How should I treat a patient of any age presenting with acute meningococcal meningitis (fever, severe headache, neck stiffness, photophobia, altered mental status, petechial rash)?

Treatment of Acute Meningococcal Meningitis

Immediately administer a third-generation cephalosporin (ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours) plus dexamethasone 10mg IV every 6 hours, starting antibiotics within 1 hour of hospital arrival and ideally within 3 hours of first medical contact. 1, 2

Immediate Actions (First Hour)

Antibiotic Therapy - Do Not Delay

• Start empiric antibiotics immediately after obtaining blood cultures, but do not wait beyond 1 hour of hospital arrival 2

• Do not delay antibiotics for lumbar puncture or neuroimaging 1, 3

• Preferred regimen for adults <60 years:

  • Ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 1
  • Alternative if penicillin allergy: Chloramphenicol 25mg/kg IV every 6 hours 1

• For adults ≥60 years, add:

  • Amoxicillin 2g IV every 4 hours (for Listeria coverage) 1

• If penicillin-resistant pneumococcus suspected (recent travel to high-resistance areas):

  • Add vancomycin 15-20mg/kg IV every 12 hours OR rifampicin 600mg IV/PO every 12 hours 1

Adjunctive Dexamethasone - Critical for Outcome

• Administer dexamethasone 10mg IV every 6 hours either shortly before or simultaneously with the first antibiotic dose 1
• Can still be initiated up to 12 hours after first antibiotic dose if not given initially 1
• Continue for 4 days if meningococcal or pneumococcal meningitis confirmed 1
• Stop dexamethasone if another cause is identified 1

Blood Cultures and Initial Stabilization

• Obtain blood cultures within 1 hour before antibiotics, but never delay treatment beyond this window 2, 3
• Assess airway, breathing, circulation 2
• Record Glasgow Coma Scale score 2

Lumbar Puncture Decision Algorithm

Contraindications to Immediate LP - Perform CT First 1, 2

• Glasgow Coma Scale ≤12 or inability to follow commands
• Focal neurological signs (gaze palsy, facial weakness, limb weakness)
• Papilledema on fundoscopy
• Continuous or uncontrolled seizures
• New seizure within past week
• Immunocompromised state or prior CNS disease

When LP is Safe

• Perform within 1 hour if no contraindications and patient is not in shock 2
• In patients with sepsis or rapidly evolving petechial rash, give antibiotics immediately after blood cultures—do not wait for LP 2

Fluid Resuscitation and Hemodynamic Management

For Meningococcal Sepsis

• Begin immediate fluid resuscitation with 500mL crystalloid bolus if sepsis present 2
• Monitor therapeutic endpoints: capillary refill <2 seconds, normal blood pressure, urine output >0.5mL/kg/hour, lactate <2mmol/L 2
• Maintain euvolemia to support normal hemodynamic parameters 1
• Common pitfall: Patients with meningococcal sepsis maintain blood pressure until late in disease, then deteriorate rapidly—examine for delayed capillary refill, dusky or cold extremities 1

Vasopressor Support

• Required if shock does not respond to initial fluid challenges 2

Critical Care Referral - Early Involvement Essential

Transfer to intensive care if: 1

• Rapidly evolving petechial/purpuric rash
• GCS ≤12 or drop of >2 points
• Cardiovascular instability, acid/base disturbance, hypoxia
• Respiratory compromise
• Frequent or uncontrolled seizures
• Evidence of limb ischemia
• Altered mental state

Strongly consider intubation if GCS <12 1

Duration of Antibiotic Therapy

Once Neisseria meningitidis Confirmed

• Meningococcal resistance to penicillin is extremely rare 1
• Continue third-generation cephalosporin for standard duration (typically 5-7 days based on clinical response) 1
• If pneumococcal meningitis confirmed and patient recovered by day 10, stop treatment 1

Adjunctive Therapies to AVOID

• Do NOT use glycerol—trials showed increased mortality in adults 1
• Do NOT use therapeutic hypothermia—trial stopped early due to excess mortality 1
• Avoid fluid restriction, as it does not improve outcomes 1

Infection Control and Prophylaxis

Isolation

• Implement droplet precautions immediately 2
• Isolate for 5 days after onset of symptoms 2

Chemoprophylaxis for Close Contacts

• Offer to household members, dormitory roommates, intimate contacts who had prolonged contact within 7 days before illness onset 2
• Effective regimens: ciprofloxacin, rifampin, or ceftriaxone 2

Vaccination

• Offer meningococcal vaccination before hospital discharge 2

Key Clinical Pitfalls

• The classic triad (fever, neck stiffness, altered consciousness) is present in <50% of cases 2
• Kernig's and Brudzinski's signs are unreliable and should not guide treatment decisions 2, 3
• Only 63% of patients with meningococcal meningitis have a rash 2
• Elderly patients may present atypically with altered mental status rather than fever or neck stiffness 2
• Never delay antibiotics for diagnostic procedures—mortality increases with each hour of delay 1, 3