Brennan Cathy A, Somerset Maggie, Granier Stephen K, Fahey Tom P, Heyderman Robert S
Department of Pathology and Microbiology/Division of Primary Health Care, University of Bristol.
Br J Gen Pract. 2003 Aug;53(493):626-31.
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.
Explore how general practitioners evaluate and manage febrile children with possible meningitis or meningococcal septicaemia.
Qualitative study using one-to-one, semi-structured interviews.
General practices in the Avon Health Authority district.
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.
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.
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.
B 群脑膜炎奈瑟菌是儿童和青年细菌性脑膜炎最常见的病因。早期识别并迅速使用抗生素进行干预被认为是预防严重并发症的关键。
探讨全科医生如何评估和处理可能患有脑膜炎或脑膜炎球菌败血症的发热儿童。
采用一对一、半结构化访谈的定性研究。
埃文卫生局辖区的全科诊所。
采用抽样框架有目的地抽取 26 名全科医生，以确保在各种环境中有一系列经验和做法。使用扎根理论方法进行数据管理和分析。
出现的关键主题包括对脑膜炎的恐惧对家长和全科医生的影响；做出诊断的困难；以及使用指南和院前使用青霉素存在障碍。在评估发热儿童时，参与研究的全科医生很少认为可能是脑膜炎或脑膜炎球菌败血症，但意识到这常常是家长主要关心的问题。他们依靠直觉而非系统方法来区分严重病症和自限性病症，很少做出明确诊断。尽管担心“漏诊病例”，受访者怀疑当前的管理方法能否改进。他们质疑指南能否具有足够的区分度以提供帮助，并认为在日常临床实践中不太可能遵循这些指南。只有在认为脑膜炎或败血症的诊断确定时才会给予院前青霉素。
在对可能患有脑膜炎或脑膜炎球菌败血症的儿童的诊断和管理方法上，初级保健和二级保健之间存在很大的认知差距。在解决这一问题之前，进一步尝试改善初级保健中的早期干预不太可能成功。
