Surveillance decision

Surveillance decision

We propose to update the NICE guideline on bacterial meningitis.

The following table gives an overview of how evidence identified in surveillance might affect each area of the guideline.

Section of the guideline

New evidence identified

Impact

1.1 Symptoms, signs and initial assessment

Investigation and management in children and young people with suspected bacterial meningitis

Yes

No

1.2 Pre-hospital management

Pre-hospital management of suspected bacterial meningitis and meningococcal septicaemia

Yes

No

1.3 Diagnosis in secondary care

Investigation and management in children and young people with petechial rash

Yes

No

Investigation and management in children and young people with suspected bacterial meningitis

Yes

Yes

Polymerase chain reaction (PCR) tests for bacterial meningitis and meningococcal disease

Yes

No

Skin samples for meningococcal disease

Yes

No

Performing lumbar puncture and interpreting cerebrospinal fluid parameters for suspected bacterial meningitis

Yes

Yes

Cranial computed tomography in suspected bacterial meningitis

No

No

1.4 Management in secondary care

Antibiotics for suspected bacterial meningitis or meningococcal disease

Yes

No

Treatment for specific infections in confirmed bacterial meningitis

No

No

Treatment of unconfirmed bacterial meningitis

Yes

No

Treatment of meningococcal disease

No

No

Other aspects of management in bacterial meningitis and meningococcal septicaemia

No

No

Corticosteroids

Yes

No

Adjunctive therapies

Yes

No

Monitoring for deterioration for meningococcal disease

Yes

No

Retrieval and transfer to tertiary care

No

No

1.5 Long-term management

Long-term effects of bacterial meningitis and meningococcal septicaemia

Yes

No

Immune testing

Yes

Yes

Reasons for the decision

This section provides a summary of the areas proposed to be updated and the reasons for the decision to update.

Diagnosis in secondary care

Procalcitonin

New systematic review and observational evidence supports the use of both serum and cerebrospinal fluid (CSF) procalcitonin (PCT) in the diagnosis of bacterial meningitis, including differential diagnosis between bacterial and viral meningitis. NICE guideline CG102 did not identify any evidence that examined the diagnostic accuracy of PCT for differentiating bacterial meningitis from other infections. Further new systematic review evidence indicates that PCT in addition to standard testing may be more cost effective than standard testing alone.

The new evidence identified through the surveillance review strengthens the evidence base for including PCT alongside other variables in diagnosis in secondary care. There is therefore a potential impact on recommendations 1.3.7 and 1.3.17, which advise that a C-reactive protein and white blood cell count should be performed, but do not include PCT testing.

Age-specific reference values

Topic expert feedback and new evidence indicates that up to date age-specific reference values, including those published by Public Health England (PHE), are available. The reference values cover normal ranges for blood test results or CSF findings to help interpret the test results in children (especially neonates) and young people with suspected bacterial meningitis. There is a potential impact to review section 5.5 of the full guideline on performing lumbar puncture and interpreting CSF parameters for suspected bacterial meningitis, specifically the text concerning normal ranges for CSF variables. Because of a lack of evidence on neonates at the time of guideline development, the normal CSF values presented in NICE guideline CG102 reflect those for the adult population for total protein concentration, and for children over 1 year old and adults for glucose concentration. The related research recommendation (4.2) should also be reviewed, to assess whether a new recommendation is needed.

Long-term management

New intelligence indicates a potential impact on recommendations 1.5.8–1.5.10, to take account of the MenB vaccine that has been introduced since publication of NICE guideline CG102. A review of the wording of these recommendations should be considered, so that any child who has received meningococcal vaccination and subsequently develops meningococcal disease should be tested for complement deficiency. The current recommendations for testing exclude children who have had meningococcal disease caused by serogroup B, based on the lower likelihood of complement deficiency in this subgroup at the time of guideline development.

For further details and a summary of all evidence identified in surveillance, see appendix A.


This page was last updated: 04 October 2018