Parenteral penicillin for children with meningococcal disease before hospital admission: case-control study BMJ Volume 332, pp 1295-7

Effectiveness of antibiotics given before admission in reducing mortality from meningococcal disease: systematic review BMJ Volume 332, pp 1299-1301

Editorial: Parenteral penicillin before hospitalisation for meningitis BMJ Volume 332, pp 1283-4

Should children with suspected meningitis be given antibiotics before transfer to hospital?

Several European countries advise doctors in primary care to do this, but the evidence is conflicting, with some studies suggesting benefit and others suggesting harm. Two papers in this week’s BMJ add to this uncertainty.

One shows that children who are given antibiotics before admission to hospital are more likely to die on reaching hospital. The other -  a review of all the current evidence -  cannot conclude whether or not pre-hospital antibiotics improve survival.

In the first study, UK researchers analysed 158 children diagnosed with suspected meningococcal disease by a general practitioner before admission to hospital. Two thirds were given parenteral (injected) penicillin, in accordance with national guidelines.

The children who were given penicillin were more likely to die than those who were not given penicillin.

However, the children who received penicillin also had more severe disease on reaching hospital. So, although a harmful effect of penicillin cannot be excluded, a more likely explanation for the higher mortality is that there is a strong bias towards giving penicillin to the most severely ill children, conclude the authors.

In the second paper, an international group of researchers reviewed evidence from 14 studies and found that oral antibiotics given before hospital admission were associated with reduced mortality. Results for parenteral antibiotics were inconsistent, though the data suggest that they might have a beneficial effect when a substantial proportion of patients is treated.

Once again, it is suggested that bias linked to illness severity may explain these results. For example, doctors are likely to prescribe oral antibiotics only in patients with milder disease.

“We cannot conclude from this review whether or not antibiotics given before admission have an effect on case fatality, though the data are consistent with benefit when a substantial proportion of cases are treated,” they write.

So, should doctors change their practice in light of these findings? Probably not, says Duncan Keeley, a general practitioner in an accompanying editorial. But frontline practitioners will be keen to hear a view from the Meningitis Research Foundation once it has considered their implications.

Meanwhile, further analysis of the data is crucial, and we should also remember the contributions general practitioners can make, including educating parents, early diagnosis, and rapid transfer to hospital with optimum supportive care, he writes. These measures may be more important for improving survival than administering parenteral penicillin in the community.