Bacterial meningitis and meningococcal septicaemia Implementing NICE guidance ABOUT THIS PRESENTATION: This presentation has been written to help you raise awareness of the NICE clinical guideline on Bacterial meningitis and meningococcal septicaemia: management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care. This guideline has been written for those who work in or use the National Health Service (NHS) in England, Wales and Northern Ireland, in particular: healthcare professionals involved in the care of children and young people with bacterial meningitis or meningococcal septicaemia (including paediatricians, GPs and nurses); those responsible for commissioning and planning healthcare services, including primary care trust commissioners, Health Commission Wales commissioners, and public health and trust managers; parents and carers of children and young people with bacterial meningitis or meningococcal septicaemia. The guideline is available in a number of formats, including a quick reference guide. NICE recommends that you download or order copies of the quick reference guide for your presentation so that your audience can refer to it. See the notes on the last page of this presentation for ordering details. You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. PROMOTING EQUALITY Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. June 2010 NICE clinical guideline 102

What this presentation covers Background Scope Key priorities for implementation Costs and savings Discussion Find out more NOTES FOR PRESENTERS: In this presentation we will start by providing some background to the guideline and why it is important. We will then present the key priorities for implementation. The NICE guideline contains ten key priorities for implementation, which you can find on pages 5-7 of your quick reference guide. Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline. Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice. Finally, we will end the presentation with further information about the support provided by NICE.

Definitions The term meningococcal disease has been used within this presentation. Meningococcal disease has two predominant patterns of illness: meningitis and septicaemia A proportion of cases show features of both. Meningococcal disease most commonly presents as: - bacterial meningitis (15% of cases) - septicaemia (25% of cases) - or a combination of the two (60% of cases)   NOTES FOR PRESENTERS: Key points to raise: Bacterial meningitis is an infection of the surface of the brain (meninges) by bacteria that have usually travelled there from mucosal surfaces via the bloodstream.

Background and scope In children and young people aged 3 months or older bacterial meningitis is most frequently caused by: - Neisseria meningitidis (meningococcus) - Streptococcus pneumoniae (pneumococcus) - and Haemophilus influenzae type b (Hib). Meningococcal disease: has a 10% case fatality rate is the leading infectious cause of death in early childhood. NOTES FOR PRESENTERS: Key points to raise: Meningitis can be caused by several types of infective organism, including bacteria and viruses. Identifying bacterial meningitis is particularly important to enable prompt recognition and referral for emergency admission to initiate antibiotic treatment. Up to 20% of the children who contract severe meningococcal septicaemia die, usually within 24 hours of the first symptoms appearing. It is crucial to remember that patients with meningitis or meningococcal septicaemia may present to primary care as well as to emergency departments. All children and young people with suspected meningococcal disease should be managed in hospital. The NICE guideline also recommends that healthcare professionals: Notify a proper officer of the local authority urgently on suspicion of meningitis or meningococcal septicaemia. This is a legal requirement under the Health Protection (Notification) Regulations 2010 [1.1.8]. The Department of Health has issued ‘Health protection legislation guidance 2010’ on the notification requirements of registered medical practitioners, laboratories testing human samples and the health protection powers available to local authorities and justices of the peace. See www.dh.gov.uk. Be aware of ‘Guidance for public health management of meningococcal disease in the UK’ (Health Protection Agency Meningococcus Forum, 2006; see www.hpa.org.uk) [1.1.9] Additional information: Children younger than 9 years are most at risk of contracting bacterial meningitis and meningococcal septicaemia. In neonates (children younger than 28 days), the most common causative organisms of bacterial meningitis are Streptococcus agalactiae (Group B streptococcus), Escherichia coli, S pneumoniae and Listeria monocytogenes. Complications of infection can include: neurological damage, loss of hearing, acute renal failure, clotting abnormalities, loss of fingertips and skin. The epidemiology of paediatric bacterial meningitis in the UK has changed in the last two decades following the introduction of vaccines developed to control the bacteria that cause meningitis. Refer to the full guideline for further background on bacterial meningitis. Bullets on the slide referring to 10% case fatality rate and complications of infection originate from the full version of the guideline (section 3, Clinical need).

