Table 2.

Adherence to audit standards*

Immediate management	Number achieved standard/total number of patients analysed	% of total	Number achieved standard/total number of patients evaluable†	% of number evaluable
1. The patient’s conscious level should be documented using the Glasgow Coma Scale	1283/1471	87%	1283/1448	89%
2. Blood cultures should be taken as soon as possible and within 1 hour of arrival at hospital	326/1471‡	22%	326/767§	42%
3. LP should be performed within 1 hour of arrival at hospital provided that it is safe to do so	8/1471¶	0.5%	8/1379**	0.6%
4. Antibiotic treatment should be commenced within the first hour	207/1471††	14%	207/1083‡‡	19%
5. Patients with meningitis and meningococcal sepsis should be cared for with the input of an infection specialist such as a microbiologist or a physician with training in infectious diseases and/or microbiology	1148/1471§§	78%	1148/1464	78%
Investigations
6. Blood culture should be sent	977/1471	66%	977/1469	67%
7. Blood pneumococcal PCR should be sent	211/1471	14%	211/1460	14%
8. Blood meningococcal PCR should be sent	232/1471	16%	232/1461	16%
9. CSF opening pressure should be documented	655/1428¶¶	46%	655/1361a	48%
10. CSF glucose with concurrent plasma glucose should be sent	607/1428¶¶	43%	607/1415	43%
11. CSF protein should be sent	1358/1428¶¶	95%	1358/1420	96%
12. Microscopy of the CSF should take place within 2 hours of the lumbar puncture	596/1428¶¶	42%	596/1203b	50%
13. CSF for pneumococcal PCR should be sent in all cases of suspected bacterial meningitis	412/1428¶¶	29%	412/1418	29%
14. CSF for meningococcal PCR should be sent in all cases of suspected bacterial meningitis	434/1428¶¶	30%	434/1418	31%
15. A swab of the posterior nasopharyngeal wall should be obtained as soon as possible, and sent for meningococcal culture, in all cases of suspected meningococcal meningitis/sepsis	54/1471	4%	54/1463c	4%
16. All patients with meningitis should have an HIV test	646/1471	44%	646/1459d	44%
Treatment
17. All patients with suspected meningitis or meningococcal sepsis should be given ceftriaxone or cefotaxime	1039/1471e	71%	1039/1423f	73%
18. If the patient has, within the last 6 months, been to a country where penicillin resistant pneumococci are prevalent, intravenous vancomycin 15–20 mg/kg should be added 12-hourly (or 600 mg rifampicin 12-hourly intravenous or orally)g	See footnote
19. Those aged 60 or over should receive 2 g intravenous ampicillin/amoxicillin 4-hourly in addition to a cephalosporin (1B)	55/233	24%	55/197h	28%
20. Immunocompromised patients (including diabetics and those with a history of alcohol misuse) should receive 2 g intravenous ampicillin/amoxicillin 4-hourly in addition to a cephalosporin	26/115i	23%	26/99j	26%
21. If there is a clear history of anaphylaxis to penicillins or cephalosporins give intravenous chloramphenicol 25 mg/kg 6-hourly	14/37	38%	14/30k	47%
22. If Streptococcus pneumoniae is identified continue with intravenous benzylpenicillin 2.4 g 4-hourly, 2 g ceftriaxone intravenous 12-hourly or 2 g cefotaxime intravenous 6-hourly	114/172	66%	114/145l	79%
23. If number of meningitidis is identified 2 g ceftriaxone intravenous 12-hourly, 2 g cefotaxime intravenous 6-hourly or 2.4 benzylpenicillin intravenous 4-hourly may be given as an alternative	52/76	68%	52/68m	76%
24. If the patient is not treated with ceftriaxone (in meningococcal disease), a single dose of 500 mg ciprofloxacin orally should also be given	0/2	0%	0/2	0%
25. If Listeria monocytogenes is identified Give 2 g ampicillin/amoxicillin intravenous 4-hourly and continue for at least 21 days. Cotrimoxazole 10–20 mg/kg or chloramphenicol are alternatives in cases of anaphylaxis to beta lactams	4/7	57%	4/6	67%n
26. If Haemophilus influenzae is identified continue 2 g ceftriaxone intravenous 12-hourly or 2 g cefotaxime intravenous 6-hourly for 10 days	9/14	64%	9/13	69%o
27. 10 mg dexamethasone intravenous 6-hourly should be started on admission, either shortly before or simultaneously with antibiotics	67/1471	5%	67/1435p	5%
28. If pneumococcal meningitis is confirmed dexamethasone should be continued for 4 days	34/172q	20%	34/158r	22%
Critical care
29. The following patients should be transferred to critical care—those with a rapidly evolving rash, those with a GCS of 12 or less and those with uncontrolled seizures	151/203s	74%	151/203	74%
Notification
30. All cases of meningitis (regardless of aetiology) should be notified to the relevant public health authority	236/1471	16%	236/1465	16%

*Only those audit standards that could be measured from the data collected.

†Excludes those where there were missing data and/or where not relevant.

‡Only 977 patients had blood cultures taken.

§Excluding those who did not have blood cultures taken and where data were missing.

¶1428 patients had an LP.

**Excludes those who did not have an LP and where data were not available.

††82 patients had data consistent with having antibiotics prior to admission, this might be due to confusion about whether admission meant admission to the emergency department or admission to a ward, or it may represent data entry error therefore, these figures are not included.

‡‡388 patients did not receive any antibiotics at all.

§§310 (21%) of patients were admitted under an infection specialist, all others received consulting advice only.

¶¶43 people did not have an LP.

aMissing data on 67.

b43 had no LP, 97 missing data, 128 time of microscopy was before or at the same time as the LP.

cPerformed in 15/76 (20%) of proven meningococcal cases.

d9 known HIV positive and 3 missing data.

e285 patients were not given any antibiotics at all.

f48 patients who were definitely given antibiotics had missing data on which antibiotics they were given.

gUsing mainland Europe data only and with reference to ECDC data—101 patients were documented to have travelled to a mainland European country within the previous 6 months. Travel history was not documented at all in 822 cases (56%). Of the 101 patients who had travelled to mainland Europe 54 (54%) had been to a country with a rate of penicillin resistant pneumococci of >5% (2017 data). 5/52 had no antibiotics. 0/47 had antibiotics to cover for penicillin resistant pneumococci.

h233 patients were aged over 60 but only 207 received antibiotics. Missing data for 10, 108 received amoxicillin at some point but only 55 received the correct dose.

iNot including those ≥60.

j15 did not received any antibiotics and missing data on 1.

k7 patients had no antibiotics at all.

l27 patients had insufficient antibiotic data.

m8 patient had insufficient antibiotic data.

n1 patient had insufficient antibiotic data.

oInsufficient antibiotic data on 1 person.

pMissing data on 36—11 on whether dexamethasone was received or not, 21 on the dose given and 4 on the timing.

qOnly 18 were given the correct dose (10 mg). Some received dexamethasone for longer than 4 days.

rMissing data on 14 individuals.

s7/11 patient with progressing rash, 131/176 patients with GCS <13 and 13/16 patients with uncontrolled seizures.

CSF, cerebrospinal fluid; GCS, Glasgow Coma Score; LP, lumbar puncture.