What is the recommended management of viral meningitis, including diagnostic work‑up, supportive care, use of antivirals, and discontinuation of empiric antibiotics?

Management of Viral Meningitis

Viral meningitis is primarily managed with supportive care, and empiric antibiotics should be discontinued once CSF analysis and PCR testing confirm a viral etiology and exclude bacterial infection. 1

Diagnostic Work-Up

Initial CSF Testing

• CSF should be tested by PCR for enteroviruses, HSV-1, HSV-2, and VZV in all suspected viral meningitis cases 1
• Additional viral PCR or serological testing should be guided by specific clinical features including immunocompromise status and travel history 1
• Stool and/or throat swabs should be tested for enterovirus by PCR to increase diagnostic yield 1

Critical Distinction from Bacterial Meningitis

• Distinguishing viral from bacterial meningitis is crucial because of different treatment approaches and outcomes 1, 2
• If altered consciousness is present, manage as suspected encephalitis or bacterial meningitis rather than simple viral meningitis 1, 2
• CSF profile in viral meningitis typically shows lymphocytic predominance, though partially treated bacterial meningitis can also present with lymphocyte predominance 3, 4

Discontinuation of Empiric Antibiotics

When to Stop Antibiotics

• Antibiotics can be safely discontinued once CSF PCR confirms a viral pathogen and CSF parameters are inconsistent with bacterial infection 1, 3
• Identifying a viral pathogen through PCR allows for cessation of antibiotics, reduces unnecessary investigations, and shortens hospital stay 1
• Do not discontinue antibiotics based solely on negative CSF cultures if clinical presentation and CSF parameters (elevated WBC, low glucose, high protein) suggest bacterial meningitis and the patient received antibiotics before lumbar puncture 3

Use of Antivirals

General Approach

• Most viral meningitis cases require only supportive care without antiviral therapy 2, 5
• Aciclovir/Valaciclovir should NOT be given as prophylaxis for recurrent herpes meningitis (HSV or VZV) 1

Specific Indication for Antivirals

• For confirmed HSV-2 meningitis, consider Aciclovir 10 mg/kg IV every 8 hours until resolution of fever and headache, followed by valaciclovir 1g three times daily to complete a 14-day course 2
• Antivirals are not indicated for enteroviral meningitis, which is the most common cause in the UK 1

Supportive Care

Symptom Management

• Analgesics such as acetaminophen and NSAIDs should be used for headache relief 2
• Adequate hydration and rest are essential components of supportive therapy 2, 5
• Monitor for neurological deterioration that might suggest encephalitis rather than meningitis 2

Psychological and Long-Term Support

• Although viral meningitis is rarely fatal in immunocompetent adults, it can cause significant morbidity and profound psychological impacts 1, 2
• Fatigue, sleep disorders, and emotional difficulties are frequently reported in weeks and months after discharge 1
• Early referral to mental health services should be considered, as emotional difficulties are well documented after acquired brain injury 1, 2
• Headaches occur in up to one-third of patients and may persist long-term 1, 2

Return to Activities

• Many patients feel well at discharge but cannot immediately return to normal activities 1, 2
• Support from hospital clinicians and GPs should facilitate staged return to work or studies on a part-time basis initially 1, 2
• Post-hospital follow-up should be offered to assess for sequelae that only become apparent after discharge 1

Common Pitfalls to Avoid

• Failing to distinguish between viral meningitis and encephalitis, which requires different management including empiric acyclovir 1, 2
• Assuming viral meningitis based solely on lymphocytic predominance in CSF, as partially treated bacterial meningitis can present identically 3, 4
• Overuse of antivirals in cases where they have not shown benefit, particularly for enteroviral meningitis 2
• Missing altered consciousness, which suggests bacterial meningitis, encephalitis, or other intracranial pathology rather than simple viral meningitis 1, 2
• Failing to provide adequate psychological support and follow-up care, which is often not routinely offered despite documented need 1