Changes

August 2025 — reviewed. A literature search was conducted in June 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Dosage for ceftriaxone for pre-hospital management has been updated to be in line with recommendation from the BNFC.

Update

Goals

To support primary healthcare professionals to:

• Make a diagnosis of suspected bacterial meningitis and meningococcal disease.
• Provide appropriate management and referral pathways for all people with suspected bacterial meningitis and meningococcal disease in primary care.
• Arrange appropriate follow up and understand how to manage close contacts.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

Meningitis (bacterial) and meningococcal disease

• People sent home after clinical assessment indicates that they are unlikely to have bacterial meningitis or meningococcal disease are given safety netting advice. 
• People with suspected meningitis have lumbar puncture without neuroimaging unless they have a contraindication to lumbar puncture that requires neuroimaging
• People with suspected bacterial meningitis or suspected meningococcal disease receive intravenous (IV) antibiotics within 1 hour of their arrival at hospital. 
• People who have had bacterial meningitis or meningococcal disease have an audiological assessment within 4 weeks of being well enough for testing.  
• People who have had bacterial meningitis or meningococcal disease have a follow-up appointment in secondary care within 6 weeks of discharge from hospital. 

[NICE, 2024a]

Fever in under 5s

• Infants and children under 5 years with unexplained fever have their risk of serious illness assessed and recorded using the traffic light system.
• Infants and children under 5 years who are seen in person by a healthcare professional have their temperature, heart rate, respiratory rate, and capillary refill time measured and recorded if fever is suspected.
• Parents and carers who are advised that they can care for an infant or child under 5 years with unexplained fever at home are given safety net advice, including information on when to seek further help.

[NICE, 2022]

What is it?

• Meningitis is inflammation of the three protective membrane layers that cover the brain and spinal cord (the meninges) of the brain and spinal cord.
  
  • This is different from encephalitis, which is inflammation of the brain tissue itself. 
• Causes of meningitis can be infective (bacterial, viral, and fungal) and non-infective (certain cancers, autoimmune disorders, and drugs).
• Bacterial meningitis is a life-threatening condition that affects all ages, but is most common in babies and children. 
  
  • Meningococcal disease is defined by infection with Neisseria meningitidis, which includes, but is not limited to, meningococcal meningitis.
  • Pneumococcal disease is defined as infection with Streptococcus pneumoniae (also called pneumococcal), which includes, but is not limited to, pneumococcal meningitis.
    • Other bacteria can also cause meningitis.
• Bacterial meningitis and meningococcal disease are notifiable diseases. 

[McGill, 2016a; van de Beek, 2016; Aksamit, 2021; NICE, 2024b; UKHSA, 2024; UKHSA, 2025a]

What causes it?

• Overall in the UK, Neisseria meningitidis (meningococcus) and Streptococcus pneumoniae (pneumococcus) are the most common causes of meningitis in adults, children, and babies over 3 months of age.
  • Haemophilus influenzae type b (Hib) used to be common, but is now rare due to vaccination.
  • In babies under the age of 3 months, group B Streptococcus, Escherichia coli, and other coliforms are common.
  • There are 12 capsular groups of meningococci — B, C, W, and Y were historically the most common in the UK; however, after the introduction of the meningococcal C vaccination programme, group B (MenB) now accounts for the majority of meningococcal cases. 
  • Although over 100 different capsular types of Streptococcus pneumoniae have been characterized, prior to the routine conjugate vaccination programme, around 69% of invasive infections are caused by the 10 most prevalent subtypes.  

[NICE, 2024b; UKHSA, 2024; UKHSA, 2025b; UKHSA, 2025a]

How is it transmitted?

