What is the management of meningitis?

Meningitis Management Protocol

The management of bacterial meningitis requires immediate administration of appropriate antibiotics, with ceftriaxone 2g IV q12h or cefotaxime 2g IV q6h as first-line therapy, along with adjunctive dexamethasone 10mg IV q6h started before or with antibiotics and continued for 4 days in cases of suspected pneumococcal meningitis. 1

Initial Assessment and Stabilization

• Assess airway, breathing, and circulation immediately
• Document Glasgow Coma Scale (GCS) score
• Obtain blood cultures within 1 hour of arrival
• Consider senior review and/or ICU admission within first hour for:
  • GCS ≤12
  • Rapidly evolving rash
  • Cardiovascular instability
  • Frequent seizures
  • Hypoxia or respiratory compromise

Diagnostic Procedures

Lumbar Puncture (LP)

• Perform LP within 1 hour of arrival if no contraindications
• Contraindications to immediate LP (requiring neuroimaging first):
  • Focal neurological signs
  • Papilledema
  • Continuous or uncontrolled seizures
  • GCS ≤12

Laboratory Testing

• CSF analysis (cell count, glucose, protein, Gram stain, culture)
• Blood cultures (before antibiotics if possible)
• Complete blood count, electrolytes, renal/liver function
• Coagulation studies

Antimicrobial Therapy

Empiric Therapy

1. Adults <60 years:

   • Ceftriaxone 2g IV q12h OR Cefotaxime 2g IV q6h 1
   • Add vancomycin 15-20mg/kg IV q12h if penicillin-resistant pneumococci suspected

2. Adults ≥60 years:

   • Ceftriaxone 2g IV q12h OR Cefotaxime 2g IV q6h
   • PLUS Amoxicillin 2g IV q4h (for Listeria coverage) 1

3. Timing:

   • Start antibiotics immediately after blood cultures if LP delayed
   • If LP can be performed promptly, give antibiotics immediately after LP
   • Do not delay antibiotics beyond 1 hour of presentation

Pathogen-Specific Therapy

Pneumococcal Meningitis

• Continue ceftriaxone 2g IV q12h or cefotaxime 2g IV q6h
• If penicillin-sensitive: can switch to benzylpenicillin 2.4g IV q4h
• If penicillin-resistant but cephalosporin-sensitive: continue ceftriaxone/cefotaxime
• If both penicillin and cephalosporin resistant: continue ceftriaxone/cefotaxime PLUS vancomycin 15-20mg/kg IV q12h PLUS rifampicin 600mg IV/PO q12h
• Duration: 10 days if recovered; 14 days if not recovered by day 10 or resistant organism 1

Meningococcal Meningitis

• Continue ceftriaxone 2g IV q12h or cefotaxime 2g IV q6h
• Alternative: benzylpenicillin 2.4g IV q4h
• If not treated with ceftriaxone, add single dose ciprofloxacin 500mg PO
• Duration: 5 days if recovered 1

Listeria Meningitis

• Amoxicillin 2g IV q4h
• Alternative: co-trimoxazole 10-20mg/kg (trimethoprim component) in 4 divided doses
• Duration: 21 days 1

Adjunctive Therapy

Dexamethasone

• Dose: 10mg IV q6h for 4 days 1
• Timing: Start before or with first antibiotic dose (ideally)
• Can still be beneficial if started within 12 hours of first antibiotic dose
• Continue for 4 days if pneumococcal meningitis confirmed or suspected
• Discontinue if another cause of meningitis is identified 1

Seizure Management

• IV benzodiazepines for acute seizures
• Consider EEG monitoring for suspected status epilepticus 2

Critical Care Considerations

ICU Transfer Criteria

• GCS ≤12 (consider intubation)
• Rapidly evolving rash
• Cardiovascular instability
• Uncontrolled seizures
• Respiratory compromise or hypoxia 1

Sepsis Management

• Initial fluid bolus: 500ml crystalloid
• Target mean arterial pressure ≥65 mmHg
• Follow Surviving Sepsis guidelines for ongoing management 1, 2

Duration of Treatment

• Meningococcal meningitis: 5 days if recovered 1
• Pneumococcal meningitis: 10 days if recovered; 14 days if not recovered by day 10 or resistant organism 1
• Listeria meningitis: 21 days 1
• Haemophilus influenzae: 10 days 1

Outpatient Parenteral Antibiotic Therapy (OPAT)

Consider OPAT if patient:

• Is clinically stable with no acute medical needs
• Has reliable IV access
• Can access medical advice 24/7
• Patient/family willing to participate

Suitable regimen: Ceftriaxone 2g IV once daily (after first 24h of twice-daily therapy) 1

Common Pitfalls to Avoid

• Delaying antibiotics while awaiting imaging or LP results
• Failing to administer dexamethasone before or with antibiotics
• Not considering resistant organisms in patients from areas with high resistance rates
• Overlooking Listeria risk in older adults or immunocompromised patients
• Inadequate fluid resuscitation (fluid restriction is not recommended)
• Delaying critical care consultation for deteriorating patients