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Dr Riordan's study on promptness of antibiotic treatment for meningococcal disease showed that “door to needle” time to administration of appropriate antibiotic for children decreased clearly from before to after a teaching intervention was given to nurses and doctors.1 That this decrease occurred only for the children who had typical rash on arrival is not a surprise, given that the intervention was a lecture that focused on recognition of the rash. But could the intervention be different from that? Petechial rash is the sign that, although not pathognomonic, is highly suggestive of meningococcal disease. I suspect that in a substantial proportion of those children who had no rash on arrival the diagnosis was actually investigated or made only when the typical rash appeared.
Notwithstanding the decrease in door to needle time, it is disappointing to learn from Riordan's study that the case-fatality ratio of cases diagnosed after the intervention was actually higher than before (11.9%, 95% confidence intervals (CI) 4.5% to 26.4% versus 6.1%, 95% CI 1. 1% to 21.6%), with a risk ratio of 1.96 (95% CI 0.41 to 9.49). Because the numbers were small one cannot rule out the role of chance to explain this finding, but one can also speculate that the decrease in door to needle time was not the major determinant in terms of risk of death from meningococcal disease. It is well possible that early recognition of petechiae by parents or caregivers and their understanding that this finding requires prompt intervention by a doctor would have a higher impact on mortality from meningococcal disease. “First manifestation to first examination” time could therefore be a better indicator of prognosis. If this is so, focus on teaching interventions should be shifted from physicians and nurses to parents and caregivers.
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Author's reply
I was interested to read Dr S de A Nishioka's letter. He wonders which interventions we should focus on to decrease the mortality from meningococcal disease. In a review of deaths from meningococcal disease, the most frequent and lengthy delays were parents not recognising that their child was seriously ill and doctors failing to make the diagnosis.1 We therefore need to improve both of these.
Early antibiotic treatment decreases the risk of dying from meningococcal disease.2 Strategies to improve this are thus worthwhile. However, in a single centre these cannot be expected to show a decrease in mortality.
Dr de A Nishioka's suggests “first manifestation to first examination time” might be a useful prognostic indicator. However, children with severe meningococcal disease become unwell rapidly and present to hospital sooner. In a previously reported cohort of children with meningococcal disease,3 median “first manifestation to first examination time” was significantly shorter in those who died compared with survivors (12 hours versus 17 hours; p=0.012). The usefulness of this time is thus confounded by disease severity. However, early recognition of meningococcal disease by parents can lead to better outcomes.4
I agree that parents require accurate and appropriate information about meningococcal disease, but improvements are also required in the early recognition and treatment of children with this potentially life threatening disease.5