Missing meningitis
Every paediatric doctor has a fear of sending home a young, septic child or missing meningitis. We constantly review our practice and guidelines on how to identify the septic child amongst the thousands of febrile two-year-olds that present to the ED. But what are the consequences if we do miss one?
This study looked at children with meningitis or septicaemia to see if they had presented to the hospital in the days preceding their eventual diagnosis.
Who was studied?
This was a retrospective cohort study looking at all non-elective hospital admissions in Ontario, Canada, over a five-year period (following the implementation of the pneumococcal vaccine programme).
Included patients were:
- aged 30 days to 5 years
- with a diagnosis of meningitis or septicaemia
- had a length of hospital stay of at least 4 days (or died in hospital)
There were 521 children included. Patients were excluded if they had been discharged from the hospital in the preceding 14 days
What were the patients?
There were two groups – those who had previous ED presentations (in the preceding five days), and those who were admitted on the first presentation to ED.
What were the outcomes measured?
The primary outcomes were length of stay, critical care admission, and mortality.
Secondary outcomes measured included the type of ED for the previous presentation, time of registration in ED, and triage acuity.
What did the results show?
125 of the 521 children (24%) admitted with meningitis or septicaemia had an ED presentation in the five days prior to admission.
Over 2/3 of the repeat presentation group were initially diagnosed with one of the following: fever, otitis media, upper respiratory tract infection, viral infection, gastroenteritis, urinary disorder, or seizures.
96.4% of patients returned within 72 hours.
Both groups had similar lengths of stay, critical care admission rates, and mortality rates.
Those treated in a community ED without review by a paediatric specialist were more likely to be in the repeat-presentation group.
How do I know what happens to my patients after I discharge them?
29.8% of the repeat presentation group had their repeat presentations in different EDs. This emphasises that it is hard for us, as clinicians, to receive feedback on our patients and to improve our practice. It’s important to have good communication between hospitals in similar geographic areas.
Was this a good study?
1. Did the study address a clearly focused issue?
Sort of – at the start, the study aim is set out as ‘How often do children visit the emergency department in the 5 days before diagnosis of meningitis or septicaemia?‘. Actually, what the authors are asking is, ‘Does having repeat presentations prior to admission for meningitis or septicaemia affect outcome?‘.
The authors do not directly answer the first question, although the data suggest that all 114 children were admitted on the second presentation to the hospital.
2. Was the cohort recruited in an acceptable way?
Yes – retrospectively via the patient database using diagnosis at admission.
3. Were the outcomes accurately measured to minimise bias?
Yes – retrospectively collected and independently verified.
4. Have the authors identified and taken into account confounding factors?
The authors identify that prior presentations to Primary Care services could affect the groups, but this cannot be accounted for.
5. Was the follow-up long enough?
Yes – patients were followed up until discharge or death.
6. Do you believe the results?
The authors identify some factors that may skew the results. For example, patients admitted on first presentation are likely to be more acutely unwell, which may make that group appear to have worse outcomes. Also, information about previous treatments/antibiotics could impact the outcomes.
7. Can the results be applied to our local population?
Yes
8. Do the results fit in with the other available evidence?
Yes
It is reassuring to think that discharging a child with meningitis or septicaemia does not affect that child’s overall outcome. However, more information about the initial clinical encounter would have been helpful – for example, the patient’s initial clinical symptoms, observations, and investigations/results.
