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Meningococcal Disease in the Office: To Treat or Not to Treat?

The effectiveness of antibiotic treatment before hospital admission remains uncertain.

Meningococcemia remains a disease that is associated with high morbidity and mortality despite improved antibiotics and supportive care. Most practitioners consider early antibiotic treatment critical for appropriate management, but others have concerns about the antibiotic-induced release of bacterial endotoxin. Two recent studies examined the effectiveness of antibiotic treatment before hospital admission in reducing the mortality associated with meningococcal disease.

Researchers in the U.K. conducted a case-control study of 158 children who had been diagnosed with meningococcal disease by general practitioners before hospital admission. The 105 children who were given parenteral penicillin before hospital admission had significantly higher mortality risk (odds ratio, 7.4) and rate of complications among survivors (OR, 5.0) than children who did not receive penicillin before admission. Children in the penicillin group also were more likely to have presented with hemorrhagic rash.

In the second study, researchers conducted a systematic review of data from 14 observational cohort studies of oral and parenteral antibiotic treatment of meningococcal disease before hospital admission. Of 12 studies with data on the use of parenteral antibiotics, 8 showed a beneficial effect compared with no treatment, and 4 showed poorer outcomes.

Comment: These conflicting findings probably result from confounding variables, because patients who are sicker or who have more classic hemorrhagic features are more likely to receive antibiotics in the practitioner’s office. A commentary by a statistician for the case-control study outlines other limitations. For the practitioner, the take-home messages must be to vaccinate individuals (for vaccine information, see JWPAM Jun 9 2006 and CDC Recommendations of the Advisory Committee on Immunization Practices), to be highly suspicious of meningococcal infection, and when suspicions are strong, to give antibiotics if possible and quickly transfer patients to an appropriate inpatient facility.

— Peggy Sue Weintrub, MD

Published in Journal Watch Pediatrics and Adolescent Medicine July 19, 2006

Citation(s):

Harnden A et al. Parenteral penicillin for children with meningococcal disease before hospital admission: Case-control study. BMJ 2006 Jun 3; 332:1295-8.

• Original article (Subscription may be required)
• Medline abstract (Free)

Hahné SJM et al. Effectiveness of antibiotics given before admission in reducing mortality from meningococcal disease: Systematic review. BMJ 2006 Jun 3; 332:1299-303.

• Original article (Subscription may be required)
• Medline abstract (Free)

Perera R. Statistics and death from meningococcal disease in children. BMJ 2006 Jun 3; 332:1297-8.

• Original article (Subscription may be required)
• Medline abstract (Free)