Objective To define early presenting features of bacterial meningitis in young infants in England and to review the adequacy of individual case management as compared with relevant national guidelines and an expert panel review.
Design Retrospective medical case note review and parental recall using standardised questionnaires.
Setting England and Wales.
Participants Infants aged <90 days with bacterial meningitis diagnosed between July 2010 and July 2013.
Results Of the 97 cases recruited across England and Wales, 66 (68%) were admitted from home and 31 (32%) were in hospital prior to disease onset. Almost all symptoms reported by parents appeared at the onset of the illness, with very few new symptoms appearing subsequently. Overall, 20/66 (30%) infants were assessed to have received inappropriate prehospital management. The median time from onset of first symptoms to first help was 5 hours (IQR: 2–12) and from triage to receipt of first antibiotic dose was 2.0 hours (IQR: 1.0–3.3), significantly shorter in infants with fever or seizures at presentation compared with those without (1.7 (IQR: 1.0–3.0) vs 4.2 (IQR: 1.8–6.3) hours, p=0.02). Overall, 26 (39%) infants had a poor outcome in terms of death or neurological complication; seizures at presentation was the only significant independent risk factor (OR, 7.9; 95% CI 2.3 to 207.0). For cases in hospital already, the median time from onset to first dose of antibiotics was 2.6 (IQR: 1.3–9.8) hours, and 12/31 (39%) of infants had serious neurological sequelae at hospital discharge. Hearing test was not performed in 23% and when performed delayed by ≥4 weeks in 41%.
Conclusions In young infants, the non-specific features associated with bacterial meningitis appear to show no progression from onset to admission, whereas there were small but significant differences in the proportion of infants with more specific symptoms at hospital admission compared with at the onset of the illness, highlighting the difficulties in early recognition by parents and healthcare professionals alike. A substantial proportion of infants received inappropriate prehospital and posthospital management. We propose a targeted campaign for education and harmonisation of practice with evidence-based management algorithms.
- young infants
- healthcare delivery
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Contributors IOO completed the ethics application form, finalised the data collection tool, coordinated the study, entered all data into an Access database, data interpretation, performed the analysis, wrote the initial manuscript, reviewed and revised the manuscript, and submitted the final manuscript. SNL helped with case ascertainment from the Public Health England, supported the data analysis and data interpretation, reviewed and revised the manuscript, and approved the final manuscript. MA co-conceived and designed the study, including the grant application, was a member of the expert panel who reviewed the management of cases, took part in data interpretation, reviewed and revised the manuscript, and approved the final manuscript. NN co-conceived and designed the study, including the grant application, was a member of the expert panel who reviewed the management of cases, took part in data interpretation, reviewed and revised the manuscript, and approved the final manuscript. PTH was the chief investigator, co-conceived and designed the study, including the grant and ethics application, was a member of the expert panel who reviewed the management of cases, contributed to the data analysis and data interpretation, reviewed and revised the manuscript, and approved the final manuscript.
Funding The Meningitis Research Foundation funded the study, and initial data collection and analysis. The funding body did not influence study design, data collection, data analysis, data interpretation, writing of the report or the decision to submit the paper for publication. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.
Competing interests All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare no support from any organisation for the submitted work. PTH is a consultant for Novartis and Pfizer on group B streptococcus vaccines but receives no payment for this. NN is a consultant for Pfizer on meningococcal group B vaccines, and has received honoraria to teaching on meningitis from Novartis. All other authors declare no conflicts of interests. The ICMJE form for disclosure of potential conflicts of interest has been submitted.
Ethics approval Ethical approval was given by Cambridgeshire 2 REC (Ref: 10/H0308/64). Paediatricians were approached by email asking if they would be willing to take part in the study. If in agreement, a National Institute for Health Research Coordinated System for gaining NHS Permission (NIHR CSP) application was made and the hospital listed once approval was granted.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Extra data can be accessed via the Dryad data repository at http://datadryad.org/ with the doi:10.5061/dryad.601m8.
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