Key priorities for implementation Symptoms and signs of bacterial meningitis and meningococcal septicaemia Management in the pre-hospital setting Diagnosis in secondary care Non-specific tests for meningococcal disease Polymerase chain reaction (PCR) Lumbar puncture Use of ceftriazone* Management in secondary care Fluids for bacterial meningitis Intravenous fluid resuscitation in meningococcal septicaemia Long-term management NOTES FOR PRESENTERS: The NICE guideline contains lots of recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into five areas of key priority. Within these are ten recommendations that we will consider in turn. Key points to raise: *A slide has been included on the recommended use of ceftriazone. Although this is not a key priority for implementation within the guideline it will be important for your presentation as advice within the guideline regarding ceftriazone could involve a change in practice for some healthcare professionals. Although the incidence of meningitis has reduced over the past 20 years, there is still variation in initial assessment and the initiation of treatment, disease severity assessment and prevention of secondary cases. The absence of a consistent approach in the management of meningitis and meningococcal disease is reflected in considerable variation in the quality of care between settings.

Symptoms and signs Healthcare professionals should be trained in the recognition and management of meningococcal disease. Consider bacterial meningitis and meningococcal septicaemia in children and young people who present with the symptoms and signs outlined in table 1 in the NICE guideline. NOTES FOR PRESENTERS: Key points to raise: Refer your audience to the table of symptoms and signs of bacterial meningitis and meningococcal septicaemia on pages 8 and 9 of the quick reference guide (QRG) and the NICE guideline. Common non-specific features of presentations in children and young people include fever, vomiting/nausea, lethargy, irritability/unsettled, ill appearance, refusing food or drink, headache, muscle ache/joint pain, respiratory symptoms/signs or breathing difficulty. Young babies may present with irritability and refusal to feed. Children and young people with septicaemia may present with the symptoms above, plus: chills/shivering, non-blanching rash, altered mental state, cold hands and feet, unusual skin colour, leg pain, back rigidity. The rash associated with meningococcal disease ranges from a non-specific macular rash to the characteristic purpuric (raised, non-blanching, bluish purple) rash which is mostly seen with septicaemia but is not always initially present. (This reference is taken from the full guideline). Be aware that a rash may be less visible in darker skin tones – check soles of feet, palms of hands and conjunctivae. Fever may not always present, especially in neonates. Additional information: The guideline assumes that fever in children younger than 5 years will be managed according to ‘Feverish illness in children‘ (NICE clinical guideline 47) until bacterial meningitis or meningococcal septicaemia is suspected. Recommendation 1.1.1 is provided in full in the notes of the following slide.

Symptoms and signs Be aware that in children and young people: some will present with mostly non-specific symptoms or signs which may be difficult to distinguish from other less important (viral) infections presenting in this way those with specific symptoms and signs are more likely to have bacterial meningitis or meningococcal septicaemia. The symptoms and signs may become more severe and more specific over time. NOTES FOR PRESENTERS: Other recommendations to highlight during your presentation: Perform a very careful examination for signs of underlying meningitis or septicaemia in children and young people presenting with petechial rashes (see table 1 in the NICE guideline or the QRG). [1.3.1] Healthcare professionals should be aware that classical signs of meningitis (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial meningitis (this recommendation is from ‘Feverish illness in children‘ [NICE clinical guideline 47]). [1.1.3] Some children with bacterial meningitis present with seizures (see table 2 in ‘Feverish illness in children‘ [NICE clinical guideline 47]). Consider other non-specific features of the child‘s or young person‘s presentation, such as: - the level of parental or carer concern - how quickly the illness is progressing, and - clinical judgement of the overall severity of the illness. [1.1.5] Recommendation 1.1.1 in full: Consider bacterial meningitis and meningococcal septicaemia in children and young people who present with the symptoms and signs in table 1. Be aware that: some children and young people will present with mostly non-specific symptoms or signs and the conditions may be difficult to distinguish from other less important (viral) infections presenting in this way children and young people with the more specific symptoms and signs are more likely to have bacterial meningitis or meningococcal septicaemia and the symptoms and signs may become more severe and more specific over time. Recognise shock (see table 1) and manage urgently in secondary care.

