Meningitis

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- The most common signs & symptoms (S&S) of bacterial meningitis are:

• fever
• stiff neck
• altered mental status
• headache.

NB: Absence of stiff neck does not rule out meningitis.

Management

- Droplet/contact precautions recommended for 24 hours or until N. meningitidis ruled out.

- Blood culture recommended.

- HIV testing recommended.

- Indications for CT before LP:

• focal neurological deficit
• papilledema
• GCS < 11 or decrease in score of 3 or more
• new onset seizures

- Lumbar puncture (LP) for cell count, glucose, protein, Gram stain and culture recommended prior to antibiotic therapy unless:

• uncorrected coagulopathy
• hemodynamically unstable

NB: Do not delay dexamethasone and antibiotics when clinical suspicion of meningitis is high if neuroimaging (CT/MRI) and/or LP cannot be performed expediently.

See Typical CSF findings

- Bacterial antigen test (latex agglutination) of CSF not recommended.

- Repeat LP should be considered if:

• patient not responding clinically after 48h of appropriate antibiotic therapy
• penicillin and/or cephalosporin intermediate/resistant S. pneumoniae

- For prophylaxis of H. influenzae,  N. meningitidis, and Group A Streptococcus in close contacts, see Prophylaxis for Contacts of Communicable Diseases.

- For organism-specific recommendations, see Recommended Therapy of Culture-Directed Infections, Treatment of Culture-proven Meningitis.

Dexamethasone Therapy in Meningitis

- Dexamethasone prior to administration of antibiotics is recommended empirically in bacterial meningitis. Corticosteroids have been shown to decrease mortality, hearing loss, and other neurological sequelae in adult patients with bacterial meningitis; mortality benefit is most well established for S. pneumoniae.

- Dexamethasone 10mg IV q6h. Ideally, give 15-20 minutes before the first dose of antibiotics.  Dexamethasone can be given concomitantly with the first dose of antibiotic, or up to 4 hours (UK guidelines – up to 12 hours) after starting antibiotics.

• If S. pneumoniae or H. influenzae, or no pathogen identified, continue dexamethasone for 4 days.
• If neither S. pneumoniae nor H. influenzae, discontinue dexamethasone.
  • If Listeria, discontinue dexamethasone immediately as associated with increased mortality.

Vancomycin has slow distribution and poor CSF penetration. It should be given AFTER the first dose of ceftriaxone and continued only if C&S results indicate ceftriaxone-resistant S. pneumoniae. Maintain trough vancomycin serum concentrations of 10-20mg/L.