: fever, nausea and vomiting, lethargy, irritable or unsettled mood, refusal of food and drink, headache, muscle ache or joint pain, and respiratory symptoms such as a cough.

More specific symptoms and signs: stiff neck, altered mental state (confusion, delirium and drowsiness, impaired consciousness), non-blanching rash, back rigidity, bulging fontanelle (in children younger than 2 years of age), photophobia, Kernig's sign, Brudzinski's sign, coma, paresis, focal neurological deficit, and seizures.

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 5

3 Aim of policy

To ensure that a patient diagnosed with meningitis (and meningococcal septicaemia) receive appropriate in-patient management To reduce the risk of transmission to staff, other patients and relatives/visitors within the hospital setting This policy outlines arrangements within Gateshead Health NHS Trust to minimise the risk of infection to patients, visitors and staff. The Trust is committed to working towards compliance with Standards for Better Health, Saving Lives and Winning Ways. All Trust staff have a responsibility to adhere to Trust policy and ensure that appropriate measures are taken to reduce risks associated with infection. In addition Service Managers and identified leads within departments/directorates have a duty to ensure compliance with Trust policy. Actions required when an increase in the number of associated infections occur is explained in the Outbreak Management Policy No. 24 Performance indicators for this policy are the achievement of the following standards

NHSLA Risk Management Standards for Acute Trusts

Code of Professional Practice for the Prevention and Control of Healthcare Associated

Infections

Standards for Better Health

Saving Lives

Winning Ways

Epic 3 Guidelines

Health & Social Care Act 2012 (See reference list)

Contact points:

Duty Medical Microbiologist: - Bleep 2092 Deputy Head of Infection Prevention & Control: Mrs L Caisley - Ext 6473 Infection Control Nurses: - Ext 3161

Surveillance - Bleep 2057 Director of Infection Prevention & Control: Mrs H Lloyd - Ext 6045/6102 Supplies Contact: Mrs Bellwood - Ext 5528

4 Duties (roles and responsibilities)

The Chief Executive has responsibility for ensuring the Trust has robust and effective Infection and Prevention Control Policies.

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 6

Trust Board has a responsibility to ensure that the risk of infection to patients, staff and visitors is minimised to its lowest potential and therefore supports the full implementation of this policy. The Directors of Infection Prevention and Control (DIPC) have executive responsibility for Infection Prevention Control and oversee Infection and Prevention Control activity via the Infection and Prevention Control Committee. Initiate a root cause analysis and where necessary convene a Hospital Coordinating Group meeting to ensure that patients, staff and visitors are protected. Consultant Microbiologist - will give advice against this policy and follow up positive suspected meningitis and/or infected patients with clinical staff that need Medical Microbiologist input. Out of hours and at weekends will follow up suspected meningitis, needing urgent input on a daily basis. Head of Infection Prevention and Control - will give advice against this policy and ensure that it is updated every two years or in line with current national guidance via the nominated Infection Prevention & Control Nurse lead within the review of policies section of the Infection Prevention & Control Committee. The Infection and Prevention Control Nurse (IPCN) – will give advice and support on suspected or known cases of bacterial meningitis management and policy interpretation. Microbiology Secretary – co-ordinates IPC policy updates ensuring the OP27 is completed via DIPC and appropriate IPCN/Microbiologist and sent forward to the Membership Co-ordinator, Trust Headquarters in order that the policies can be uploaded to the Trust intranet. The Infection Prevention and Control Committee - is responsible for the ratification of Trust wide infection prevention and control policies, procedures and guidance, providing advice and support on the implementation of policies and monitoring the progress of the annual infection control programme. Acknowledging progress against action plans presented by the Divisions related to Healthcare associated infection RCA incidents. Heads of Department - Must ensure that appropriate training is available and that staffunderstand and comply with this Policy. Divisional Managers – will ensure that all staff are aware of and follow this policy and are aware of their own roles and responsibilities to ensure safe practice. That staff have access to intranet copies of Infection Prevention & Control Policies. All Trust staff - have a responsibility to adhere to Trust policy and ensure that appropriate measures are taken to reduce risks associated with infection. All Trust staff have aresponsibility to ensure they attend annual Infection Prevention and Control mandatory training. Public Health England Health Protection Team ( PHE HPT) – Will investigate suspected / confirmed cases and manage the public health actions required following notification of a single case and management of clusters.