Symptoms and signs Recognise shock and manage urgently in secondary care. Signs of shock Capillary refill time more than 2 seconds Unusual skin colour Tachycardia and/or hypotension Respiratory symptoms or breathing difficulty Leg pain Cold hands/feet Toxic/moribund state Altered mental state/decreased conscious level Poor urine output NOTES FOR PRESENTERS: Key points to raise: In children and young people with suspected bacterial meningitis or meningococcal septicaemia undertake and record physiological observations of heart rate, respiratory rate, oxygen saturation, blood pressure, temperature, perfusion (capillary refill) and neurological assessment (for example the Alert, Voice, Pain, Unresponsive [AVPU] scale) at least hourly. Recommendation 1.1.1 is provided in full in notes of the previous slide: Additionally, it can be found in table 1 on page 9 of the quick reference guide or in the NICE version of the guideline.

Management in pre-hospital setting Transfer children and young people with suspected bacterial meningitis or meningococcal septicaemia to secondary care as an emergency by telephoning 999. NOTES FOR PRESENTERS: Other recommendations to highlight during your presentation: Suspected bacterial meningitis without non-blanching rash Transfer cases of suspected bacterial meningitis without non-blanching rash directly to secondary care without giving parenteral antibiotics. [1.2.2] If urgent transfer to hospital is not possible, administer antibiotics [in line with recommendations in the NICE guideline]. [1.2.3] Suspected meningococcal disease (non-blanching rash or meningococcal septicaemia) Give parenteral antibiotics (intramuscular or intravenous benzylpenicillin) at the earliest opportunity, either in primary or secondary care. [1.2.4] Do not delay urgent transfer to hospital to give the parenteral antibiotics. [1.2.4] Withhold benzylpenicillin only in children and young people who have a clear history of anaphylaxis after a previous dose; a history of a rash following penicillin is not a contraindication. [1.2.5] If urgent transfer to hospital is not possible (for example, in remote locations or adverse weather conditions) administer antibiotics to children and young people with suspected bacterial meningitis. [1.2.3] Recommendation 1.2.1 in full: Primary care healthcare professionals should transfer children and young people with suspected bacterial meningitis or suspected meningococcal septicaemia to secondary care as an emergency by telephoning 999. [1.2.1]

Diagnosis in secondary care Give intravenous ceftriaxone immediately to children and young people with a petechial rash if any of the following occur at any point during assessment: petechiae start to spread the rash becomes purpuric there are signs of bacterial meningitis there are signs of meningococcal septicaemia the child or young person appears ill. Perform whole blood real-time PCR testing (EDTA sample) for N meningitidis to confirm a diagnosis of meningococcal disease. NOTES FOR PRESENTERS: Other recommendations to highlight during your presentation: If a child or young person has an unexplained petechial rash and fever (or history of fever) carry out the following investigations: full blood count; C-reactive protein (CRP); coagulation screen; blood culture; whole-blood polymerase chain reaction (PCR) for N meningitidis; blood glucose; blood gas. [1.3.3] The PCR blood sample should be taken as soon as possible because early samples are more likely to be positive. [1.3.9] Be aware that a negative blood PCR test result for N meningitidis does not rule out meningococcal disease. [1.3.11] Submit CSF to the laboratory to hold for PCR testing for N meningitidis and S pneumoniae, but only perform the PCR testing if the CSF culture is negative. [1.3.12] If the child or young person is assessed as being at low risk of meningococcal disease and is discharged after initial observation, advise parents or carers to return to hospital if the child or young person appears ill to them. [1.3.5] This slide features recommendations 1.3.2 and 1.3.8. Additional information: Be aware that while a normal CRP and normal white blood cell count mean meningococcal disease is less likely, they do not rule it out. The CRP may be normal and the white blood cell count normal or even low in severe meningococcal disease. [1.3.4] Do not use any of the following techniques when investigating for possible meningococcal disease: skin scrapings, skin biopsies, petechial or purpuric lesion aspirates (obtained with a needle and syringe), or throat swabs. [1.3.14] All of the recommendations referred to here can be found in full in the NICE guideline.

