What is the initial evaluation and treatment for a patient suspected of having meningitis?

Initial Evaluation and Treatment for Suspected Meningitis

In patients with suspected meningitis, immediate stabilization of airway, breathing, and circulation should be the first priority, followed by prompt diagnostic testing and antibiotic administration within the first hour of hospital arrival to reduce mortality and improve outcomes. 1, 2

Initial Assessment (First Hour)

• Document Glasgow Coma Scale (GCS) score to assess severity and monitor changes in neurological status 1, 2
• Assess for presence of rash (particularly petechial or hemorrhagic) which may indicate meningococcal infection 1, 3
• Document use of pre-admission antibiotics as this may affect subsequent culture results 1
• Obtain blood cultures within the first hour of arrival and before antibiotic administration 1, 2
• Make decision regarding need for senior review and/or intensive care admission within the first hour 1

Diagnostic Approach

For Patients WITHOUT Signs of Shock or Severe Sepsis:

• Perform lumbar puncture (LP) within 1 hour of hospital arrival if no contraindications exist 1, 2
• Start antibiotic treatment immediately after LP and within the first hour 1, 2
• If LP cannot be performed within 1 hour, obtain blood cultures and start antibiotics immediately, then perform LP as soon as possible afterward (preferably within 4 hours of antibiotic initiation) 1, 2

Contraindications for Immediate LP (Requiring Neuroimaging First):

• Focal neurological signs 1, 3
• Presence of papilledema 1, 3
• Continuous or uncontrolled seizures 1, 3
• GCS ≤ 12 1, 3
• New onset seizure within 1 week 3
• Immunocompromised state or history of CNS disease 3

For Patients WITH Signs of Shock, Sepsis, or Rapidly Evolving Rash:

• Obtain blood cultures immediately 1
• Start antibiotics immediately after blood cultures are taken 1, 4
• Begin fluid resuscitation with an initial bolus of 500 ml crystalloid given rapidly (over 5-10 minutes) 1
• Follow Surviving Sepsis guidelines 1
• Do not perform LP at this time; stabilize patient first 1

Initial Treatment

Antibiotic Selection:

• For adults, empiric therapy typically includes ceftriaxone or cefotaxime plus vancomycin 3, 5
• For pediatric meningitis, ceftriaxone at 100 mg/kg/day (not exceeding 4 grams daily) is recommended 5
• Administer intravenously over 30 minutes (60 minutes in neonates) 5

Adjunctive Therapy:

• Consider dexamethasone administration before or at the time of first antibiotic dose 3, 4
• For patients with septic shock, continue careful fluid resuscitation with therapeutic endpoints including:
  • Capillary refill time less than 2 seconds 1
  • Normal blood pressure (mean BP >65 mmHg in adults) 1
  • Urine output >0.5 ml/kg/hour 1
  • Normal mental status 1

Common Pitfalls to Avoid

• Delaying antibiotics while waiting for LP or neuroimaging increases mortality 2, 4
• Failing to recognize signs of increased intracranial pressure that contraindicate immediate LP 2, 4
• Underestimating the potential for rapid deterioration in patients with meningitis or meningococcal sepsis, even with initially reassuring vital signs 1, 6
• Relying solely on clinical signs (neck stiffness, Kernig sign, Brudzinski sign) which have poor sensitivity for diagnosing meningitis 3
• Delaying senior clinical review for patients with suspected meningitis 1

Monitoring and Follow-up

• Monitor vital signs frequently to detect early signs of deterioration 1
• Reassess response to initial fluid resuscitation in patients with shock 1
• Consider transfer to intensive care for patients with severe sepsis, altered mental status, or respiratory compromise 1
• Continue antibiotic therapy for at least 7-14 days depending on the causative organism and clinical response 5