What are the subsequent steps if meningitis is suspected in a hospital patient?

Management of Suspected Meningitis in Hospital

When meningitis is suspected in a hospitalized patient, immediately start empiric antibiotics and dexamethasone within 1 hour of suspicion, obtain blood cultures first, and perform lumbar puncture unless contraindications exist—in which case obtain CT imaging first but do not delay antibiotics.

Immediate Actions (Within First Hour)

1. Stabilization and Assessment

• Assess airway, breathing, circulation, and document Glasgow Coma Scale (GCS) score immediately 1, 2
• Involve intensive care teams early if the patient has: 3
  • Rapidly evolving rash
  • GCS ≤12 or drop of >2 points
  • Cardiovascular instability or acid/base disturbance
  • Hypoxia or respiratory compromise
  • Frequent or uncontrolled seizures
  • Altered mental state
• Strongly consider intubation if GCS <12 3

2. Blood Cultures

• Obtain blood cultures before administering antibiotics—this is mandatory but should not delay antibiotic administration beyond 1 hour 1, 2

3. Determine Need for CT Before Lumbar Puncture

Perform CT head before lumbar puncture if ANY of the following are present: 1, 2

• Age ≥60 years
• Immunocompromised state
• History of CNS disease (mass lesion, stroke, focal infection)
• New-onset seizure (within 1 week)
• Altered mental status or GCS ≤12
• Focal neurological deficits
• Papilledema

If no contraindications exist, proceed directly to lumbar puncture after starting antibiotics 1

4. Start Empiric Antibiotics Immediately

Do not delay antibiotics waiting for imaging or lumbar puncture—delay is strongly associated with increased mortality and poor neurological outcomes 1, 2

Empiric Antibiotic Regimens by Age:

Adults <60 years:

• Ceftriaxone 2g IV every 12 hours OR Cefotaxime 2g IV every 6 hours 3, 1
• PLUS Vancomycin 15-20 mg/kg IV every 8-12 hours (target trough 15-20 mg/L) 3, 1

Adults ≥60 years or immunocompromised:

• Ceftriaxone 2g IV every 12 hours OR Cefotaxime 2g IV every 6 hours 3, 1
• PLUS Vancomycin 15-20 mg/kg IV every 8-12 hours 3, 1
• PLUS Amoxicillin 2g IV every 4 hours (for Listeria coverage) 3, 1

Special considerations:

• Add Vancomycin or Rifampicin 600mg twice daily if penicillin-resistant pneumococci suspected (e.g., recent travel to areas with high resistance) 3
• Alternative if severe penicillin allergy: Chloramphenicol 25 mg/kg every 6 hours 3

5. Adjunctive Dexamethasone

• Give Dexamethasone 10mg IV every 6 hours immediately before or simultaneously with first antibiotic dose 3, 1
• Can still be initiated up to 12 hours after first antibiotic dose if not given initially 3
• Continue for 4 days if pneumococcal meningitis confirmed or probable 3
• Stop dexamethasone if another cause confirmed 3

Lumbar Puncture

Timing

• Perform as soon as possible after antibiotics started, ideally within 4 hours to maximize culture yield 1
• If CT required, perform LP only after imaging shows no mass effect or elevated intracranial pressure 1, 2

CSF Studies to Send

• Cell count with differential 1, 2
• Glucose and protein 1, 2
• Gram stain and culture 1, 2
• Note: CSF findings (elevated WBC, decreased glucose, elevated protein) remain diagnostically useful even after antibiotics started, though culture yield may be reduced 1

Critical Care Transfer Criteria

Transfer to ICU if: 3

• Rapidly evolving rash
• GCS ≤12 or drop of >2 points
• Requiring monitoring or specific organ support
• Uncontrolled seizures
• Evidence of severe sepsis (manage per Surviving Sepsis guidelines)

Important: Patients with meningococcal sepsis may maintain blood pressure until late in disease, then deteriorate rapidly—assess for other signs of impaired perfusion (delayed capillary refill, cold/dusky extremities) 3

Definitive Antibiotic Therapy (Once Organism Identified)

Streptococcus pneumoniae

• If penicillin-sensitive (MIC ≤0.06 mg/L): Continue ceftriaxone/cefotaxime OR switch to benzylpenicillin 2.4g IV every 4 hours 3
• If penicillin-resistant but cephalosporin-sensitive: Continue ceftriaxone/cefotaxime 3
• If both penicillin and cephalosporin-resistant: Continue ceftriaxone/cefotaxime PLUS vancomycin PLUS rifampicin 600mg twice daily 3
• Duration: 10 days if recovered by day 10; 14 days if not recovered or if resistant organism 3

Neisseria meningitidis

• Continue ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 3
• Alternative: Benzylpenicillin 2.4g IV every 4 hours 3
• Give single dose ciprofloxacin 500mg PO if not treated with ceftriaxone (for eradication) 3
• Duration: 5 days if recovered 3

Listeria monocytogenes

• Amoxicillin 2g IV every 4 hours for 21 days 3
• Alternative if allergic: Co-trimoxazole 10-20 mg/kg (trimethoprim component) in 4 divided doses 3

Haemophilus influenzae

• Continue ceftriaxone or cefotaxime for 10 days 3

No organism identified

• If recovered by day 10, discontinue antibiotics 3

Common Pitfalls to Avoid

• Never delay antibiotics for imaging—this significantly increases mortality 1, 2
• Never perform LP before CT in patients with seizures, altered consciousness (GCS ≤12), focal deficits, or other contraindications—this risks cerebral herniation 1, 2, 4
• Do not fail to cover Listeria in patients ≥60 years or immunocompromised—add amoxicillin to empiric regimen 3, 1
• Do not use suboptimal antibiotic doses—high doses are required for adequate CSF penetration 1
• Do not forget to give dexamethasone with or before first antibiotic dose—this reduces mortality and neurological complications in pneumococcal meningitis 3, 1
• Do not underestimate severity based on initial vital signs—patients can deteriorate rapidly 3, 4

Outpatient Therapy Consideration

Once clinically stable, consider outpatient IV antibiotic therapy (OPAT) if patient: 3

• Is afebrile and clinically improving
• Has received 5 days of inpatient therapy
• Has reliable IV access
• Can access 24-hour medical advice
• Has no other acute medical needs

OPAT regimen: Ceftriaxone 2g twice daily IV (can use 4g once daily after first 24 hours) 3