INITIAL MANAGEMENT OF
SUSPECTED BACTERIAL
MENINGITIS
Stephanie Singson PGY2
Case


Mr. B is a 70 year old M evaluated in the ED for a
1-day history of fever and altered mental status.
PMH is notable for CAD and HTN on HCTZ, ASA,
Lisinopril, and Atenolol.
On physical exam, T 38.3C (101F), BP 96/52, HR
101/min, RR 20/min. Patient is confused and
oriented only to person. Neurologic exam is
nonfocal.
Objectives

Identify patient
Initial presentation
 Signs of meningeal irritation


Diagnostics
Role of CT
 LP: CSF Analysis



Microbiology review
Treatment
Antibiotic regimen
 Role of steroids

Initial Presentation



Triad of fever, nuchal rigidity, change in mental
status.
In a 2004 review of >600 cases, only 44% had the
clinical triad. 99% had at least one classic feature.
Other common complaints include headache,
nausea, vomiting and photophobia.
Physical Exam:
Signs of Meningeal Irritation



Brudzinski sign: Involuntary flexion of the hips with neck
flexion.
Kernig sign: Resistance with knee extension. Patient is
supine, with hip and knee flexed to about 90 degrees.
Studies report a wide range of sensitivities for both tests
(5-39%) although specificity is high >95%.
To CT or Not to CT?

Based on IDSA guidelines for 2004, a CT scan of
the head before LP should be done in patients who
have one or more risk factors:
 Immunocompromised
state
 History of CNS disease
 New onset seizure
 Papilledema
 Abnormal level of consciousness
 Focal neurological deficit
LP: CSF Analysis





Opening pressure: 200-500 mm H2O
WBC count: 1000-5000/microL with a percentage
of neutrophils >80%
Protein: 100-500mg/dL
Glucose: <40mg/dL
Gram stain and culture
The Usual Suspects

Major causes of community acquired bacterial
meningitis in developed countries:
 Streptococcus
pneumoniae
 Neisseria meningitidis
 Listeria monocytogenes in patients >50 years old or
who have deficiencies in cell-mediated immunity
The Usual Suspects cont.

Major causes of healthcare-associated bacterial
meningitis:
 Staphylococci
 Aerobic
gram-negative bacilla (Pseudomonas,
Klebsiella)
Initial Treatment:
Community Acquired
•
Vancomycin 15-20mg/kg IV q8-12h
•
•
PLUS Third generation Cephalosporin (Ceftriaxone 2g IV
q12h or Cefotaxime 2g IV q4-6h )
•
•
Adjust to achieve trough of 15-20mcg/mL
Note: Increased dose of Cephalosporin compared to standard
antibiotic dose
ADD Ampicillin 2g IV q4h to cover Listeria
Initial Treatment:
Healthcare-associated
•
Vancomycin 15-20mg/kg IV q8-12h
•
•
•
Adjust to achieve trough of 15-20mcg/mL
PLUS Cefepime 2g IV q8h OR Meropenem 2g IV q8h to
cover Pseudomonas aeruginosa and Klebsiella pneumoniae
Think recent neurosurgery, complicated head trauma
Role of Steroids

Adjunct Dexamethasone 0.15mg/kg IV q6h to
prevent neurologic complications given before or
at the same time as the first dose of antibiotics
(Grade 1B).
Suspected bacterial meningitis
Fever, nuchal rigidity, AMS
Obtain blood cultures, head CT (if
indicated), lumbar puncture
Community acquired
Recent neurosurgery
Complicated head trauma
Dexamethasone 0.15mg/kg IV q6h
Vancomycin
+
Ceftriaxone or
Cefotaxime
+/Ampicillin
Vancomycin
+
Cefepime or
Meropenem
(For Pseudomonas and
Klebsiella coverage)
(Age >50 or
immunocomrpomised )
Await culture results
for targeted therapy
Back to the Case:


Mr. B is a 70 year old M evaluated in the ED for a
1-day history of fever and altered mental status.
PMH is notable for CAD and HTN on HCTZ, ASA,
Lisinopril, and Atenolol.
On physical exam, T 38.3C (101F), BP 96/52, HR
101/min, RR 20/min. Patient is confused and
oriented only to person. Neurologic exam is
nonfocal.
How would you manage Mr. B?
Non-contrast head CT
Indication: Abnormal level of consciousness
Result: Negative for bleed or acute abnormality
Draw blood cultures. Perform LP.
Result:
Opening pressure 300 mmH2O
Leukocyte count 1200/uL 60% neutrophils, 40%
lymphocytes
Glucose level 30mg/dL
Protein level 350mg/dL
Gram stain negative
Administer: Dexamethasone, Vancomycin, Ceftriaxone, and
Ampicillin (Age> 50)
Await culture results to titrate antibiotic regimen and
determine duration of treatment
Summary





Consider bacterial meningitis in a patient with fever and
AMS, with or without signs of meningeal irritation.
Consider head CT before LP based on IDSA
recommendations.
Perform blood cultures and LP prior to administering IV
antibiotics.
Administer Dexamethasone with first dose or prior to IV
antibiotics.
Mortality rate of untreated disease approaches 100%.
References





LeBlond RF, Brown DD, Suneja M, Szot JF. The Nervous System. In: LeBlond RF, Brown
DD, Suneja M, Szot JF. eds. DeGowin’s Diagnostic Examination, 10e. New York, NY:
McGraw-Hill; 2014. http://accessmedicine.mhmedical.com. Accessed February 22,
2015.
Roos KL, Tyler KL. Chapter 381. Meningitis, Encephalitis, Brain Abscess, and
Empyema. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds.
Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.
http://accessmedicine.mhmedical.com. Accessed February 20, 2015.
Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig's
sign, Brudzinski's sign, and nuchal rigidity in adults with suspected meningitis. Clin
Infect Dis 2002; 35:46.
Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of
bacterial meningitis. Clin Infect Dis 2004; 39:1267.
www.uptodate.com