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 7

5 Definitions for Meningococcal Sepsis/Meningococcal Meningitis

Cases requiring notification to Public Health England Health Protection Team for public health (PHE HPT) action.

Confirmed case

A clinical diagnosis of meningitis, septicaemia or other invasive disease (such as *orbital cellulitis, septic arthritis) AND at least one of the following:

Neisseria meningitidis isolated from a normally sterile site

Gram negative diplococci in a normally sterile site

Meningococcal DNA in a normally sterile site

Meningococcal antigen in blood, CSF or urine

*Although meningococcal infection of the conjunctiva does not meet the definition of a confirmed case, it is considered an indication for public health action because of the high immediate risk of invasive disease.

Probable case Clinical diagnosis of meningitis or septicaemia or other invasive disease where the physician, in consultation with the microbiologist, considers that meningococcal infection is the most likely diagnosis.

Cases not requiring public health action Possible case A clinical diagnosis of meningitis or septicaemia where the physician, in consultation with the microbiologist, considers that diagnoses other than meningococcal disease are at least as likely. This category includes cases who may be treated with antibiotics but whose probable diagnosis is viral illness.

6 When A Case Occurs

6.1 Statutory Notification

Meningococcal meningitis and septicaemia are statutorily notifiable by registered medical practitioners under the health protection legislation (2010). (http://www.legislation.gov.uk/uksi/2010/659/contents/made). Neisseria meningitidis is a notifiable causative agent under the Health Protection (Notification) Regulations 2010. Laboratory operators are required to notify cases in writing to the Health Protection Agency; this can be undertaken by routine SGSS reporting.

Its is the responsibility of the clinician making or suspecting the diagnosis to notify Public Health England North East Health Protection Team on 0300 303 8596 option 1 both in and out of hours. This should take place with 24 hours of diagnosis. In addition to telephone reporting (above – for public health action), registered medical practitioners should send a completed statutory notification by email to nenotifications@nhs.net or fax to 0191 221 2584 .

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 8

6.2 Notification of Cases and Treatment of Contacts

All cases of acute bacterial meningitis and all forms of invasive meningococcal disease andinvasive Haemophilus influenzae type b (Hib) disease are notifiable This policy should be read in conjunction with the following policies in order to maintain a high standard of care and protection for Trust users and staff:

IC2 PPE Policy IC3 Standard Precautions Policy IC4 Hand Hygiene Policy IC6 Isolation Policy

Contact Details MEDICAL MICROBIOLOGISTS: Duty Medical Microbiologist: Bleep 2092 (Out of hours via Microbiology BMS on-call – QEH Switchboard) North East Public Health England Centre Health Protection Team Floor 2 Citygate Gallowgate Newcastle upon Tyne NE1 4WH Telephone: 0300 303 8596 option 1 Out of hours access to PHE HPT telephone 0300 303 8596 option 1, a recorded message will provide you with the appropriate contact number

6.3 IPC Precautions

6.3.1 Transmission occurs through close contact, droplets, or direct contact with respiratory secretions. Ensure that the local policy for isolation nursing is implemented. The patient should be admitted to a negative pressure isolation room where available and respiratory precautions be instituted. See IC6 Isolation Policy. Continue isolation until at least 48 hours of antibiotic treatment.

Respiratory precautions including wearing a type IIR surgical face mask must be taken by staff. For meningococcal meningitis (and/or septicaemia) respiratory precautions must continue until at least 24 hours of appropriate (systemic) antibiotic therapy is completed. FFP3 masks must be worn when exposure to aerosols can be expected, e.g. endotracheal suction, intubation.

6.3.2 Visiting

Ideally visiting should be restricted for the first 24 hours of treatment to those individuals recently in contact with the patient. Visitors who have not had recent contact and need to visit within 24 hours of admission should follow Infection Prevention and Control Special Precautions.

