Emergency management of meningococcal disease.

Meningococcal disease remains a major cause of mortality in children in the UK. Aggressive early volume resuscitation, meticulous attention to the normalisation of all physiological and laboratory parameters, and prompt referral to specialist paediatric intensive care may lead to a sharp reduction in mortality. Application of the management algorithm described in this article may be helpful to those involved in the early part of management of critically ill patients with meningococcal disease.     

Management of meningococcal disease

In recent years remarkable progress has been made in the development of vaccines against the different disease-causing serotypes of Neisseria meningitidis. Despite this, invasive meningococcal disease (IMD) remains a life-threatening illness with significant mortality, morbidity and long term sequelae. Prompt recognition and early treatment with antibiotics are the first steps in its management. Professionals looking after children with suspected IMD should be familiar with its clinical course, so that progression of the disease can be identified early, and its complications including septic shock, coagulopathy and raised intracranial pressure managed aggressively. This article summarizes the clinical features, presentation, pathophysiology and management of IMD focusing on its two common clinical presentations: septicaemia with associated shock and meningitis.     

Prevention of meningococcal disease

Neisseria meningitidis is the most common cause of meningitis in children aged 2-18 with a mortality rate ranging from 4-40% and substantial morbidity in 11-19% of survivors. Of the four serogroups ofNeisseria meningitidis, serogroups B and C are the most common causes in the United States, with serogroup C causing most disease among adolescents, a population at risk for invasive meningococcal disease. The meningococcal polysaccharide vaccine was developed in response to increasing rates of bacterial meningitis among military recruits. With widespread use of the vaccine in the military, there was a dramatic decreased incidence in invasive meningococcal disease. However, there may be limitations to the polysaccharide vaccine including lack of durable protection, lack of induction of T-cell-dependent immune response, and lack of immunogenicity in children less than 2 years of age. Based on the success of other conjugate vaccines in pediatrics, a new conjugate polysaccharide vaccine, Menactra, has been approved by the Food and Drug Administration and recommended for routine vaccination in adolescents by the Advisory Committee on Immunization Practices.     

Chronic lung disease of prematurity and respiratory outcome at eight years of age

AIM: The study aimed to determine the respiratory outcome of children who had chronic lung disease of prematurity (CLD) compared with a preterm control group of children at school age. METHODS: Fifty-two preterm infants with CLD born between 26 and 33 weeks gestation were assessed regarding respiratory illness with 47 having lung function testing. Information regarding respiratory illness was obtained from 52 children in the birthweight-matched control group of whom 45 had lung function testing. The results were compared between the CLD and control groups. RESULTS: There was no difference in respiratory symptomatology between CLD groups and control preterm infants. On lung function testing, a significantly lower mean forced expiratory flow at 25-75% of vital capacity was identified compared with the preterm controls (P=0.024). This significant difference did not persist after bronchodilator therapy. There was no evidence of increased air trapping or bronchial hyper-reactivity in the CLD children compared with the controls. CONCLUSION: Lung function in CLD children is largely normal in comparison with preterm controls, apart from some evidence of reversible small airway obstruction. Respiratory symptomatology is not increased in chronic disease children in comparison with control preterm children.     

Vaccines against meningococcal disease

The meningococcal disease has been a source of preoccupation all over the world. Epidemics have been registered periodically in developed or developing countries. The most frequent meningococci are those concerned with serogroups A, B and C. Researches to develop effective vaccines against the disease have been taking place since the 40's. Presently, only vaccines against the meningococci from the serogroups A, C, Y and W-135 are available. These vaccines have important limitations both due to the age range that they protect and the period of time that the protection lasts. They are not routinely used in vaccination programs and are indicated only in risky situations. This demands a strict epidemiological surveillance of the disease. There are no vaccines against the serogroup B meningococci with recognized effectiveness, although, in the last decades, many have been tested. There are perspectives of important advances in this area, mainly with the development of conjugated vaccines, like the Haemophilus influenzae type B vaccine. Until the present, the chemoprophylaxis of the intimate communicants of a case is the best way to avoid secondary cases.     

The impact of meningococcal polymerase chain reaction testing on laboratory confirmation of invasive meningococcal disease

Laboratory methods of diagnosis were examined for 266 children with invasive meningococcal disease. Seventy-five (36%) of 207 cases with bloodstream infection had both positive blood culture and blood meningococcal polymerase chain reaction (PCR), 130 (63%) negative blood culture and positive blood PCR, and 2 (1%) had positive blood culture and negative blood PCR. Sixty-three percent of cases were diagnosed by PCR alone.