• Bacterial meningitis and meningococcal disease are transmitted by aerosol, droplets, or direct contact with secretions from the upper respiratory tract. Transmission usually requires either frequent or prolonged close contact.
  • Fewer than 2% of invasive meningococcal disease (IMD) cases are considered to result from close contact with a primary IMD case. 
• Neisseria meningitidis is usually commensal. Prevalence increases through childhood to a peak in 18–20 year olds, decreasing in adulthood. Carriage episodes may last for several months.
  • The incubation period is usually 3–5 days. 
    • The onset of disease can vary from fulminant with acute and overwhelming symptoms, to insidious with mild prodromal symptoms. 
  •  N. meningitidis capsular group B (MenB) is the most common cause of meningococcal disease in people aged under 25 years. 
    • In 2015, a four-component MenB vaccine was included in the routine UK immunization schedule, and a MenACWY conjugated vaccine was introduced to replace the MenC conjugate vaccine previously given at 14 years of age. For more information, see the CKS topic on Immunizations - childhood. 
• Streptococcus pneumoniae — some serotypes of pneumococcus may be carried in the nasopharynx without symptoms, with disease occurring in a small proportion of infected people. 
  
  • The incubation period is not clearly defined, but can be as short as 1–3 days. 
  • Pneumococcal vaccination is offered to all adults aged over 65 years and to all children (as part of the routine UK childhood immunization programme), as well as to other high-risk groups. For further information, see the CKS topics on Immunizations - childhood and Immunizations - pneumococcal.

  [NICE, 2024b; UKHSA, 2024; UKHSA, 2025a; UKHSA, 2025b; UKHSA, 2025c]

How common is it?

• Meningococcal disease is very rare.
• In 2023/24, 301 individuals were confirmed with MenB invasive disease, compared to 356 cases in 2022/23, 179 cases in 2021/22, and 61 in 2020/21.
  • MenB accounted for 88.3% of all cases, MenW 5%, MenY 4.4%, and MenC 0.9%. 
• The overall incidence of invasive meningococcal disease (IMD) was below 1 per 100,000 population in 2023/24.
  
  • Babies under 1 year of age accounted for 9% (29 cases); children aged 1–4 years accounted for 12% (40 cases); children between 5 and 14 years accounted for 12% (41 cases); young adults aged 15–24 years accounted for 25% (85 cases); and people aged over 25 years accounted for 43% (146 cases) of all laboratory-confirmed cases of IMD.
• In England in 2023/24, the provisional IMD case fatality ratio was 2.3% (8 of 341).

[NICE, 2024b; UKHSA, 2025b]

What are the risk factors for bacterial meningitis and meningococcal disease?

• Young age is the most significant risk factor.
  
  • Although bacterial meningitis can affect all ages, incidence of bacterial meningitis and meningococcal disease is highest in children aged under 2 years and declines during childhood.
  • There is also an increased risk in adolescence and early adulthood. 
• Other risk factors include: 
  • Winter season — bacterial meningitis is more prevalent during the winter. 
  • Older age (more than 65 years).
  • Reduced or absent spleen function.
  • Congenital complement deficiency or acquired inhibition 
  • Immunocompromised state (for example, HIV infection or chemotherapy). 
  • Incomplete immunization — for more information, see the CKS topics on Immunizations - childhood and Immunizations - pneumococcal.
  • Cancer – people with leukaemia and lymphoma are more susceptible to bacterial meningitis.
  • Organ dysfunction — for example, liver or kidney disease.
  • Smoking.
  • They are a student in further or higher education, particularly if they are in large shared accommodation (such as halls of residence).
  • Contact with someone with Hib disease or meningococcal disease, or have recently been to an area with an outbreak of meningococcal disease.  
  • Family history of meningococcal disease.
  • Previous episode of bacterial meningitis or meningococcal disease. 
  • Cranial anatomical defects — congenital or acquired. 
  • Cochlear implants. 
  • Cerebrospinal leak. 
  • Contiguous infection — for example, otitis media, sinusitis, pneumonia, mastoiditis. 
  • Sickle cell disease. 

[van de Beek, 2016; Lundbo, 2017; NICE, 2024b; UKHSA, 2024]

What are the complications of bacterial meningitis?

