What are the symptoms and treatment options for bacterial meningitis?

Symptoms and Treatment of Bacterial Meningitis

Bacterial meningitis presents with variable symptoms depending on age, with fever, headache, neck stiffness, and altered mental status being the most common manifestations in adults, though classic signs may be absent in many cases, necessitating a high index of suspicion and prompt cerebrospinal fluid examination for diagnosis. 1

Symptoms in Different Age Groups

Neonates

• Present with nonspecific symptoms such as irritability, poor feeding, respiratory distress, pale or marble skin, and hyper- or hypotonia 1
• Fever is present in only a minority (6-39%) of cases 1
• Seizures occur in 9-34% of cases, more commonly with Group B streptococcal meningitis 1, 2
• Respiratory distress or failure is frequently reported as an initial symptom 1
• Septic shock may be diagnosed in about 25% of cases 1

Children Beyond Neonatal Age

• Fever is the most common symptom (92-93% of cases) 1
• Headache is reported in 2-9% of children up to 1 year of age and 75% of children older than 5 years 1
• Vomiting occurs in 55-67% of cases 1
• Neck stiffness is present in 40-82% of cases 1
• Seizures occur in 10-56% of children at hospital admission 1
• Altered mental status is reported in 13-56% of cases 1
• Petechial and purpuric rash is usually associated with meningococcal disease (61% of cases) but can also occur in pneumococcal meningitis (9% of cases) 1

Adults

• Headache is reported in 58-87% of cases 1, 3
• Fever occurs in 77-97% of cases 1, 3
• Neck stiffness is present in 65-83% of cases 1, 3
• Altered mental status is reported in 30-69% of cases 1
• Nausea/vomiting occurs in 45-74% of cases 1
• Rash is identified in 20-52% of patients and is indicative of meningococcal infection in over 90% of cases 1
• The classic triad of fever, neck stiffness, and altered mental status is present in only 41-51% of cases 1, 4

Important Diagnostic Considerations

• Clinical signs alone have poor diagnostic accuracy for bacterial meningitis 1
• Sensitivity of neck stiffness is only 51% in children and 31% in adults 1
• Kernig sign has a sensitivity of 53% in children and 11% in adults 1
• Brudzinski sign has a sensitivity of 66% in children and 9% in adults 1
• Absence of classic symptoms cannot be used to rule out bacterial meningitis 1, 3
• Cerebrospinal fluid examination is essential for diagnosis when bacterial meningitis is suspected 1, 3

Treatment Approach

Empiric Antibiotic Therapy

• Treatment should be initiated as soon as blood cultures are obtained, preceding any imaging studies 5
• In countries with >1% ceftriaxone-resistant S. pneumoniae, vancomycin and ceftriaxone are the empirical antibiotics of choice 3
• Add ampicillin for neonates, older patients, and immunocompromised patients to cover Listeria monocytogenes 3, 2

Specific Treatment for Pediatric Bacterial Meningitis

• For children 3 months and older with bacterial meningitis, meropenem is indicated for treatment of meningitis caused by Haemophilus influenzae, Neisseria meningitidis, and penicillin-susceptible isolates of Streptococcus pneumoniae 6
• Dosage for pediatric patients: 40 mg/kg every 8 hours (maximum dose 2 grams every 8 hours) 6
• For pediatric patients weighing over 50 kg: 2 grams every 8 hours for meningitis 6

Adjunctive Therapy

• Dexamethasone should be used as adjunctive treatment in bacterial meningitis but stopped if Listeria monocytogenes is confirmed 5, 3

Common Pitfalls and Caveats

• Relying solely on the classic triad of symptoms (fever, neck stiffness, altered mental status) will miss approximately 50-60% of bacterial meningitis cases 1, 4
• Symptoms may be scarce or atypical in children, the elderly, and in meningococcal disease 5
• The younger the patient, the more subtle and atypical the symptoms 1
• Bacterial meningitis should not be ruled out solely on the absence of classic symptoms 1
• Delayed diagnosis and treatment can lead to high mortality (up to 54% in low-income countries) and neurological sequelae in up to 24% of survivors 3
• Post-recovery complications may include fatigue, headaches, sleep disorders, and emotional problems in the weeks and months after discharge 4