Common sense says that any delays in treatment of so devastating an infection as meningitis would adversely affect outcome.
For meningitis presenting in the Emergency Room of a US city children's hospital, emergentologists' estimates of median time to first dose of antibiotic averaged less than an hour, infectious diseases specialists' one and three-quarter hours. Reality was 2 hours[1].
PRACTICE POINT
Expert witnesses on standard of care may have significantly inaccurate perceptions of reality
For delays in diagnosis of infantile meningitis (that is, in children under a year of age) attributable to substandard care and followed by death or poor outcome[2] , payments in the States averaged rather more than $1 million.
Such delays should surely provide a strong basis for findings of medical negligence? The evidence on Causation is not that straightforward.
Meta-Analysis involves the statistical manipulation of data from all available quality studies which contain sufficient detail. By combining the populations studied by each writer, spurious and anomalous findings are eliminated, and trends which are not statistically significant in an individual study may prove to be valid. The author[3] reviewed 22 studies - a total of 4,707 patients.
For the relatively rare cases of meningitis which were fulminating, treatment was generally initiated promptly, but, perhaps surprisingly, any delays did not seem to influence outcome.
When the symptoms were non-specific - fever, malaise, irritability, vomiting - delays of even 3 to 5 days in diagnosis and treatment did not appear to alter risks of permanent brain damage or death. Indeed, patients with a slowly evolving illness did better during the acute phase than those with rapid progression.
PRACTICE POINT
Only in the easily-diagnosed minority of cases of meningitis with characteristic symptoms can treatment delays be proven harmful
Only for clinically overt meningitis - marked drowsiness, coma, seizures, neck stiffness, bulging fontanelle in an infant - did (undefined) inappropriate delay in starting treatment incrementally increase the risk of permanent injury.
Similar studies in adults have not been undertaken, perhaps because the disease is much less common. From first principles, delays would likely be even less critical, and initial studies suggest only a marginal effect of relatively short treatment delays[4].
If, in adults, none of the classic triad of symptoms - fever, neck stiffness and alteration in consciousness or headache - is present, meningitis can be virtually ruled out[5]. However, none of these symptoms either alone or in combination is specific for meningitis.
By contrast, physical examination is useful for confirming the condition. Kernig's sign and Brudzinski's sign are highly specific for meningitis and should be explicitly documented. In the presence of headache and fever, jolt accentuation of headache should probably mandate spinal tap, whereas a negative jolt accentuation test essentially excludes the diagnosis.
Streptococcus pneumoniae (pneumococcus) is the commonest cause of bacterial meningitis in adults. Although rather less than 50% of adults with pneumoccocal meningitis have a good treated outcome[6], major factors in poor outcome - chronic debilitation illness, age greater than 60, severity at initial assessment - do not apply to most potential litigants at the time the diagnosis was missed.
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