• Although overall mortality from acute bacterial meningitis has fallen in recent years, there has been no change in the rate of complications. 
  • Complications are more common following pneumococcal meningitis and occur in about 30% of people compared with 7% with meningococcal meningitis. 
  • The frequency of complications is much higher in meningococcal septicaemia (up to 57%). 
• Cerebral infarction occurs in one in four people with bacterial meningitis — this leads to focal neurological deficits. These are present in 50% of people on admission and develop during the clinical course in the others.
  • However, neurological complications may also be caused by other pathologies, such as subdural empyema, cerebral abscess, or intracerebral bleeding.
• Neurological complications include: 
  • Hearing loss (34%).
    • This has been reported in up to 19% of infants, 13% of children, 12% of adolescents, and 8% of adults with meningococcal meningitis.
  • Seizures (13%).
    • This has been reported in up to 5% of infants, 9% of children, and 2% of adolescents with meningococcal meningitis.
  • Cognitive impairment (9%).
  • Motor deficits (12%).
  • Visual impairment (6%).
  • Speech impediment.
• Physical complications include: 
  • Amputations — these have been reported in up to 8% of children and 3% of adults/adolescents with meningococcal meningitis.
  • Skin scars — these have been reported in up to 55% of children, 18% of adolescents, and 2% of adults with meningococcal meningitis.
• Other complications include:
  • Hydrocephalus (7% of meningitis in children, more common in neonates and infants).
  • Reduced quality of life. 
  • Anxiety.
  • Learning difficulties.
  • Emotional and behavioural difficulties.
• A systematic review of data from 3408 people with a history of pneumococcal meningitis found that multiple sequelae were reported in a significant proportion (about 20%). The most common multiple impairment combinations were cognitive deficit plus hearing loss (39.1%) and cognitive deficit plus motor impairment (21.1%) [Jit, 2010].

[Brouwer, 2010; Edmond, 2010; Olbrich, 2018; Zainel, 2021; NICE, 2024b]

What is the prognosis of acute bacterial meningitis?

• With prompt and adequate antimicrobial treatment and supportive therapy, the outcome of acute bacterial meningitis is excellent. 
• Factors that affect the prognosis of bacterial meningitis include: 
  • Age — fatality rates are high among people at the extremes of age (neonates and older people).
  • The causative organism.
    • In England in 2023/24, the case-fatality ratio for invasive meningococcal disease was 2.3%. 
    • Case-fatality rates are higher for infections caused by Listeria monocytogenes, Escherichia coli, pneumococcal meningitis, and meningitis caused by other streptococci.
  • Presence of comorbidities.
  • Severity at presentation.
  • Sex — male individuals are more likely to have poor outcomes.
• In children aged up to 18 years with bacterial meningitis, other significant prognostic factors include:
  • Symptoms lasting more than 48 hours before admission.
  • Coma/impaired consciousness.
  • Prolonged seizures (more than 12 hours after admission).
  • Prolonged fever (more than 7 days).
  • Shock.
  • Peripheral circulatory failure.
  • Respiratory distress.
  • Absence of petechiae (petechiae occurs much less with S. pneumoniae).
• Features associated with a poor prognosis in adults include: 
  
  • Low Glasgow Coma Scale score on admission (low level of consciousness).
  • Tachycardia. 
  • Absence of rash.
  • Thrombocytopenia.
  • Elevated erythrocyte sedimentation rate (ESR). 
  • Positive blood culture. 
  • Alcoholism.
  • Cerebrospinal fluid leucocyte count of less than 1000 x 10⁹ cells per mL.
• Complications of bacterial meningitis occur in up to 30% of children and up to one-third of adults and are more common in pneumococcal meningitis than in meningococcal meningitis.

[McGill, 2016a; Olbrich, 2018; UKHSA, 2025b]

When should I suspect bacterial meningitis or meningococcal disease?

