What is the initial treatment for a patient presenting with symptoms of spinal meningitis?

Initial Treatment for Spinal Meningitis

The initial treatment for a patient presenting with symptoms of spinal meningitis should prioritize stabilization of airway, breathing, and circulation, followed by immediate blood cultures and prompt administration of antibiotics within one hour of hospital arrival, with lumbar puncture performed when safe to do so. 1

Initial Assessment and Stabilization

1. Immediate priorities 1:

   • Stabilize airway, breathing, and circulation
   • Document Glasgow Coma Scale (GCS) score
   • Assess for presence of rash and pre-admission antibiotic use
   • Use National Early Warning Score to determine urgency of senior review

2. Decision points within first hour 1:

   • Need for senior review and/or intensive care admission
   • Blood cultures (must be taken within 1 hour of arrival)
   • Determination of treatment pathway based on presentation

Treatment Algorithm Based on Presentation

For patients with suspected meningitis WITHOUT signs of shock or severe sepsis:

1. Perform lumbar puncture (LP) within 1 hour of arrival if safe to do so 1

   • Contraindications to immediate LP (requiring neuroimaging first) 1:
     • Focal neurological signs
     • Papilloedema
     • Continuous or uncontrolled seizures
     • GCS ≤ 12

2. Administer antibiotics:

   • Immediately after LP is performed (within the first hour)
   • If LP cannot be performed within 1 hour, give antibiotics immediately after blood cultures 1
   • For meningitis, pediatric dosing: 100 mg/kg/day of ceftriaxone (not exceeding 4 grams daily) 2
   • For adults: 1-2 grams of ceftriaxone given once daily or in divided doses twice daily 2

For patients with predominantly sepsis or rapidly evolving rash:

1. Immediate interventions 1:

   • Give antibiotics immediately after blood cultures are taken
   • Start fluid resuscitation with initial bolus of 500 ml crystalloid
   • Follow Surviving Sepsis guidelines
   • Do NOT perform LP at this time

2. Monitor for therapeutic endpoints in septic shock 1:

   • Capillary refill time less than 2 seconds
   • Normal blood pressure (mean BP > 65 mmHg in adults)
   • Normal pulses without differential between peripheral and central
   • Warm extremities
   • Urine output > 0.5 ml/kg/hour
   • Normal mental status
   • Central venous pressure 8-12 mmHg
   • Lactate < 2 mmol/L

Antibiotic Selection and Administration

• Ceftriaxone is the primary antibiotic of choice for bacterial meningitis 2
• Administration considerations:
  • Intravenous administration over 30 minutes (60 minutes in neonates) 2
  • Do not use diluents containing calcium (e.g., Ringer's solution) 2
  • Duration of therapy typically 7-14 days 2

Important Clinical Pitfalls to Avoid

1. Delaying antibiotics - Evidence shows delays increase mortality 1

   • If LP cannot be performed within 1 hour, start antibiotics after blood cultures

2. False reassurance from normal early warning scores - Patients with meningitis can deteriorate rapidly 1

3. Performing LP when contraindicated - Could lead to cerebral herniation in patients with significant brain swelling 1

4. Delayed LP after antibiotics - Should be performed within 4 hours of starting antibiotics to maximize chances of identifying causative bacteria 1

5. Inadequate fluid resuscitation in septic patients - Monitor carefully for fluid overload 1

Early recognition and treatment are crucial for improving outcomes in bacterial meningitis and viral encephalitis, as delayed treatment can lead to poor neurological outcomes or death 3.