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 9

6.3.3 Decontamination and Cleaning

The organisms responsible for meningitis die rapidly in the environment, therefore routine cleaning of the side room is adequate. Clinical waste and linen can be disposed of as usual. No special precautions are required.

6.4 Prophylaxis of Contacts

For contacts of invasive meningococcal and H. influenza disease

Case - Unless index cases have been given IV Ceftriaxone they should receive chemoprophylaxis as soon as they are able to take oral medication.

Close household contacts within 24 hours

PHE HPT will carry out a risk assessment to identify and define household / close contacts and advise on prophylactic treatment. Prophylaxis is prescribed by the hospital clinician looking after the index case, on the advice from PHE HPT (Refer to appendix 2). Prophylaxis is mainly offered to close contacts living in the same “household” as the case. Household contacts are defined as people who have had close/prolonged contact with the case in a household type setting. In addition to those sleeping in the same house and close contacts, both grandparents and childminders may be included. Prophylaxis should be considered for contacts of patients with probable or confirmed meningococcal meningitis/ septicaemia and HIB. 6.4.1 Chemoprophylaxis for Contacts

Should be given as soon as possible, ideally within 24 hours of diagnosis of the index case. Ciprofloxacin is the recommended drug for chemoprophylaxis. The advantages of ciprofloxacin over rifampicin are that it is given as a single dose, does not interact with oral contraceptives, and is more readily available in community pharmacies. (Recommended for use in all age groups and in pregnancy). Rifampicin was the drug of choice, however due to new evidence of Ciprofloxacin, this has now changed. * Alternatives in pregnancy: Ceftriaxone injection OR Azithromycin single dose 500mg stat. Please check the BNF for contraindications before prescribing (Side Effects/Precautions): The administration of ciprofloxacin may, however, be followed by anaphylactic reactions,81,82 (P Monk, M Evans, unpublished data). Healthcare staff should give out information sheets that include the risk of side effects (Appendix A), and be prepared to deal with allergic reactions.

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 10

It can also interact with other drugs but a single dose is unlikely to have a significant effect. It has an unpredictable effect on epilepsy but may be preferable to rifampicin if the patient is on treatment with Phenytoin).

Age Ciprofloxacin dosage Adults and Children > 12 years 500mg stat Children aged 5 – 12 years 250mg stat Children under 5 yrs 30mg/kg up to a maximum of 125mg stat *Ciprofloxacin suspension contains 250mg/5ml Rifampicin Recommended for use in all age groups. Evidence grade B Rifampicin is contraindicated in the presence of jaundice or known hypersensitivity to Rifampicin. Interactions with other drugs, such as anticoagulants, phenytoin, and hormonal contraceptives should be considered. Side effects should be explained including staining of urine and contact lenses Written information for patients should be supplied with the prescription (Appendix A). This is the responsibility of the prescriber. Dosage All to be given twice daily for 2 days: Adults and children over 12 years 600 mg Children aged 1–12 years 10 mg/kg Infants (under 12 months of age) 5 mg/kg Suitable doses in children based on average weight for age are: 0–2 months 20 mg (l ml*) 3–11 months 40 mg (2 ml*) 1–2 years 100 mg (5 ml*) 3–4 years 150 mg (7.5 ml*) 5–6 years 200 mg (10 ml*) 7–12 years 300 mg (as capsule/or syrup) * Rifampicin syrup contains 100 mg/5 ml CONTACTS SHOULD CONTACT THEIR GENERAL PRACTITIONER URGENTLY IF THEY BECOME UNWELL OR ATTEND THE NEAREST ACCIDENT AND EMERGENCY DEPARTMENT. In cases/ contacts of meningitis or other invasive infections with Haemophilus influenzae type b ie meningitis/septicaemia however rifampicin is still used for prophylaxis : Rifampicin induces enzymes in the liver and may affect other medication the patient is taking. Drug: Rifampicin (note precautions) Dose: Adults and children over 12 years 20MG/KG/DAY (Max.600 mg) OD X 4 days