• When considering a diagnosis of bacterial meningitis or meningococcal disease, be aware that:
  • They are rapidly evolving conditions.
  • They can present with non-specific symptoms and signs (without the red flag combination for bacterial meningitis or any of the red flag symptoms for meningococcal disease), particularly in young babies and older adults.
  • They may be difficult to distinguish from other infections with similar symptoms and signs. 
  • Symptoms and signs may be more difficult to identify in young people and young adults, who may appear well at presentation.
  • Meningitis and sepsis can occur at the same time, particularly in people with a rash.
  • Bacterial meningitis has a poor prognosis when unrecognised.
• Complete an assessment of signs, symptoms and risk factors.
  • For people with reduced consciousness or communication difficulties, ask family members or carers about recent changes in symptoms.
• Strongly suspect bacterial meningitis in people with all the symptoms in the red flag combinations: 
  • Fever.
  • Headache.
  • Neck stiffness.
  • Altered level of consciousness or cognition (including confusion or delirium). 
• Note: bacterial meningitis can still be strongly suspected based on clinical assessment, even in people who do not have all the symptoms in the red flag combination.
• Suspect bacterial meningitis based on an assessment of symptoms and signs in Table 1. Take into account that:
  • Bacterial meningitis can present with any of these symptoms and signs
  • The more symptoms and signs a person has, the more likely it is that they have bacterial meningitis.

Table 1: Symptoms and signs of bacterial meningitis

• Strongly suspect meningococcal disease in people with any of these red flag combinations:
  • Haemorrhagic, non-blanching rash with lesions larger than 2 mm (purpura).
  • Rapidly progressive and/or spreading non-blanching petechial or purpuric rash.
  • Any symptoms and signs of bacterial meningitis.
• Do not rule out meningococcal disease just because a person does not have a rash.
• Suspect meningococcal disease based on an assessment of symptoms and signs in Table 2.
  • Take into account that meningococcal disease can present with any combination of the non-specific symptoms and signs of severe illness

Table 2: Symptoms and signs of meningococcal disease

• Be alert to the possibility of bacterial meningitis or meningococcal septicaemia when assessing children or young people with acute febrile illness. 
• Be aware that:
  • Children and young people with bacterial meningitis commonly present with non-specific symptoms and signs, including fever, vomiting, irritability, reduced feeding in babies, and upper respiratory tract symptoms. These may be difficult to distinguish from other viral infections. 
    • Some children with bacterial meningitis present with seizures.
  • Children and young people with more specific symptoms and signs are more likely to have bacterial meningitis or meningococcal septicaemia, and the symptoms and signs may become more severe and more specific over time. 
  • Classical signs of meningitis (neck stiffness, bulging fontanelle, high pitched cry) are often absent in infants with bacterial meningitis. 
• Consider other non-specific features of the presentation and use clinical judgement, taking into account: 
  • The level of parental or carer concern (particularly compared with previous illness in the child or young person, or their family).
  • The speed of progression of the illness.
  • The overall severity of the illness.
• Be on heightened alert in people with risk factors for meningitis or meningococcal disease.
• Transfer all suspected cases urgently to secondary care for a second opinion if there is any doubt. 

How should I assess a rash that is suspicious of meningococcal disease?

• When a non-blanching rash is present, it may appear as a: 
  • Petechial rash (red or purple non-blanching macules smaller than 2 mm in diameter).  
  • Purpuric (haemorrhagic) rash (spots larger than 2 mm in diameter) — this may be absent in the early phase of the illness and may initially be blanching or macular in nature. 
• Examine the whole body systematically (including nappy areas) for rash and unusual skin colour — particularly for non-blanching rashes and petechiae. 
  • Ask the parent or person about any new rashes or marks (such as a bruise, spot, blister, or stain — the person may use other words to describe a rash). 
    • Advise them to look for any changes in the rash, as it can change from blanching to non-blanching. 
  • Consider checking for non-blanching rashes using the 'glass test'. 
    • This involves pressing the side of a glass or tumbler firmly against the rash to see if the rash fades or loses colour under pressure. A petechial or purpuric rash does not fade.
    • Be aware that the glass test should not be used solely for diagnosing bacterial meningitis and meningococcal septicaemia.
  • A rash may be hard to detect on brown, black or tanned skin (even when using the glass test). Check paler areas of the body (such as the soles of the feet or palms of the hands) or the conjunctivae or palate. 
• Be aware that:
  • The disease process can be advanced before the rash starts to appear. 
  • A blanching rash may develop into a non-blanching rash as the illness progresses. 
  • A rapidly evolving petechial or purpuric rash is a sign of very severe disease and is a risk factor for a fatal outcome. 
• The risk of meningococcal disease is high in a child or young person with petechiae if: 
  • The petechiae start to spread.
  • The rash becomes purpuric.
  • There are signs of bacterial meningitis.
  • There are signs of meningococcal septicaemia.
  • The child or young person appears unwell.

