Advice on meningitis 'ignored' by doctors

MANY FAMILY doctors who see patients with suspected meningitis are ignoring government advice to give penicillin before transfer to hospital, despite good evidence that it can reduce the death rate from the illness.

Two new studies show that despite regular reminders to GPs, many do not regularly carry an injectable or intravenous form of the drug, or they fail to administer it in suspected cases of bacterial meningitis.

In one study by public health laboratory scientists in Gloucester, Plymouth and Bath, which is published in tomorrow's British Medical Journal, the use of antibiotics did not exceed 40 per cent. In a second study, also in the BMJ, and carried out by the public health department at the Memorial Hospital in Darlington, the rate was 28 per cent.

Meningococcal disease is a major cause of childhood mortality in the UK. Of 170 deaths in England and Wales last year, 110 were in children under 15. The death rate in the past 30 years has remained between 5 and 10 per cent, but it has been known for many years that early antibiotic treatment is vital.

After an outbreak of meningitis in Stroud, Gloucestershire, in 1988, the chief medical officer wrote to all doctors recommending that an injectable form of penicillin be given to all patients suspected of having meningitis before admission to hospital. The advice has been repeated several times since, according to the Public Health Laboratory Service (PHLS).

In the Darlington study, researchers examined the cases of 46 patients admitted to the hospital with meningococcal disease between January 1986 and March 1991. None of the 13 patients given penicillin before admission died, compared with eight deaths (24 per cent) in a group of 33 patients admitted without this treatment.

The West Country study involving 381 patients admitted between 1 January 1988 and 31 December 1991, found that penicillin given by GPs was associated with a reduction in the death rate from 9 per cent to 5 per cent. Patients who had a rash - those with the worst prognosis - were more likely to have had antibiotic treatment, and the death rate in this group was reduced from 12 per cent to 5 per cent.

In an accompanying editorial in the BMJ, Norman Begg, a consultant epidemiologist at the PHLS Communicable Disease Centre in London, gave two reasons why GPs are reluctant to give the drug. They are worried that the patient may suffer an allergic reaction - penicillin allergy is very common. However, Dr Begg says that this is not a good enough reason to deny patients a potentially life-saving treatment. In addition, doctors are taught not to give antibiotics before laboratory tests have confirmed the infection, as this can confuse the diagnosis.

But Dr Begg said: 'Even if the diagnosis of meningococcal infection cannot be confirmed . . . little harm is likely to result, and the consequences are likely to be insignificant compared with failing to initiate treatment.' He says that the case for early administration of antibiotics is now 'stronger than ever' and that 'frequent reminders of this simple, cheap measure are needed to reinforce the message.'