We are grateful for the opportunity to provide some comment following the letter by Saeed et al1 that points out an apparent discrepancy between NICE recommendations2 for primary care antibiotic therapy (penicillin) and secondary care management (ceftriaxone) and makes a case for availability of a third generation cephalosporin in the GPs ‘black bag’.
Unfortunately, the authors' arguments are based on a fundamental misunderstanding of the guidance as the population they discuss should not have been given antibiotic therapy in the first place. The only population for whom there is a recommendation for universal pre-hospital antibiotic therapy in this setting are those with suspected meningococcal disease (both meningococcal meningitis and septicaemia), that means patients who are ill with a non-blanching rash. The previous chief medical officer's (CMO's)3 advice and the NICE guideline2 only refers to these patients. The arguments about Haemophilus influenzae type B meningitis and pneumococcal meningitis put forward by the authors, although microbiologically correct, are irrelevant as such patients with suspected meningitis and no rash should not receive pre-hospital antibiotics.
The reason for avoiding antibiotics in non-meningococcal meningitis is that such patients should have investigations in hospital (for example, lumbar puncture) and important therapeutic interventions (for example, steroids) before or at the same time as they receive antibiotic therapy. At present such interventions are not available in most community settings. So for these individuals the priority is to provide rapid access to hospital and minimise the time from presentation to appropriate management. This is discussed in the full version of the NICE guideline where GPs are advised to send such cases to hospital urgently.2
The NICE guideline development group searched the evidence for the use of pre-hospital antibiotic use in meningococcal disease and concluded that there was insufficient high quality evidence to recommend antibiotic therapy in this setting (some studies indicated a worse outcome when antibiotics were used pre-hospital, and others implied improved outcomes but all were inadequate to draw firm conclusions) and, therefore, the NICE guideline has emphasised urgent transfer to hospital for children with a non-blanching rash. Despite the lack of supportive evidence, the recommendation to administer parenteral penicillin as previously recommended by the CMO3 was not rescinded as it was also considered that there was insufficient evidence to change the current practice. The NICE guideline therefore changes the emphasis for GPs seeing cases of suspected meningococcal disease. Where previously all such cases should have received penicillin prior to transfer to hospital, the emphasis is now on urgent transfer to hospital with opportunistic use of penicillin where this can be done without incurring any delay.
The appearance of antibiotic resistant bacteria in the community is a concern but is best managed by limiting antibiotic use rather than wider use of broad spectrum agents. With regard to the moderate penicillin resistance that the authors note was documented by Kyaw et al4 (and elsewhere), it is important to monitor through good surveillance (best achieved by obtaining blood and cerebrospinal fluid cultures in hospital) but, as Kyaw et al say in their paper, the clinical significance of moderate resistance among meningococci remains unknown.4
Meeting a case of meningococcal disease is thankfully a once in a lifetime experience for most GPs and, carriage of ceftriaxone over a GPs' career is unnecessary and wasteful, especially as we are still uncertain whether antibiotic therapy outside a hospital environment even helps. We recommend that GPs continue to carry benzylpenicillin, at minimal cost, and to administer it if its use will not delay hospital admission.
- © British Journal of General Practice 2011
