Meningitis Symptoms and Treatment
The classic triad of fever, neck stiffness, and altered mental status is present in only 41-51% of patients with bacterial meningitis, and its absence does not rule out the disease; immediate administration of parenteral antibiotics upon suspicion of bacterial meningitis is essential for reducing mortality and morbidity. 1
Clinical Presentation
Adult Symptoms
- Fever (77-97%)
- Headache (58-87%)
- Neck stiffness (65-83%)
- Altered mental status (30-69%)
- Nausea/vomiting (45-74%)
- Rash (20-52%), particularly petechial or purpuric rash suggestive of meningococcal disease
- Focal neurological deficits (15-34%)
Pediatric Symptoms
- Fever (92-93%)
- Vomiting (55-67%)
- Poor feeding (common in young children)
- Altered mental status (13-56%)
- Seizures (10-56%)
- Petechial or purpuric rash (particularly suggestive of meningococcal disease)
Neonatal Symptoms
- Non-specific symptoms rather than classic meningeal signs
- Irritability
- Bulging fontanelle
- Lethargy
- Feeding refusal
Diagnosis
Key Diagnostic Steps
- Lumbar puncture: Essential for definitive diagnosis unless contraindicated 1
- Initial laboratory studies:
- Complete blood count
- Blood cultures
- Renal and liver function tests
- PCR/VSG
Neuroimaging Before Lumbar Puncture
Perform neuroimaging before lumbar puncture if any of the following are present:
- Signs of increased intracranial pressure
- Focal neurological deficits
- New-onset seizures
- Severe altered mental status
- Immunosuppression
Treatment
Antibiotic Therapy
- Immediate administration: Administer parenteral antibiotics immediately upon suspicion of bacterial meningitis, even before hospital arrival 1
- Timing: Start antibiotic therapy within the first hour of hospital arrival 1
Antibiotic Selection by Age
- Children over 3 months: Intravenous cefotaxime 1, 2
- Adults under 50: Ceftriaxone 2g IV every 12 hours or cefotaxime 2g IV every 4-6 hours plus vancomycin or rifampicin 1, 3
- Adults over 50 or immunocompromised: Ceftriaxone or cefotaxime plus vancomycin or rifampicin plus amoxicillin/ampicillin 1
Adjunctive Therapy
- Corticosteroids: Dexamethasone should be administered before or at the start of antibiotics in adults with suspected bacterial meningitis 1
- Fluid management: Rapid infusion of intravenous fluids if signs of shock are present; maintain euvolemia to preserve normal hemodynamic parameters 1
Duration of Treatment
- Meningococcal disease: 7 days, assuming satisfactory clinical progress 1
- Other bacterial meningitis: Generally 4-14 days; in complicated infections, longer therapy may be required 3
- Streptococcus pyogenes infections: At least 10 days 3
Intensive Care Considerations
Consider ICU admission for patients with:
- Rapidly evolving rash
- Glasgow Coma Scale score ≤12
- Need for organ support
- Uncontrolled seizures
- Evidence of severe sepsis 1
Complications and Prognosis
Neurological Complications
- Decreased mental status
- Focal neurological deficits
- Seizures
- Hydrocephalus
Systemic Complications
- Shock (particularly in meningococcal disease)
- Respiratory insufficiency
- Sepsis
Long-term Sequelae
- Hearing loss (5-35%)
- Cognitive impairment
- Neurological deficits
- Seizures (13% in children)
- Motor deficits (12% in children)
- Fatigue and sleep disorders
- Emotional difficulties
- Headaches (up to one-third of patients)
Mortality
- Overall mortality for bacterial meningitis: approximately 20%, increasing with age 1
- Mortality varies by pathogen:
- Streptococcus pneumoniae: 30-58%
- Neisseria meningitidis: 7%
- Listeria monocytogenes: up to 100% in elderly patients
- Gram-negative bacilli: 83% in elderly patients
Common Pitfalls to Avoid
- Relying on the absence of the classic triad: The classic triad of fever, neck stiffness, and altered mental status is present in less than 50% of cases 1, 4
- Relying solely on Kernig's and Brudzinski's signs: These have low sensitivity 1
- Delaying antibiotic administration: This can significantly worsen outcomes 1
- Not recognizing atypical presentations: Especially in elderly patients, neonates, and immunocompromised individuals 1, 5
- Underestimating severity in young patients: Young patients can deteriorate rapidly 1
Follow-up Care
- Hearing evaluation should be performed during admission or within 4 weeks of recovery 1
- Document and evaluate hearing loss, cognitive deficits, epilepsy, movement disorders, visual disturbances, and communication problems 1
- Inform patients, family members, and caregivers about potential sequelae, as many issues only become apparent after discharge 1