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Strongly suspected meningococcal disease with severe beta-lactam allergy — MSRA MCQ

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HardInfectious DiseasesStrongly suspected meningococcal disease with severe beta-lactam allergyMSRA

A 22-year-old university student is assessed urgently at a GP surgery. He has had 8 hours of fever, severe myalgia, vomiting and increasing drowsiness. His temperature is 39.4°C, heart rate 128 bpm, BP 94/58 mmHg and respiratory rate 24 breaths/min. He has a rapidly spreading, non-blanching purpuric rash on his trunk and legs. He reports an episode of anaphylaxis requiring adrenaline after amoxicillin 2 years ago. He has never received a cephalosporin. An ambulance can arrive within 8 minutes and the emergency department is 20 minutes away. The practice has IM ceftriaxone and benzylpenicillin available. What is the most appropriate immediate management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Arrange immediate emergency transfer with pre-alert, without giving pre-hospital antibiotics

Explanation lettering: E = shown as A · C = shown as B · B = shown as C · A = shown as E

This is strongly suspected meningococcal disease: a rapidly progressive non-blanching purpuric rash with systemic toxicity and haemodynamic compromise is highly concerning for meningococcal septicaemia. He requires immediate emergency transfer and pre-alert to enable prompt senior assessment and definitive treatment in hospital. Although NICE advises IM or IV ceftriaxone or benzylpenicillin as soon as possible outside hospital for strongly suspected meningococcal disease, it makes a specific exception: do not give pre-hospital antibiotics when there is severe allergy to either ceftriaxone or benzylpenicillin. His previous adrenaline-treated amoxicillin reaction constitutes severe beta-lactam allergy; absence of known cephalosporin exposure does not remove this NICE pre-hospital exception. Hospital transfer must not be delayed. A is contraindicated because of his severe penicillin allergy. B is tempting because ceftriaxone is usually the preferred pre-hospital agent, but is not recommended outside hospital in this severe allergy context. C is not the recommended empirical pre-hospital alternative; specialist advice is needed for severe allergy. E delays transfer for investigations that should not be pursued in primary care before emergency conveyance.

Reference: NICE NG240: Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management — Transfer to hospital and antibiotics before arrival at hospital (19 March 2024) — https://www.nice.org.uk/guidance/ng240/chapter/Recommendations NICE NG240: Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management — Transfer to hospital and antibiotics before arrival at hospital (19 March 2024) — https://www.nice.org.uk/guidance/ng240/chapter/Recommendations NICE NG240 rationale and impact — When to suspect meningococcal disease (19 March 2024) — https://www.nice.org.uk/guidance/ng240/chapter/Rationale-and-impact