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 11

Child 1 – 12 years 10 mg per kilogram OD X 4 days In cases of invasive infections with Haemophilus influenzae type i.e. meningitis/septicaemia please contact a Medical Microbiologist for advice regarding treatment of contacts. Side effects/Precautions: Rifampicin is contra-indicated in the presence of jaundice or known sensitivity. Red discolouration of urine/tears/sputum. May permanently stain soft contact lenses. Rifampicin may significantly interfere with a variety of drugs. Important interactions arise with ANTICOAGULANTS, ANTICONVULSANTS, ANTI-ARRHYTHMICS AND ORAL CONTRACEPTIVES. This may influence the choice of chemoprophylaxis. When given with oral contraceptives additional contraceptive precautions will be needed during that entire menstrual cycle. (British National Formulary (BNF) recommends use additional precautions for four weeks). Household contacts able to attend hospital may be given Rifampicin (available in the hospital on a 24 hour basis) and the GP should be informed by PHE HPT. PHE HPT will liaise with the GP regarding prophylaxis for contacts unable to attend hospital. Chemoprophylaxis should be initiated as soon as possible after diagnosis of the index case. Ceftriaxone is now available as an alternative to Rifampicin or Ciprofloxacin for chemoprophylaxis. A single injection is given (250 mg IM in adults, children less than 12 years, 125 mg). Ceftriaxone is contraindicated in patients with hypersensitivity and in the first 6 weeks of life. CONTACTS SHOULD CONTACT THEIR GENERAL PRACTIONER URGENTLY IF THEY BECOME UNWELL OR ATTEND THE NEAREST ACCIDENT AND EMERGENCY DEPARTMENT

School and Work Chemoprophylaxis is not usually indicated for one sporadic case, but is indicated if there are 2 or more connected cases. Necessary arrangements will be made by PHE HPT.

6.4.2 Prophylaxis of healthcare personnel

The risk of meningococcal disease in healthcare workers is very low. Chemoprophylaxis is recommended only for those whose mouth or nose is directly exposed to large particle droplets/secretions from the respiratory tract of a probable or confirmed case of meningococcal disease during acute illness until completed 24 hours of systemic antibiotics. This type of exposure will only occur among staff who are working close to the face of the case without wearing a mask or other mechanical protection. In practice this implies a clear perception of facial contact with droplets/secretions and is unlikely to occur unless using suction during airway management, inserting an airway, intubating, or if the patient coughs in your face. General medical or nursing care of cases is not an indication for prophylaxis.

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 12

Ciprofloxacin 500 mg as a single dose is recommended for prophylaxis. (Alternatively 600mg BD Rifampicin orally x 2 days). Exposure of the eyes to respiratory droplets is not considered an indication for prophylaxis. Such exposure may however carry a low risk of meningococcal conjunctivitis and subsequent invasive disease. Staff should be counselled about this risk and advised to seek early treatment if conjunctivitis should develop within 10 days of exposure.

6.5 Investigations:

Blood cultures within 1 hour of admission preferably before antibiotics given.

CSF – microscopy, culture, biochemistry; Can be sent for viral or bacterial (meningococcal and pneumococcal PCR) if required.

EDTA blood for bacterial (pneumococcal, meningococcal) PCR.

Nasopharyngeal swab, rash aspirate for meningococcal culture.

Full blood count, urea, creatinine, electrolytes,glucose,lactate.

Liver function tests and clotting screen.

As part of enhanced national surveillance: In <5 year olds -acute serum (2ml) and additional EDTA sample (2ml) for non-culture typing of vaccine antigens (ideally within 72 hours of treatment) should be taken & stored locally - for confirmed cases in England, the PHE Immunisation Team will request both samples to be sent to MRU using the PHE sample submission form (MenSAM01). (https://www.gov.uk/government/publications/meningococcal-disease-enhanced-surveillance-forms) In >5 years and adults- additional EDTA sample (2ml) to be sent to MRU for non-culture typing of vaccine antigens using the PHE sample submission form MenSAM01

6.6 Treatment

Pre-Admission Treatment - NICE recommends that children and young people with suspected bacterial meningitis without non-blanching rash should be transferred directly to secondary care without giving parenteral antibiotics (except if urgent transfer is NOT possible when antibiotics should be administered immediately). For suspected meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia) parenteral antibiotics (intramuscular or intravenous benzylpenicillin or third generation cephalosporin unless history of anaphylaxis) should be given at the earliest opportunity, either in primary or secondary care, but urgent transfer to hospital should not be delayed in order to give the parenteral antibiotics.

