• 95% of patients present with at least two of headache, fever, nuchal rigidity, and altered mental status.
• 8 to 15% of patients with bacterial meningitis die within 48 hours of symptom onset even with early diagnosis and treatment.

• Initial Management:
  • IV fluid resuscitation as you would for sepsis
  • Management of acute cerebral edema or elevated intracranial pressure (ICP) (above 15 or 20 mm Hg):
    • Endotracheal intubation and hyperventilation aiming for a PaCO₂ of 35 mmHg.
    • IV osmotic agents such as mannitol (0.25 – 2 G/kg IV infused over 30-60 minutes) while monitoring closely to ensure that the patient does not become volume depleted or hypotensive or hypertonic saline (3% saline 250 mL IV bolus).
    • Elevate head of bed to 30 degrees.
    • Induction of hypothermia.
    • ICU may consider placement on an ICP monitoring device.

• If patient is IMMUNOCOMPROMISED or has a history of central nervous system disease, new onset seizures, papilledema, altered consciousness, focal neurologic deficit, or delay in lumbar puncture (LP):
  • Obtain blood cultures.
  • Administer empiric antimicrobial therapy, plus dexamethasone if suspecting bacterial meningitis, STAT.
  • Obtain LP if head CT results are negative.
  • Modify empiric antimicrobial therapy based on results of CSF analysis.
  • Droplet precautions for 1^st 24 hours of effective antibiotic therapy

Do not delay the initiation of antimicrobial therapy, i.e. if LP is delayed, in a patient with suspected meningitis!

• If patient is IMMUNOCOMPETENT and has NO history of central nervous system disease, new onset of seizures, papilledema, altered consciousness, focal neurologic deficit, and no delay in LP, do all of the following:
  • Obtain blood cultures and perform LP. (see videos: Lumbar Puncture,  Lumbar Puncture with Ultrasound)
  • Administer empiric antibiotics, plus dexamethasone if suspecting bacterial meningitis, immediately after LP.
  • Modify empiric antimicrobial therapy based on results of CSF analysis and gram stain.
  • Droplet precautions for 1^st 24 hours of effective antibiotic therapy.

Empiric Antimicrobial Therapy

• Empiric Antimicrobial Therapy (unless directed otherwise by local consultants):
  • Ceftriaxone 2 g IV every 12 hours
    • If severe beta lactam allergy, replace with moxifloxacin 400 mg IV once daily.
  • AND Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours.
  • AND Ampicillin 2 g IV every 4 hours in adults > 50 years old, pregnant or immunocompromised patients.
  • Acyclovir 10 mg/kg IV every 8 hours if CSF profile compatible with viral meningitis (elevated WBC predominantly lymphocytes, increased protein and low glucose).

When should you administer dexamethasone?

• Shown to lower the rate of hearing loss and other neurologic complications, and mortality in some patients with bacterial meningitis due to pneumoniae.
• Adjunctive dexamethasone (0.15 mg/kg i.e.10 MG) IV q6H for four days) should be given 15-20 minutes before or at the same time as the first dose of antibiotics when bacterial meningitis is suspected.
• Only continue dexamethasone if subsequent CSF analysis or blood cultures reveal  pneumoniae as the responsible pathogen.
• Do not give adjunctive dexamethasone to patients who have already received antimicrobial therapy, as it is unlikely to be beneficial.

Recommended duration of treatment based on pathogenic bacterial species:

• Neisseria meningitidis: 7 days
• Streptococcus pneumoniae: 10 to 14 days
• Listeria monocytogenes:  ≥ 21 days
• Haemophilus influenzae: 7 to 10 days

• All suspected/confirmed bacterial, fungal, or TB meningitis/meningoencephalitis.
  • monitoring of neurologic status and vital signs.

• If monitoring of neurologic status and vital signs not possible at your center.
• Significant altered mental status (raised ICP) or sepsis needs a higher level of care.

• All suspected/confirmed bacterial, fungal, or TB meningitis/meningoencephalitis.

• All typically admitted from the ED although viral meningitis may be discharged after a short stay.

1. Clinical Key: Elsevier Point of Care – Clinical Overview: Bacterial Meningitis

   
   

2. Rosen’s Emergency Medicine: Central Nervous System Infections, Chapter 99, 1328-1340. e9

   
   

3. UpToDate: Dexamethasone to prevent neurologic complications of bacterial meningitis in adults

   
   

4. UpToDate: Initial therapy and prognosis of bacterial meningitis in adults

   
   

5. UpToDate: Clinical features and diagnosis of acute bacterial meningitis in adults

   
   

6. Spectrum Mobile App