Lumbar puncture Perform a lumbar puncture unless any of the following contraindications are present: signs suggesting raised intracranial pressure shock extensive or spreading purpura after convulsions until stabilised coagulation abnormalities local superficial infection at the lumbar puncture site respiratory insufficiency. NOTES FOR PRESENTERS: Please refer your audience to page 9 of the QRG for further detail of the contraindications for performing a lumbar puncture. Signs suggesting raised intracranial pressure include: reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more); relative bradycardia and hypertension; focal neurological signs; abnormal posture or posturing; unequal, dilated or poorly responsive pupils; papilloedema; abnormal ‘doll’s eye’ movements. [1.3.18] Signs of shock are covered on slide 7 of this presentation, and in table 1 on page 9 of the quick reference guide. Other recommendations to highlight during your presentation: Perform a lumbar puncture as a primary investigation unless this is contraindicated. [1.3.15] Use clinical assessment and not cranial computed tomography (CT), to decide whether it is safe to perform a lumbar puncture. [1.3.27] CT is unreliable for identifying raised intracranial pressure.[1.3.27] Do not allow lumbar puncture to delay the administration of parenteral antibiotics. [1.3.16] Use local or national protocols to treat raised intracranial pressure. [1.4.20] Additional information: The guideline also recommends that: in children and young people with suspected bacterial meningitis, if contraindications to lumbar puncture exist at presentation consider delaying the procedure until there are no longer contraindications. Delayed lumbar puncture is worthwhile if there is diagnostic uncertainty or unsatisfactory clinical progress. [1.3.19] CSF white blood cell counts, total protein and glucose concentrations should be made available within 4 hours to support the decision regarding adjunctive steroid therapy. [1.3.20] Recommendation 1.3.18 featured on the slide can be found in the quick reference guide and in full within the NICE guideline.

Use of ceftriaxone Use intravenous ceftriaxone to treat children and young people aged 3 months or older with suspected or confirmed bacterial meningitis or meningococcal disease. Where ceftriaxone is used, do not administer it at the same time as calcium-containing infusions. Instead use cefotaxime. Treat children younger than 3 months with suspected bacterial meningitis without delay using intravenous cefotaxime plus either amoxicillin or ampicillin.   NOTES FOR PRESENTERS: Key points to raise: Ceftriaxone should be administered without delay. [1.4.1] [1.4.3] On the basis of the cost effectiveness data, ceftriaxone is recommended as the first-line agent, chiefly driven by the reduction in staff costs associated with a once-daily dose. There is also the possibility of early discharge from hospital while the child is receiving once daily dosing. Other recommendations to highlight during your presentation: In children younger than 3 months, ceftriaxone may be used as an alternative to cefotaxime (with or without ampicillin or amoxicillin), but be aware that ceftriaxone should not be used in premature babies or in babies with jaundice, hypoalbuminaemia or acidosis as it may exacerbate hyperbilirubinaemia. [1.4.6] Additional information: See Medicines and Healthcare products Regulatory Agency (2009) Drug Safety Update: Vol. 3 Issue 3, available from www.mhra.gov.uk Recommendations 1.4.1, 1.4.2, 1.4.3 and 1.4.5 can be found in full within the NICE guideline.