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 13

On admission: If bacterial meningitis is suspected, treatment should be started immediately i.e. not delayed for investigations such as lumbar puncture or CT scan. Treatment may have been initiated by the patients GP prior to admission. For the most up-to-date guidance on treatment please see the antibiotic website on the hospital intranet (Homepage >guidelines> adult antimicrobial policy) http://pandora/docs/policies/DOCUMENTS%20POLICIES/Adult%20Antimicrobial%20Guidelines.docx or Rx guidelines mobile device App

6.7 Vaccination against Meningococcal disease

Meningitis C vaccine MenC vaccine (Meningitec®, Menjugate® or NeisVac®) was included in the routine infant programme from November 1999. The vaccine is 88–96% effective against invasive meningococcal disease due to serogroup C infection for all ages within the first year following a primary course. However, protection against MenC disease declines over time and confers no protection against other serogroups (eg A, B, W, or Y). The national MenC vaccine schedule has been revised several times over the past decade. In teenagers, MenC vaccine offered to 13-14 year olds and new university entrants from autumn 2013 was replaced with MenACWY vaccination from August 2015.

The remaining infant MenC dose, at 3 months, was removed from the national immunisation schedule in July 2016. A single dose of Menitorix® vaccine (combined MenC-Haemophilus influenzae type B [Hib]) is offered at 12 months of age. NeisVac® is the only MenC vaccine now marketed in the UK.

Quadrivalent MenACWY vaccines

The MenACWY conjugate vaccine (Menveo®, Nimenrix®) replaced the MenC vaccine for 13-14 year-olds and new university entrants up to 25 years of age from August 2015; catch-up vaccination has also been offered during 2015-17 to those who were aged 14-18 years in 2015

MenB vaccine

The MenB vaccine (Bexsero®) has been included in the routine infant programme since 01 September 2015. Infants born in May 2015 were eligible for the vaccine at 4 and 12 months, those born in June were eligible for the vaccine at 3, 4 and 12 months and those born since 01 July 2015 are offered the vaccine at 2, 4 and 12 months alongside their other routine immunisations. In 2017, another MenB vaccine, using bi-valent lipidated fHbp (Trumenba®; Pfizer), was licensed in Europe. Trumenba® is licensed for individuals aged 10 years and older;

The vaccine is licensed to be given as two doses (0.5 ml each) administered at a 6 month interval or as 3 doses (2 doses at least 1 month apart, third dose at least 4 months later).

Both vaccines have also been used in university-associated Men B outbreaks.

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 14

6.7.1 Vaccination Schedule – refer to the Green Book: https://www.gov.uk/government/publications/meningococcal-the-green-book-chapter-22.

6.7.2 Vaccination Following a Case of Meningitis

Once recovered from their illness unimmunised/partially immunized index cases should receive all their vaccinations according to the national schedule for their age.

Close contacts of men ACWY – offered vaccine on advice of PHE through GP.

Men B – not recommended after a single case, but if a cluster on advice from PHE.

Close contact vaccination with Men ACWY or men B when required is in addition to abx prophylaxis.

6.8 Care of the Deceased Patient Including Mortuary Procedure

Transmission of meningitis to autopsy workers is extremely rare but not impossible. Therefore standard precautions should be taken when managing the deceased patient. If the deceased has been treated with an effective antibiotic for at least 24 hours prior to death, risks to relatives who wish to view the body are minimal. A body bag is not required for the transportation of the patient’s remains. Personal Protective Equipment should be worn by all staff who participate in a post-mortem examination. This should consist of:

A surgical shirt and trousers A long-sleeved surgical gown A plastic apron Waterproof boots with dorsal reinforcement Cut-resistant protective gloves A visor which covers the entire face and neck area Transfer of care from Mortuary to Funeral Services

6.9 Disseminating Information General issues:

The Medical Microbiologist will liaise with PHE HPT on a regular basis in order to ensure the accuracy of local information.

