Synopsis
Recognise fulminant pneumococcal and meningococcal sepsis or meningitis, start immediate ceftriaxone-based treatment, secure microbiological confirmation, notify health protection and prevent secondary meningococcal cases.
- Meningococcal disease may present as septicaemia, meningitis or both; pneumococcus commonly causes meningitis, bacteraemic pneumonia and overwhelming sepsis.
- Absence of rash does not exclude meningococcal disease, and a blanching early rash can evolve into purpura as coagulopathy develops.
- Give ceftriaxone immediately for suspected invasive disease after cultures when this causes no material delay; use meningitis dosing when CNS infection is possible.
- Take EDTA blood for meningococcal and pneumococcal PCR plus blood cultures because prior antibiotics reduce culture yield but not all molecular yield.
- Lumbar puncture is valuable when safe but follows stabilisation and must not precede urgent antibiotics in a deteriorating patient.
- Notify suspected meningococcal disease promptly and let the health-protection team define close contacts, prophylaxis and vaccine needs.
- Ceftriaxone treatment does not reliably eradicate meningococcal carriage for every regimen; discharge clearance follows specialist advice.
- Investigate recurrent invasive encapsulated infection for asplenia, complement deficiency, immunoglobulin disorder, CSF leak or cochlear implant risk.
Key red flags
A non-blanching rash with fever or toxicity is meningococcal disease until urgent assessment proves otherwise.
Shock, prolonged capillary refill, oliguria, lactate rise or altered consciousness requires immediate critical-care escalation.
Meningism, focal neurology, papilloedema or seizure changes lumbar-puncture safety but never delays antibiotics.
Asplenia, complement deficiency or complement-inhibitor therapy markedly increases risk of overwhelming encapsulated bacterial disease.
Abrupt fever, severe myalgia, limb pain, mottling, purpura, shock and rapid capillary leak may occur before meningism.
Headache, fever, neck stiffness, photophobia and altered cognition is a medical emergency even without rash.
Focal consolidation with sepsis, pleuritic pain or hypoxia can accompany pneumococcal bloodstream invasion.
Expanding ecchymoses, acral ischaemia and coagulopathy indicate severe endothelial and coagulation injury requiring critical care.
Investigation priorities
Confirm viable organism and preserve diagnosis after prior antibiotics.
Management branches
Invasive meningococcal or pneumococcal disease is clinically suspected.
- Use ABCDE, capillary refill, lactate, urine output and neurological examination and involve critical care early for shock or altered consciousness.
- Take blood culture and PCR quickly, then give ceftriaxone at meningitis dose when CNS infection cannot be excluded.
- Manage hypoglycaemia, seizures, coagulopathy and raised intracranial pressure while using reassessed fluids and vasopressors.
- Perform lumbar puncture only after safety criteria are met and never use CT as a routine prerequisite that delays treatment.