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Br J Gen Pract. Oct 2011; 61(591): 606.
PMCID: PMC3177115

‘One for all’ concerns regarding NICE antibiotic guidelines on suspected bacterial meningitis!

Kordo Saeed, Consultant Microbiologist
Royal Hampshire County Hospital, Romsey Road, Winchester, SO22 5DG. E-mail: ten.shn@deeasodrok
Timothy Stannard
Friarsgate Practice, Winchester
Matthew Dryden
Royal Hampshire County Hospital, Winchester

The most common bacteria causing meningitis include Streptococcus pneumoniae, Neisseria meningitides, and Haemophillus influenzae. Guidelines issued by the National Institute for Health and Clinical Excellence (NICE) in regards to bacterial meningitis recommend administration of benzylpenicillin for children and young patients with suspected meningococcal disease in the pre-hospital setting. This is in accordance with existing advice issued by the chief medical officer.1,2 However, when the same patient comes in to hospital, the advice on the empirical antibiotic choice changes to third generation cephalosporins (with or without high dose amoxicillin depending on risk factors for Listeria monocytogenes infections) this means that, essentially, the same patient can be prescribed different antibiotics depending on where he or she is first seen!

At present there is convincing evidence suggesting an independent incremental association between ‘delays’ in administering ‘the correct’ antibiotics and mortality from acute bacterial meningitis.5 In addition, we know that delay in commencing adequate antibiotic therapy in septic shock cases is associated with higher mortality, and the use of inappropriate antibiotics is associated with higher mortality in blood stream infections.68 Penicillin resistant rates among UK Haemophillus species isolates is 17.7% and penicillin intermediate S. pneumoniae is 10.8%. In a Scottish study the prevalence of moderate penicillin resistant meningococci was 8.3%, the majority of isolates (52.2%) belonged to serogroup B,3,4 and according to the same NICE guidelines the prevalence of Haemophillus resistance to third generation cephalosporins is almost zero. There is currently a low prevalence of pneumococcal cefotaxime/ceftriaxone resistance in the UK, with only 1.7% of strains reported to have intermediate or high resistance to cefotaxime between 2004 and 2007. Given these numbers it is unclear as to why NICE is still recommending benzylpenicillin.

Paul Erlich's ‘Frapper fort et frapper vite’ statement is correct, however, in addition to ‘hit hard and hit fast’ we believe that in these cases we need to ‘hit right’ to achieve a more favourable outcome. Therefore, the choice of empirical antibiotic should be the same both in pre- and post-hospital settings, and benzylpenicillin in the doctors bag should be replaced with a third generation cephalosporin, for example, cefotaxime, to be administered to patients in a timely manner, unless of course there is history of true beta-lactam allergy or other contraindications.

REFERENCES

1. National Institute for Health and Clinical Excellence. Bacterial meningitis and meningococcal septicaemia (CG102) London: NICE; 2010. http://guidance.nice.org.uk/CG102 (accessed 5 Sep 2011)
2. Department of Health. Professional letter — chief medical officer: meningococcal infection. London: Department of Health; 1999. http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletters/Chiefmedicalofficerletters/DH_4004235 (accessed 5 Sep 2011)
3. Sahm DF, Jones ME, Hickey ML, et al. Resistance surveillance of Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis isolated in Asia and Europe, 1997-1998. J Antimicrob Chemother. 2000;45(4):457–466. [PubMed]
4. Kyaw MH, Bramley JC, Clarke S, et al. Prevalence of moderate penicillin resistant invasive Neisseria meningitidis infection in Scotland, 1994-9. Epidemiol Infect. 2002;128(2):149–156. [PMC free article] [PubMed]
5. Proulx N, Fréchette D, Toye B, et al. Delays in the administration of antibiotics are associated with mortality from adult acute bacterial meningitis. QJM. 2005;98(4):291–298. [PubMed]
6. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589–1596. [PubMed]
7. Ibrahim EH, Sherman G, Ward S, et al. The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest. 2000;118(1):146–155. [PubMed]
8. Leibovici L, Shraga I, Drucker M, et al. The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection. J Intern Med. 1998;244(5):379–386. [PubMed]

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