Leaflets for patients are available from:

Meningitis Now Tel No: 0808 80 10 388 Meningitis Research Foundation Tel No: 080 8800 3344

Meningitis Now 0808 80 10 388 (Freephone) 9am to 8pm every day. In addition to obtaining leaflets and posters by calling the Meningitis Now office, they can also be viewed and downloaded from the website: https://www.meningitisnow.org/how-we-help/resources/view-download-order/

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 15

Meningitis Research Foundation 0808 800 3344 (Freefone). Information and support is also offer by email and on social media: helpline@meningitis.org; www.facebook.com/meningitisresearch; @M_R_F

For further information please refer to Public Health England website: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/688835/Public_health_management_of_meningococcal_diseaseguidelines.pdf

6.10 Information for Patients This is routinely provided by PHE HPT for the patient and all contacts.

6.10.1 Antibiotics are given to the contacts of patients with meningococcal and invasive Haemophilus influenzae b infection to clear any bacteria they may be carrying in the nose and throat. This prevents the passage of the bacteria to other people and substantially reduces the risk of developing meningitis.

6.10.2 Meningococcal cases contacts:

The antibiotic usually prescribed is Ciprofloxacin. It comes in tablet or liquid form and you will receive either one of two tablets or a single dose of liquid. Please tell the doctor if you are:

Allergic to Ciprofloxacin

Have epilepsy or G6PD deficiency

Ciprofloxacin does NOT interfere with the contraceptive pill. 6.10.3 Haemophilus influenzae b infection contacts

The antibiotic usually prescribed is Rifampicin, but as this may interfere with other medicines you may be taking (anticoagulants, anticonvulsants and some heart drugs) an alternative may be used. As Rifampicin also interferes with the effectiveness of the contraceptive pill, women on the pill must use additional contraceptive methods during the cycle in which Rifampicin was taken. Extra contraceptive precautions are recommended for 4 weeks in the BNF.

Rifampicin is red in colour and as it ends up in body fluids, it may cause

urine, tears and sputum to develop a red discolouration. Soft contact lenses may become permanently stained.

6.10.4 You should contact your General Practitioner urgently if you become unwell

or attend the nearest Accident and Emergency department.

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 16

7 Training

All staff will be made aware of existence of the policy at induction.

Treatment guidelines are also available on the antibiotic policy on the Trust intranet.

Training from the IPC perspective included in relevant policies.

This is one of the diseases in the notifiable disease list and staff will be reminded by Microbiologists

Mandatory training to include guides for hand hygiene, PPE use, isolation and environmental cleaning.

8 Equality and diversity

The Trust is committed to ensuring that, as far as reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act 2010).

The policy has been appropriately assessed.

9 Monitoring compliance with the policy

Standard/process/issue Monitoring and audit

Method By Committee Frequency

Antimicrobial prescribing in cases of meningitis

Retrospective audit of cases

Microbiologist +/- pharmacist

Antibiotic Prescribing Committee

6 monthly

PPE and Respiratory isolation of suspected meningitis cases (or meningococcal sepsis)

Prospective audit of case and datix of non compliant cases

Microbiologists

IPCC

Review datix entry 6 monthly

10 Consultation and review

Members of Infection Prevention and Control team (IPCT) and Infection Prevention and Control Committee (IPCC) and Antimicrobial prescribing Committee

11 Implementation of policy (including raising awareness)

All members of staff will be informed via trust wide e mail, Mandatory Training and Safecare Bulletins and individual team meetings when due for review.

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 17

12 References

1. Guidance for the public health management of meningococcal disease in the UK (Updated February 2018).

2. British National Formulary (BNF) 52 – September 2006. British Medical Association and Royal Pharmaceutical Society of Great Britain.

