What is the recommended management and treatment for a patient with suspected meningitis?

Management of Suspected Bacterial Meningitis

Antibiotics must be administered within 1 hour of hospital arrival for all patients with suspected bacterial meningitis, as delays are strongly associated with increased mortality and poor neurological outcomes. 1

Immediate Priorities (First Hour)

Stabilization and Assessment

• Stabilize airway, breathing, and circulation immediately upon presentation 2
• Document Glasgow Coma Scale (GCS) score for prognostic value and monitoring 2
• Strongly consider intubation if GCS <12 1
• Obtain blood cultures before antibiotics, but do not delay antibiotic administration beyond 1 hour 2, 1

Decision Point: CT Scan Before Lumbar Puncture?

Perform CT scan before LP only if the patient has: 1

• Age ≥60 years
• Immunocompromised state
• History of CNS disease (mass lesion, stroke, focal infection)
• New-onset seizures
• Altered mental status
• Focal neurological deficits
• Papilledema

If no CT indications present: Proceed directly to lumbar puncture after starting antibiotics 1

If CT is indicated: Perform CT after antibiotics initiated; only do LP if CT shows no mass effect or elevated intracranial pressure 1

Empiric Antibiotic Regimens

Adults <60 Years (Immunocompetent)

Ceftriaxone 2g IV every 12 hours OR Cefotaxime 2g IV every 6 hours 2, 1, 3

PLUS

Vancomycin 15-20 mg/kg IV every 8-12 hours 1, 3

• Third-generation cephalosporins are the empirical antibiotics of choice due to proven bactericidal activity against pneumococci and meningococci with excellent CSF penetration 3
• Vancomycin should never be used as monotherapy due to concerns about CSF penetration 3

Adults ≥60 Years OR Immunocompromised

Same as above PLUS:

Ampicillin 2g IV every 4 hours (for Listeria monocytogenes coverage) 2, 1, 3

• Risk factors for Listeria include age >50 years, diabetes mellitus, immunosuppressive drugs, cancer, and other immunocompromising conditions 1
• Listeria remains fully susceptible to aminopenicillin 4

Special Consideration: Penicillin-Resistant Pneumococci

Add Vancomycin 15-20 mg/kg IV every 12 hours OR Rifampicin 600mg twice daily if: 2, 3

• Patient traveled to country with high penicillin-resistant pneumococci rates within last 6 months
• Check European Centre for Disease Prevention and Control or WHO websites for current resistance patterns 2

Alternative Regimen (Penicillin Allergy)

Chloramphenicol 25 mg/kg IV every 6 hours 2

PLUS

Co-trimoxazole 10-20 mg/kg (trimethoprim component) in four divided doses (if age ≥60 years) 2

Adjunctive Dexamethasone Therapy

Dexamethasone 10mg IV every 6 hours should be administered immediately before or simultaneously with the first antibiotic dose 1, 3

• Continue for 4 days if pneumococcal meningitis confirmed or probable 1
• Dexamethasone is the only proven adjunctive treatment and reduces mortality and neurological morbidity in pneumococcal meningitis 1
• Critical timing: Must be given with or before first antibiotic dose to be effective 3

Lumbar Puncture Considerations

If LP Performed Before Antibiotics:

• Send CSF for cell count, glucose, protein, Gram stain, and culture 1
• Administer antibiotics immediately after LP is completed, within the first hour 2

If LP Delayed or Contraindicated:

• Start empiric antibiotics immediately after blood cultures obtained 2, 1
• CSF findings (elevated WBC, decreased glucose, elevated protein) will still provide diagnostic evidence even after antibiotics started 1
• PCR can detect pathogens up to 9 days after antibiotics given, though antibiotic susceptibilities will not be available 2

Definitive Therapy (Once Organism Identified)

Streptococcus pneumoniae

• Continue ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 2
• If penicillin-sensitive (MIC ≤0.06 mg/L): May use benzylpenicillin 2.4g IV every 4 hours 2
• If penicillin and cephalosporin resistant: Continue ceftriaxone/cefotaxime PLUS vancomycin PLUS rifampicin 600mg IV/orally every 12 hours 2
• Duration: 10 days if recovered by day 10; 14 days if not recovered or if resistant organism 2

Neisseria meningitidis

• Continue ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 2
• Alternative: Benzylpenicillin 2.4g IV every 4 hours 2
• If not treated with ceftriaxone, give single dose ciprofloxacin 500mg orally for eradication 2, 1
• Duration: 5 days if recovered 2

Listeria monocytogenes

• Ampicillin 2g IV every 4 hours for 3 weeks 5
• PLUS gentamicin or co-trimoxazole 5

Pediatric Dosing

Neonates (≤28 days)

• Administer IV doses over 60 minutes to reduce risk of bilirubin encephalopathy 6
• Ceftriaxone contraindicated in premature neonates and those requiring calcium-containing IV solutions 6
• For bacterial meningitis: 100 mg/kg initial dose (not to exceed 4 grams), then 100 mg/kg/day (not to exceed 4 grams daily) 6

Children

• Cefotaxime or ceftriaxone PLUS vancomycin or rifampicin 1
• For meningitis: 100 mg/kg/day (not to exceed 4 grams daily) 6
• Duration: 7-14 days 6

Patients with Predominantly Sepsis or Rapidly Evolving Rash

This represents meningococcal sepsis—a medical emergency requiring different priorities: 2

• Give antibiotics immediately after blood cultures taken 2
• Start fluid resuscitation immediately with initial bolus of 500 mL crystalloid 2
• Follow Surviving Sepsis guidelines 2
• Do NOT perform LP at this time 2
• Involve intensive care teams early 1

Critical Care Transfer Criteria

Transfer to ICU if: 1

• Rapidly evolving rash
• GCS ≤12
• Cardiovascular instability or hypoxia
• Requiring monitoring or specific organ support

Common Pitfalls to Avoid

• Never delay antibiotics for imaging—start antibiotics first, then obtain CT if indicated 1
• Never use inadequate coverage—failing to add ampicillin for Listeria in patients ≥60 years or immunocompromised is a critical error 1
• Never use insufficient dosing—suboptimal antibiotic doses will not achieve adequate CSF penetration 1
• Never neglect blood cultures—but obtaining them should not delay antibiotics beyond 1 hour 1
• Never give vancomycin as monotherapy—it has poor CSF penetration, especially with dexamethasone 3
• Never use diluents containing calcium with ceftriaxone—precipitation can occur 6
• Never delay senior clinician review—most patients should be seen much earlier than the standard 14-hour timeframe 2

Administration Details

Ceftriaxone IV 6

• Administer over 30 minutes in adults (60 minutes in neonates)
• Concentrations between 10-40 mg/mL recommended
• Must not be administered simultaneously with calcium-containing IV solutions

Ampicillin IV 7

• For bacterial meningitis: 150-200 mg/kg/day in equally divided doses every 3-4 hours
• May initiate with IV drip therapy and continue with IM injections
• Use only freshly prepared solutions within one hour