How should babies with meningitis symptoms be treated? The issues shown in negligence cases
Meningitis in a very young baby is a very dangerous condition, which will prove fatal if left untreated, and may also result in cerebral palsy, blindness, deafness, seizure disorders and other serious conditions if the child survives. The most common cause of neonatal meningitis is bacterial infection of the blood, often arising from Group B Streptococcus (GBS), but also from E Coli and Listeria. Fortunately there is a low mortality rate from neonatal meningitis in the UK and other developed countries, but nonetheless in order to avoid a tragic outcome, it is vital in such cases to make the diagnosis promptly and to ensure that the correct antibiotic regime is put in place at the earliest opportunity.
As a firm we have dealt with a number of these sad and difficult cases, and her I will look at some of the medico-legal issues which arise from them.
Making the diagnosis
Symptoms of neonatal meningitis are often non-specific, and may be consistent with other conditions such as sepsis. They can include fever, irritability and dyspnoea (laboured or obstructed breathing). Other indications might be apnoeas (brief periods of cessation of breathing), bradycardia (slow heart rate), desaturations, and a rising CO2 indicating a respiratory acidosis.
Due to the non-specific nature of the symptoms, it is wise to assume meningitis is within the category of a differential diagnosis (where you could assume the symptoms indicate a number of different conditions); the alternative is carry out a lumbar puncture, which can make the diagnosis definitively, but sometimes a child may be too sick to undergo such an invasive investigation.
The symptoms which are more clearly diagnostic of meningitis (bulging fontanelle, high-pitched cry) tend not to appear until the disease has advanced to a point where permanent neurological damage has been sustained. It is not, therefore, an option to wait until those symptoms occur before treating for meningitis.
Prescribing the correct antibiotics
With a differential diagnosis of sepsis and meningitis in a neonate, what antibiotics are appropriate to prescribe? There is some support in medical textbooks for treating sepsis with Flucloxacillin and Gentamicin, but while Flucloxacillin is effective against Staphylococcus Aureus infection, Staph Aureus is no longer a common cause of neonatal sepsis in the developed world.
There is a strong argument therefore that, where meningitis cannot be excluded as a possible diagnosis, it is good practice to administer broad spectrum antibiotics, including Cefotaxime, which is known to penetrate the Cerebro-Spinal Fluid (CSF) and therefore to be effective against meningitis. This is all the more so where a decision has been taken not to carry out a lumbar puncture test.
How effective are antibiotics against bacterial infection such as GBS?
Meningitis in neonates tends to have a poor outcome, but there is well-respected research which indicates that early treatment (within two and a half hours of onset) leads to a normal outcome in a significant number of cases (61% according to some research). The damage to the child’s brain is caused by the infective organism multiplying and causing inflammation in the brain. Cefotaxime has a bactericidal effect on the infective organisms in the CSF, and stops the organisms multiplying, so prompt treatment means that the damaging inflammation is prevented or minimised.
There is, however, some controversy as to whether other antibiotics such as Benzylpenicillin or Flucloxacillin have any effect upon, for example, GBS infection. This controversy is a crucial element in certain medico-legal cases, where the optimal antibiotic regime has not been put in place in good time, but a less efficacious one has been tried.
It is crucial in cases of suspected neonatal meningitis to make the diagnosis promptly. Because the symptoms can be so non-specific, it is vital to have a high index of suspicion in relation to meningitis, and to be alert to the possibility of its being the cause of worrying symptoms in a young baby. This is all the more so in the case of premature babies, who are more susceptible to such infection.
If meningitis cannot be excluded from the differential diagnosis then it is good practice to prescribe an antibiotic regime which will cover meningitis (usually cefotaxime, gentamicin and amoxicillin) rather than taking the chance that the child has a more common but less dangerous form of infection.