3. Handbook of Common Hospital Infections. S Dundas and P D Welsby. Science Press

Ltd, 2002. 4. The Sandford Guide to Antimicrobial Therapy – 38th edition, 2008. D N Gilbert, R C

Moellering, G M Eliopoulos and M A Sande. 5. Control of Communicable Diseases Manual. A S Benenson, Editor. American

Public Health Association. 19th edition, 2008. 6. Control of Communicable Diseases Manual 17th Ed 2000. Edited by James Chin. 7. Preventing secondary cases of invasive meningococcal capsular group B (MenB)

disease: benefits of offering vaccination in addition to antibiotic chemoprophylaxis to close contacts of cases in the household, educational setting, clusters and the wider community. (Version 1.1, Dated 01 April 2014)

8. Immunisation against meningococcal B disease for infants aged from two months.

Information for health care professionals. Public Health England. July 2015 9. Introduction of a meningococcal ACWY immunisation programme for adolescents.

Information for health care professionals. Public Health England. July 2015 13 Associate documentation

IC Policy 2 Personal Protective Equipment in Clinical Practice

IC Policy 3 Standard Precautions for the Prevention and Control of Infection IC Policy 4 Hand Hygiene Policy IC Policy 6 Isolation Policy (including respiratory isolation)

Form: Meningococcal disease: enhanced surveillance forms

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 18

Appendix 1

Ciprofloxacin drug information leaflet

The antibiotic you will be given is called Ciprofloxacin. The meningococcal germs that cause meningitis and septicaemia can be carried in the nose and throat. This antibiotic will kill them. It comes in tablet or liquid form. You will receive either one or two tablets of Ciprofloxacin or one dose of a liquid. Tablets are taken by mouth as a one-off dose with a glass of water. It is important to drink plenty of fluids for the rest of the day after taking this antibiotic. Do not take the tablet or medicine if you have taken antacid/indigestion medicines or preparations containing iron or mineral supplements within the last four hours. Please see the doctor or nurse if this is the case. You should also avoid drinking alcohol with this medication as it may make you drowsy, affecting your ability to drive or operate machinery. Ciprofloxacin is an antibiotic that is frequently used to treat lots of different conditions. It is recommended in national guidelines for close contacts of someone with meningococcal disease.

The side effects of Ciprofloxacin may include:

tummy ache, diarrhoea and nausea

tiredness and headaches

rash and itching

facial swelling - very rarely breathing difficulties may occur with the facial swelling. You should

seek medical attention urgently if this occurs

pain and inflammation around the joints Please tell the public health doctor or nurse if you are:

allergic to ciprofloxacin

have a history of epilepsy or G6PD deficiency so that they can arrange an alternative medicine. Ciprofloxacin does not interfere with the contraceptive pill.

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 19

Rifampicin drug information leaflet

The antibiotic you will be given is called Rifampicin. It comes as either tablets or syrup and is

suitable for people of all ages. The meningococcal germs that cause meningitis and septicaemia

can be carried in the nose and throat, this antibiotic will kill them.

Rifampicin must be taken twice a day for two days (morning & evening), the instructions will be

clearly written on the box or bottle. It is important that you take a two-day course. It is taken by

mouth and should be taken one hour before a meal to obtain the best effect. You may have extra

medicine left, which should be disposed of safely.

Rifampicin is an antibiotic that is frequently used to treat lots of different conditions. It is

recommended in national guidelines for close contacts of someone with meningococcal disease.

The side effects of Rifampicin may include:

orange/reddish staining of urine, saliva and tears. This is normal – so do not be alarmed.

Rifampicin may permanently stain some contact lenses so you should not wear contact lenses

whilst on treatment or for the following week

tummy upset, diarrhoea and nausea

skin flushing and itching, with or without a rash

very rarely, jaundice (yellowing of the skin or whites of the eyes) Rifampicin may reduce the effect of several medicines including

blood thinning medication (anticoagulants)

diabetic medication

some types of epilepsy medication (anticonvulsants).

