What is the initial management for suspected meningitis?

Initial Management of Suspected Meningitis

The initial management of suspected meningitis requires immediate stabilization of airway, breathing, and circulation, followed by prompt blood cultures and antibiotic administration within 1 hour of presentation to reduce mortality. 1

Immediate Assessment and Actions

• Stabilize ABC (Airway, Breathing, Circulation) as the immediate priority 2, 1
• Document Glasgow Coma Scale (GCS) score to assess neurological status and for prognostic value 2, 1
• Obtain blood cultures within 1 hour of hospital arrival 2
• Assess severity using National Early Warning Score - a score of 5/6 or 3 in any single parameter requires urgent review; score of 7+ requires critical care team assessment 2

Management Algorithm

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

1. Perform lumbar puncture (LP) within 1 hour if safe to do so 2
2. Administer antibiotics immediately after LP but within the first hour 2
3. If LP cannot be performed within 1 hour, give antibiotics immediately after blood cultures and perform LP as soon as possible afterward 2

For patients with sepsis or rapidly evolving rash:

1. Give antibiotics immediately after blood cultures 2, 1
2. Start fluid resuscitation with initial 500 ml crystalloid bolus 2, 1
3. Follow Surviving Sepsis guidelines 2
4. Defer lumbar puncture until the patient is stabilized 2

Antibiotic Selection

• First-line treatment: Ceftriaxone IV 2g every 12-24 hours 1, 3
• Alternative: Cefotaxime IV if ceftriaxone unavailable 2, 1, 4
• For patients with severe penicillin/cephalosporin allergy, consult infectious disease specialist urgently 1

Indications for Neuroimaging Before LP

Perform CT scan before LP if any of these are present:

• Focal neurological signs
• Papilledema
• Continuous or uncontrolled seizures
• GCS ≤ 12 2

Adjunctive Therapy

• For patients with meningitis component, administer dexamethasone 10 mg IV every 6 hours before or with antibiotics, continuing for 4 days if pneumococcal meningitis is confirmed 1

Intensive Care Considerations

Involve intensive care teams early for patients with:

• Rapidly evolving rash
• Evidence of limb ischemia
• Cardiovascular instability
• GCS ≤ 12 or drop >2 points
• Uncontrolled seizures 1

Common Pitfalls to Avoid

• Delayed antibiotic administration - increases mortality significantly 1
• Underestimating severity - especially in young patients who may remain alert despite severe cardiovascular collapse 1
• Inadequate fluid resuscitation - critical for survival but requires careful monitoring 1
• Missing meningococcemia without meningitis - occurs in 10-20% of patients 1
• Failure to involve critical care early - can lead to rapid deterioration 1

Monitoring Parameters

Monitor for therapeutic endpoints in septic shock:

• Capillary refill time < 2 seconds
• Normal blood pressure (mean BP > 65 mmHg in adults)
• Warm extremities
• Urine output > 0.5 ml/kg/hour
• Normal mental status
• Lactate < 2 mmol/L 2

Early antibiotic treatment improves outcomes, but effectiveness may be threatened by multidrug-resistant bacteria 5. The classic symptoms of bacterial meningitis include fever, neck stiffness, altered mental status, and headache, but clinicians must maintain a high index of suspicion, especially in young and immunocompromised patients who may present atypically 6.