Assessing vital signs in a person with suspected bacterial meningitis or meningococcal disease

• In all people with suspected bacterial meningitis or meningococcal disease, perform a risk stratification and assess: 
  • Conscious level (for example, using the Glasgow Coma Scale [GCS], or the Alert, Voice, Pain, Unresponsive [AVPU] scale).
    • For people with reduced consciousness or communication difficulties, ask family members or carers about recent changes in symptoms.
  • Heart rate and blood pressure.
  • Respiratory rate, oxygen saturation (if a pulse oximeter is available).
  • Temperature.
  • Capillary refill time.
• Features of shock include: 
  • Capillary refill time of more than 2 seconds, cold hands and feet.
  • Unusual skin colour.
  • Tachycardia and/or hypotension.
  • Respiratory symptoms or breathing difficulty.
  • Leg pain.
  • Toxic/moribund state.
  • Altered mental state/decreased conscious level.
  • Poor urine output.

What else might it be?

The diagnosis of acute bacterial meningitis can be challenging, as it can present with common, non-specific clinical features. Differential diagnoses include:

• Other infective meningitis and meningoencephalitis, for example:
  • Viral meningitis — common and can occur at any age, although most commonly occurs in children. Management is generally conservative, and most cases are self-limiting with a very good prognosis. 
    • Enteroviruses (for example Coxsackie A and B viruses, and echoviruses) are the most common cause in children and adults.
    • Herpes simplex virus (HSV) — this is usually a complication of primary genital herpes, especially with HSV-2. For more information, see the CKS topic on Herpes simplex - genital.
  • Fungal meningitis — life-threatening, but rare. Immunocompromised people are at increased risk. Presentation is often insidious with onset over weeks or months.
    • Cryptococcus is the most common cause of fungal meningitis in immunocompromised people. 
  • Tuberculous meningitis — history of contact, or resident in endemic area. Signs and symptoms of pulmonary and extra-neural disease. Some features are indistinguishable from bacterial meningitis. For more information, see the CKS topic on Tuberculosis.
  • Drug-induced meningitis — history of responsible drug (such as nonsteroidal anti-inflammatory drug, trimethoprim/sulfamethoxazole, amoxicillin, ranitidine).
• Sepsis — for more information, see the CKS topic on Sepsis.
• Pneumonia — for more information, see the section on Community-acquired pneumonia in the CKS topic on Chest infections - adult.
• Encephalitis — suggested by abnormal cerebral function, such as altered behaviour and speech or motor function, particularly if associated with fever. 
• Malignancy. 
• Central nervous system abscess. 
• HIV infection — for more information, see the CKS topic on HIV infection and AIDS. 
• Subarachnoid haemorrhage. 
• Other non-infective causes of meningitis, for example:
  • Autoimmune disorders such as systemic lupus erythematosus (can cause aseptic meningitis) and Behçet's syndrome.

Petechiae may have other causes, such as:

• Other infections — for example, enterovirus, Epstein-Barr virus, rubella, adenoviruses, and respiratory viruses.
• Non-infective causes — for example, clotting factor or platelet deficiencies. Petechiae in the eyes or on the face may also result from non-infective causes (such as sneezing, coughing, vomiting, and trauma). For more information, see the CKS topic on Bruising.

Scenario: Meningitis or meningococcal disease

From birth onwards.

Scenario: Managing close contacts

From birth onwards.

Scenario: Follow up after hospital discharge

From birth onwards.

Benzylpenicillin

Ceftriaxone

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on the primary care management of bacterial meningitis and meningococcal disease.

Search dates

June 2020 - June 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 26th June 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S4 S1 OR S2 OR S3
S3 TI ( meningitis or meningococcal )
S2 (MH "Meningococcal Infections+"
S1 (MH "Meningitis, Bacterial+")

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
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• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.