Rifampicin can interact with oral contraceptives. If you are taking an oral contraceptive pill, you

should use an additional method of birth control (such as condoms) as well as your oral

contraceptive pill during treatment with rifampicin and for at least 4 weeks after finishing the

treatment. Please tell the public health doctor or nurse if you:

take any medication

are allergic to rifampicin as you may need an alternative medicine.

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 20

Appendix 2

North East Health Protection Team Meningococcal Infection

Reporting cases for public health action

Health Protection Team (HPT) contact details

During working hours (Mon-Fri 9 am-5pm) 0300 303 8596 option 1.

Outside normal office hours contact first on-call for HPT on 0191 269 7714

National guidance recommends specific public health actions for probable or confirmed cases of meningococcal infection (see case definitions below). This includes offering antibiotic prophylaxis +/- vaccination to household and close contacts. The Health Protection team will also manage communication to schools, universities, wider public and partner organisations. Probable or confirmed cases who are admitted to hospital in the North East should be reported to the Public Health England North East Health Protection Team (HPT) as soon as possible, including out of hours. Reports should be made by clinicians treating the case and can also be made by microbiologists receiving clinical samples. Telephone reporting is the preferred route; calls regarding meningococcal cases are prioritised and managed as ‘urgent’ within the HPT. Clinicians are also asked to report cases that are transferred to their care from another hospital (within or outside NE). Once HPT staff have undertaken a risk assessment they will liaise with ward staff and, if necessary GPs, to arrange prescription of antibiotic chemoprophylaxis. It has been agreed with all trusts in the North East that hospital staff will prescribe for household contacts. It is expected that chemoprophylaxis will be arranged urgently for household contacts and within 24 hours of referral of the index case for other close contacts. The HPT will collect information about all cases who are admitted to hospitals in the North East of England, regardless of where they are resident. For cases that are not normally resident in the North East, the North East HPT will liaise with the out of area HPT to ensure appropriate public health actions are undertaken.

Management of Bacterial Meningitis and Meningococcal Disease Policy v11 21

Case Definitions

Confirmed case A clinical diagnosis of meningitis, septicaemia or other invasive disease (such as *orbital cellulitis, septic arthritis) AND at least one of the following:

Neisseria meningitidis isolated from a normally sterile site

Gram negative diplococci in a normally sterile site

Meningococcal DNA in a normally sterile site

Meningococcal antigen in blood, CSF or urine *Although meningococcal infection of the conjunctiva does not meet the definition of a confirmed case, it is considered an indication for public health action because of the high immediate risk of invasive disease. Probable case Clinical diagnosis of meningitis or septicaemia or other invasive disease where the physician, in consultation with the microbiologist, considers that meningococcal infection is the most likely diagnosis. Possible case A clinical diagnosis of meningitis or septicaemia where the physician, in consultation with the microbiologist, considers that diagnoses other than meningococcal disease are at least as likely. This category includes cases who may be treated with antibiotics but whose probable diagnosis is viral illness. The HPT often manage requests for information about cases (possible, probable and confirmed) e.g. from schools, other organisations), particularly when there is community anxiety about the possible diagnosis. In these situations the HPT may contact the clinical team for further information. The HPT is happy to receive information about possible cases – particularly if clinicians are aware of anxiety about the possible diagnosis or if there have been recent cases in same school / area.

NB: Change in clinical condition or microbiological test results (e.g. rising antibody levels/PCR) or may change the case category from “possible” to “probable” or “confirmed”, in which case the Health Protection Team should be informed.

Statutory notification

Acute meningitis and meningococcal septicaemia are notifiable infectious diseases (NOIDs) under the Health Protection (Notification) Regulations 2010. In addition to telephone reporting (above – for public health action), registered medical practitioners should send a completed statutory notification by email to nenotifications@nhs.net or fax to 0191 221 2584 . Neisseria meningitidis is a notifiable causative agent under the Health Protection (Notification) Regulations 2010. Laboratory operators are required to notify cases in writing to the Health Protection Agency; this can be undertaken by routine SGSS reporting.