Clinical recognition of meningococcal disease

Abstract

Matthew Thompson and colleagues1Thompson MJ Ninis N Perera R et al.Clinical recognition of meningococcal disease in children and adolescents.Lancet. 2006; 367: 397-403Summary Full Text Full Text PDF PubMed Scopus (379) Google Scholar use the findings of their study to call for a change to the diagnostic framework of meningococcal disease. They argue that recognising early symptoms of sepsis (such as cold feet and hands, leg pain, and change in skin colour) could increase the proportion of children identified by primary care clinicians and shorten the time to hospital admission. Although they have identified the importance of further research into the predictive value of such sepsis features (an issue also highlighted in the accompanying Comment2Nascimento-Carvalho CM Moreno-Carvalho OA Changing the diagnostic framework of meningococcal disease.Lancet. 2006; 367: 371-372Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar), we feel that the following three issues also merit consideration. First, the method used in this paper is based on the retrospective interviewing of parents by use of a checklist to record the presence and timing of predefined clinical features. Thompson and colleagues accept these as limitations of the study and additionally raise the possibility of selective memory and recall bias in what is for most parents a “life-changing experience”. However, it is difficult to imagine that these research-based scenarios would be truly transferable to a real-time consultation in a primary care setting where the interaction between practitioner and patient can vary so widely depending on the dynamics of each consultation. Second, Thompson and colleagues state that the recognition of sepsis symptoms could reduce the proportion of cases missed at first consultation from a half to a quarter; we question the evidence base for this assertion. Wider issues such as the interaction between primary care and secondary care services would also need to be considered before a reduction in cases missed at first consultation could be correlated to actual improvements in outcomes. Third, there is the challenge of promoting such symptoms to a lay audience with different levels of understanding and concerns about meningococcal disease. There is a risk of losing the central over-riding message (ie, to look out for the classic symptoms and remember that not everyone develops them, and to trust gut instinct and seek immediate further consultation if things are felt to be getting worse) at the expense of increased awareness of earlier symptoms that have not yet been robustly tested in everyday settings. The response of parents to such messages should be piloted before they are widely advocated. Thompson and colleagues raise an issue of potential value in the drive to improve outcomes in meningococcal disease. However, more evidence that the signs of early sepsis identified are reliable, predictive, or generalisable in a real-time primary-care setting is needed before the widespread introduction of such a strategy. We declare that we have no conflict of interest. Clinical recognition of meningococcal disease – Authors' replyWe acknowledge that the original study design we used to identify children with meningococcal disease included a greater proportion of fatal cases (and hence septicaemia) than would be expected in a typical UK cohort of children with meningococcal disease. It was for this reason that we presented the weighted frequency of symptoms in fatal and non-fatal cases using age-specific case-fatality rates. Given that the data were collected retrospectively (but validated where possible with contemporaneous doctors' records), both N Makwana and colleagues and Aidan Kirkpatrick and colleagues echo the limitation noted in the discussion regarding the possibility of recall bias. Full-Text PDF