Management in secondary care Do not restrict fluids in cases of bacterial meningitis unless there is evidence of: raised intracranial pressure or increased antidiuretic hormone secretion. NOTES FOR PRESENTERS: Key points to raise: After reviewing the evidence base, NICE recommends that maintenance fluids should be given to children and young people with bacterial meningitis to maintain adequate hydration. Fluid restriction has traditionally been recommended for children with bacterial meningitis, but it is increasingly recognised within clinical practice that children with bacterial meningitis may be underhydrated. (this text is from the full guideline). Other recommendations to highlight during your presentation: Close monitoring of hydration and electrolyte balance is essential. The NICE guidance states that electrolytes and blood glucose should be regularly monitored (at least daily while the child or young person is receiving intravenous fluids). [1.4.28] The NICE guideline uses the National Patient Safety Agency definition of antidiuretic hormone secretion (ADH). Additional information: Give full-volume maintenance fluids to avoid hypoglycaemia and maintain electrolyte balance. [1.4.24] Monitor fluid administration and urine output to ensure adequate hydration and avoid overhydration. [1.4.27] If there are signs of raised intracranial pressure or evidence of shock, initiate emergency management for these conditions and discuss ongoing fluid management with a paediatric intensivist. [1.3.32] NPSA guidance ‘Reducing the risk of hyponatraemia when administering intravenous infusions to children’ issued in March 2007 (NPSA/2007/22) includes information about monitoring requirements when providing fluids, to detect hyponatraemia. It can be accessed via www.npsa.nhs.uk. Some children with bacterial meningitis may be dehydrated and may need rehydration in addition to maintenance fluids. Recommendation 1.4.23 can be found in full in the quick reference guide.

Management in secondary care Intravenous fluid resuscitation in suspected or confirmed meningococcal septicaemia Stage Administer fluids Intervention Signs of shock present 20 ml/kg sodium chloride 0.9% over 5–10 minutes Reassess immediately after fluids administered Signs of shock persist 20 ml/kg sodium chloride 0.9% or human albumin 4.5% over 5–10 minutes Signs of shock still persist 20 ml/kg sodium chloride 0.9% or human albumin 4.5% over 5–10 minutes Call for anaesthetic assistance and start vasoactive drugs Consider a further 20ml/kg sodium chloride 0.9% or human albumin 4.5% Administration based on clinical signs and appropriate laboratory investigations NOTES FOR PRESENTERS: Key points to raise: Refer your audience to the signs of shock table on page 9 of the QRG. Fluids should be administered if there are signs of shock present (covered on slide 7). Be aware that some children and young people may require large volumes of fluid over a short period of time to restore their circulating volume. If a third bolus of fluid is necessary anaesthetic assistance should be called for urgent tracheal intubation and mechanical ventilation. If a fourth fluid bolus is required, appropriate laboratory investigations should be conducted, including urea and electrolytes. Other recommendations to highlight during your presentation: If shock persists despite fluid resuscitation (more than 40 ml/kg) and treatment with either intravenous adrenaline or intravenous noradrenaline, or both, consider potential reasons (such as persistent acidosis, incorrect dilution, extravasation) and discuss further management options with a paediatric intensivist [1.4.31]. Use local or national protocols for the administration of vasoactive agents in children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia [1.4.32]. Additional information: Further management should be discussed with a paediatric intensivist. Fluids can be administered either intravenously or via an intraosseous route. Recommendation 1.4.30 can be found in full in the quick reference guide or the NICE guideline.

Long-term management Children and young people should be reviewed by a paediatrician (along with the results of their hearing test) 4–6 weeks after discharge from hospital. Specifically consider the following morbidities: hearing loss orthopaedic complications skin complications psychosocial problems neurological and developmental problems renal failure. NOTES FOR PRESENTERS: Key points to raise: Referral to appropriate services should be offered. Other conditions that should be considered at the appointment include: - potential damage to bones and joints - skin problems include scarring from necrosis. [1.5.5] Other recommendations to highlight during your presentation: Offer a formal audiological assessment as soon as possible, preferably before discharge, within 4 weeks of being fit to test. [1.5.3] Offer children and young people with a severe or profound deafness an urgent assessment for cochlear implants as soon as they are fit to undergo testing (further guidance on the use of cochlear implants for severe to profound deafness can be found in 'Cochlear implants for severe to profound deafness in children and adults' [NICE technology appraisal 166]). [1.5.4] Healthcare professionals with responsibility for monitoring the child’s or young person’s health should be alert to possible late-onset sensory, neurological, orthopaedic and psychosocial effects of bacterial meningitis and meningococcal septicaemia. [1.5.7] Additional information: Long-term complications of meningococcal disease include: residual headaches, memory disturbances, epilepsy, learning difficulties and other neurological sequelae including deafness, blindness and cerebral palsy.

