What is the treatment for a patient presenting with meningeal signs?

Treatment of Meningeal Signs

Patients presenting with meningeal signs require immediate empiric antibiotic therapy with ceftriaxone 2g IV every 12 hours (or cefotaxime 2g IV every 6 hours), initiated within 1 hour of hospital arrival and ideally before lumbar puncture if the procedure will cause delay. 1

Immediate Priorities (First Hour)

Stabilization and Assessment

• Stabilize airway, breathing, and circulation immediately as the highest priority 1
• Document Glasgow Coma Scale (GCS) score for prognostic value and monitoring 1
• Obtain blood cultures within 1 hour of arrival, before antibiotics if possible 1
• Assess for signs of severe sepsis or shock: rapidly evolving rash, limb ischemia, cardiovascular instability, delayed capillary refill, cold/dusky extremities 1

Critical Care Decision

• Involve intensive care teams immediately if patient has: 1
  • Rapidly evolving rash
  • GCS ≤12 (or drop of >2 points)
  • Cardiovascular instability or severe sepsis
  • Uncontrolled seizures
  • Respiratory compromise or hypoxia
• Consider intubation for GCS <12 1

Antibiotic Therapy Algorithm

Empiric Treatment (Before Organism Identified)

For adults <60 years:

• Ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 1
• Add vancomycin 15-20 mg/kg IV every 12 hours if penicillin-resistant pneumococci suspected (recent travel from areas with high resistance) 1

For adults ≥60 years:

• Ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 1
• PLUS amoxicillin 2g IV every 4 hours (to cover Listeria monocytogenes) 1
• Add vancomycin if penicillin resistance suspected 1

Alternative for penicillin allergy:

• Chloramphenicol 25 mg/kg IV every 6 hours 1
• For patients ≥60 years, add co-trimoxazole 10-20 mg/kg (trimethoprim component) in 4 divided doses 1

Timing of Antibiotics vs. Lumbar Puncture

Patients WITHOUT severe sepsis/shock:

• Perform LP within 1 hour if safe to do so 1
• Start antibiotics immediately after LP, within first hour 1
• If LP cannot be performed within 1 hour, start antibiotics immediately after blood cultures 1

Patients WITH severe sepsis or rapidly evolving rash:

• Give antibiotics immediately after blood cultures 1
• Do NOT perform LP at this time 1
• Begin fluid resuscitation with 500 mL crystalloid bolus 1

Contraindications to Immediate LP (Require CT First)

• Focal neurological signs 1
• Papilledema 1
• Continuous or uncontrolled seizures 1
• GCS ≤12 1

Pathogen-Specific Treatment (After Identification)

Pneumococcal Meningitis

• Continue ceftriaxone 2g IV every 12 hours for 10-14 days 1
• If penicillin-sensitive (MIC ≤0.06 mg/L): benzylpenicillin 2.4g IV every 4 hours is acceptable alternative 1
• If penicillin AND cephalosporin resistant: continue ceftriaxone 2g every 12 hours PLUS vancomycin 15-20 mg/kg every 12 hours PLUS rifampicin 600 mg every 12 hours 1
• Stop at day 10 if recovered; continue to day 14 if not recovered or if resistant organism 1

Meningococcal Meningitis

• Continue ceftriaxone 2g IV every 12 hours for 5 days 1
• Alternative: benzylpenicillin 2.4g IV every 4 hours 1
• Give single dose ciprofloxacin 500 mg orally if patient not treated with ceftriaxone (for eradication) 1

Listeria Meningitis

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

Haemophilus influenzae Meningitis

• Ceftriaxone 2g IV every 12 hours for 10 days 1
• Alternative: moxifloxacin 400 mg IV daily 1

Adjunctive Dexamethasone

Dexamethasone should be administered before or with the first antibiotic dose in adults with suspected bacterial meningitis 1, 2. This reduces inflammation-mediated complications including cerebral edema, increased intracranial pressure, and neuronal injury 1.

Critical Pitfalls to Avoid

• Do NOT delay antibiotics for imaging or LP in patients with severe sepsis, shock, or rapidly evolving rash 1
• Do NOT be falsely reassured by low early warning scores - patients with meningococcal disease can deteriorate rapidly 1
• Do NOT forget Listeria coverage in patients ≥60 years - this requires amoxicillin, not covered by cephalosporins 1
• Do NOT use calcium-containing IV solutions with ceftriaxone due to precipitation risk 3
• Average time to antibiotics in bacterial meningitis is 136 minutes, but mortality increases with delays - aim for <60 minutes 1, 4

Infection Control

• Implement respiratory isolation immediately until meningococcal disease excluded or patient receives 24 hours of ceftriaxone 1
• Use droplet precautions and surgical masks for close contact 1
• Antibiotic prophylaxis for healthcare workers only if exposed to respiratory secretions during intubation/CPR without mask 1

Supportive Management

• Maintain euvolemia with crystalloids as initial fluid choice 1
• Target mean arterial pressure ≥65 mmHg 1
• Use norepinephrine as first-line vasopressor 1
• Consider hydrocortisone 200 mg daily for persistent hypotensive shock 1
• Do NOT restrict fluids to reduce cerebral edema 1
• Do NOT use therapeutic hypothermia - associated with increased mortality 1