Management of diagnostic uncertainty in children with possible meningitis: a qualitative study.

BACKGROUND: Neisseria meningitidis serogroup B is the most common cause of bacterial meningitis in children and young adults. Early recognition and prompt intervention with antibiotics are thought to be key to preventing serious complications. AIM: Explore how general practitioners evaluate and manage febrile children with possible meningitis or meningococcal septicaemia. DESIGN OF THE STUDY: Qualitative study using one-to-one, semi-structured interviews.
SETTING: General practices in the Avon Health Authority district.
METHOD: Twenty-six general practitioners were purposefully sampled, using a sampling frame to ensure a range of experience and practices in a variety of settings Data management and analysis were conducted using a grounded theory approach.
RESULTS: Key themes to emerge were the effect that fear of meningitis has upon parents and general practitioners; the difficulties associated with reaching a diagnosis; and the existence of barriers to the use of guidelines and pre-hospital penicillin. When assessing a febrile child, participating general practitioners rarely thought that meningitis or meningococcal septicaemia were likely, but were aware that this was frequently the principal parental concern. They relied upon intuitive rather than systematic methods to distinguish serious from self-limiting conditions, rarely making a definitive diagnosis. Although concerned about 'missed cases', interviewees doubted that current management could be improved. They questioned the assumption that guidelines could be sufficiently discriminating to be helpful and thought it unlikely that they would be followed in everyday clinical practice. Pre-hospital penicillin was only given if the diagnosis of meningitis or septicaemia was thought to be certain.
CONCLUSIONS: There is a substantial gap in perception between primary and secondary care in the diagnostic and management approach to children who may have meningitis or meningococcal septicaemia. Until this is addressed, further attempts to improve early intervention in primary care are unlikely to succeed.