Costs and savings The guideline on bacterial meningitis and meningococcal septicaemia is unlikely to result in a significant change in resource use in the NHS. However, recommendations in the following areas may result in additional costs/savings depending on local circumstances: healthcare professionals should be trained in the recognition and management of meningococcal disease investigation of children and young people with petechial rash transfer suspected cases to secondary care as an emergency by telephoning 999. NOTES FOR PRESENTERS: NICE has found that implementing this guideline is unlikely to result in any significant changes in resource use, based on national assumptions. This is because the number of patients involved is small and that most of the recommendations reflect current good practice, which the guideline reinforces. However, different areas may vary from the national average and it is important to look at the recommendations most likely to have a resource impact to make sure that local practice matches the national average. These recommendations are: Training [1.1.7] There are many resources available to fulfil training in this area. For example, the Meningitis Research Foundation has published a training booklet endorsed by the Royal College of Paediatrics and Child Health (RCPCH) and College of Paediatric Emergency Medicine. Electronic learning modules relevant to this clinical topic are available from a number of sources including BMJ Learning and the RCPCH. Therefore, we do not consider the recommendation to have a significant impact on the NHS resources. However, there is need to evaluate and assess the training needs locally. Investigation in children and young people with petechial rash [1.3.3] Based on clinical opinion this recommendation reflects the current practice and the population is likely to be small. Therefore, the cost implication on the NHS resources is insignificant. However, in areas not performing in line with standard practice organisations are encouraged to evaluate their services and locally assess the costs of complying with the guideline. Transfer to secondary care via 999 [1.2.1] This recommendation might have cost implications in some local areas, as it may not be part of current practice. There is also a view that the guidance might lead to an increase in 999 calls from carers‘ (in response to signs of a petechial rash and fever in a child) rather than them calling for medical help (for example via a GP or NHS Direct). This would have cost implications. It is difficult to quantify the number of children that may be involved. However, It is not anticipated that there will be a large number of cases so we do not expect any significant cost implications to the NHS at a national level. Organisations are however encouraged to estimate costs locally.

Discussion When considering cases of bacterial meningitis and meningococcal disease: How could training on the recognition, assessment and management of both suspected and confirmed cases be improved in our Trust? What is our first line antibiotic? What are our local protocols for the administration of fluids? What are our long-term management pathways? NOTES FOR PRESENTERS: These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation. It may be helpful to raise the role of audit in helping your audience to answer some of these discussion questions. An additional question could be: When do children and young people within our locality usually receive a hearing test after recovering from meningococcal disease?

Find out more Visit www.nice.org.uk/guidance/CG102 for: the guideline the quick reference guide ‘Understanding NICE guidance’ costing statement audit support Visit www.learning.bmj.com for modules on: Meningococcal disease in children Feverish illness in children Febrile toddler in the emergency department NOTES FOR PRESENTERS: You can download the guideline documents from the NICE website. For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on 0845 003 7783 or email publications@nice.org.uk and quote reference numbers N2201 (quick reference guide) and/or N2202 (‘Understanding NICE guidance’). NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing statement – details of the likely costs and savings when the cost impact of the guideline is not considered to be significant. Audit support – for monitoring local practice. Associated guidance: This guideline is intended to complement other existing and proposed works of relevance, including the following guidance published by NICE: ‘Diarrhoea and vomiting in children under 5’, NICE clinical guideline 84; ‘Feverish illness in children’, NICE clinical guideline 47; ‘Tuberculosis’, NICE clinical guideline 33; 'Cochlear implants for children and adults with severe to profound deafness' [NICE technology appraisal 166] . This guideline also draws on clinical questions and searches developed for the Scottish Intercollegiate Guidelines Network (SIGN) clinical guideline on management of invasive meningococcal disease in children and young people. BMJ Learning: there are existing modules that are relevant to this clinical area. Further information on the condition and support services can also be found on the Meningitis Research Foundation and Meningitis Trust websites. www.meningitis.org www.meningitis-trust.org