What are the signs and treatment of meningitis?

Signs and Treatment of Meningitis

Immediate empiric antibiotic therapy with ceftriaxone or cefotaxime should be started within 1 hour of hospital arrival in all suspected meningitis cases, with lumbar puncture performed when safe to do so. 1

Clinical Signs of Meningitis

Cardinal Signs

• Fever
• Headache
• Neck stiffness (meningism)
• Altered mental status
• Photophobia
• Nausea/vomiting

Important to note that the "classic triad" of fever, neck stiffness, and altered consciousness is present in less than 50% of bacterial meningitis cases 1. Clinical presentation may vary significantly, especially in elderly patients who are more likely to present with altered mental status and less likely to have fever or neck stiffness 1.

Additional Signs to Assess

• Rash (particularly petechial or purpuric rash, highly suggestive of meningococcal disease)
• Seizures
• Focal neurological deficits
• Signs of increased intracranial pressure (papilledema)
• Signs of shock (hypotension, poor capillary refill)
• Glasgow Coma Scale (GCS) score

Unreliable Signs

• Kernig's and Brudzinski's signs have high specificity (up to 95%) but very low sensitivity (as low as 5%) and should not be relied upon for diagnosis 1

Emergency Management Algorithm

1. Initial Assessment (First Hour)

• Stabilize airway, breathing, and circulation
• Document GCS score
• Assess for rash and pre-admission antibiotic use
• Take blood cultures immediately (within 1 hour of arrival)
• Determine treatment pathway based on presentation 1

2. Decision Pathway

For suspected meningitis without shock or severe sepsis:

• Perform lumbar puncture (LP) within 1 hour if safe to do so
• Start antibiotics immediately after LP is performed (within first hour)
• If LP cannot be performed within 1 hour, start antibiotics after blood cultures 1

For patients with sepsis, shock, or rapidly evolving rash:

• Give antibiotics immediately after blood cultures
• Start fluid resuscitation with 500 ml crystalloid bolus
• Follow Surviving Sepsis guidelines
• Do not perform LP at this time 1

3. Contraindications to Immediate LP

• Focal neurological signs
• Papilledema
• Continuous or uncontrolled seizures
• GCS ≤ 12 1

Antibiotic Treatment

Empiric Antibiotic Therapy

• Age <50 years: Ceftriaxone 2g IV every 12h or cefotaxime 2g IV every 4-6h plus vancomycin or rifampicin 1
• Age >50 years or immunocompromised: Ceftriaxone or cefotaxime plus vancomycin or rifampicin PLUS amoxicillin/ampicillin 1

Pediatric Dosing

• Ceftriaxone: 50-100 mg/kg/day (not to exceed 4g daily)
• For meningitis: 100 mg/kg/day (not to exceed 4g daily) 2

Pre-hospital Antibiotics

• Give benzylpenicillin 1200 mg IM/IV or ceftriaxone 2g IM/IV if:
  • Signs of meningococcal disease (rash with meningism)
  • Signs of severe sepsis
  • Suspected meningitis with >1 hour delay to hospital 1

Adjunctive Therapy

Corticosteroids

• Dexamethasone should be administered to adults with suspected bacterial meningitis before or at the time of antibiotic initiation 1
• Consider discontinuing dexamethasone if pathogens other than S. pneumoniae or H. influenzae are identified 1

Fluid Management

• Keep patients euvolemic to maintain normal hemodynamic parameters
• Fluid restriction to reduce cerebral edema is not recommended
• Use crystalloids as initial fluid of choice
• Consider albumin for persistent hypotensive shock 1

Critical Care Considerations

Indications for ICU Transfer

• Rapidly evolving rash
• GCS of 12 or less (or drop of >2 points)
• Need for monitoring or specific organ support
• Uncontrolled seizures
• Evidence of severe sepsis 1

Intubation Considerations

• Strongly consider intubation for GCS <12 1

Follow-up Care

Hearing Assessment

• All patients should have a hearing test if:
  • Clinician, patient, or family thinks hearing may be affected
  • Patient no longer has capacity to report hearing loss
• Test should be performed before discharge or within 4 weeks 1

Long-term Sequelae Assessment

• Document and assess for:
  • Hearing loss
  • Cognitive deficits and learning impairment
  • Epilepsy
  • Movement disorders
  • Visual disturbances
  • Communication problems 1

Common Pitfalls to Avoid

1. Delayed antibiotic administration: Mortality increases with delays in antibiotic therapy; administer within 1 hour of arrival 1, 3

2. Waiting for LP results before starting antibiotics: If LP cannot be performed promptly or is contraindicated, start antibiotics after blood cultures 1

3. Missing atypical presentations: Especially in elderly patients who may not present with classic signs 1

4. Relying on Kernig's or Brudzinski's signs: These have poor sensitivity and should not be used to rule out meningitis 1, 4

5. Underestimating severity in young patients: Young patients with meningococcal sepsis may maintain blood pressure until late in disease despite severe shock 1

6. Inadequate fluid resuscitation: Careful fluid management is essential, avoiding both under-resuscitation and fluid overload 1

7. Failure to involve critical care early: Intensive care teams should be involved early in patients with concerning signs 1