How do you manage a patient with meningitis?

Resuscitation & Supportive Management
  • Ensure appropriate staff available to manage patient
  • ABC approach treating abnormalities as found:
  • Consider need for intubation for airway protection:
    • Strongly consider if GCS <12
  • Maintain adequate blood pressure aiming MAP {{gt}65mmHg:
    • Ensure euvolemia with crystalloids as first-line fluid
    • Noradrenaline or vasopressin first-line vasopressor agents
    • Albumin replacement fluid and hydrocortisone 200mg should be considered if hypotensive shock despite initial corrective measures
  • Treat suspected or proven seizures early:
    • EEG monitoring useful in suspected or proven seizures or those with fluctuant GCS
  • Treat suspected or proven raised intracranial pressure:
    • Ensure basic (tier 1) therapy is instigated to control ICP and maintain cerebral perfusion
    • Routine monitoring of ICP not routinely recommended
  • Manage bleeding and overt DIC
Specific Management
  • Ensure antibiotics given immediately:
    • Should be given within 1 hour of diagnosis
    • Don't wait for identification of organism or delay for CT/LP
    • Aim to take blood cultures before administration
  • Treat with appropriate empiric antibiotic therapy initially:
    • Neonates (<1 month):
      • Cefotaxime plus amoxicillin/ampicillin/penicillin
    • Children 1month-18 years:
      • Cefotaxime or ceftriaxone
      • If suspected resistance to penicillin (recently travelled to at risk country), add vancomycin or rifampicin
    • Adults:
      • Cefotaxime 2 g 6 hourly or ceftriaxone 2 g 12 hourly
      • If >60, add amoxicillin 2g 4 hourly in those >60 to cover listeria
      • If suspected resistance to penicillin (recently travelled to at risk country), add vancomycin or rifampicin
  • Target antibiotic therapy subsequently if organisms isolated
  • Commence steroid therapy in suspected bacterial meningitis:
    • 10 mg dexamethasone IV 6 hourly
    • Commence on admission, either shortly before or simultaneously with antibiotics
    • If pneumococcal meningitis is confirmed or probable, continue for 4 days
  • If viral meningitis is suspected, aciclovir or valaciclovir may be beneficial
Referral & Deposition
  • Consider critical care admission if:
    • Evidence of meningococcal sepsis
    • Cardiovascular instability
    • Frequent seizures
    • Altered mental status
  • Notify relevant public health authority of all suspected cases regardless of aetiology:
    • Acute meningitis is a notifiable disease in the UK