Author: Dr. Trevor Landas
Defined as inflammation of the meninges, or covering layers of the central nervous system, meningitis has a high morbidity and mortality if not identified and treated promptly. The incidence is approximately 1.38 per 100,000 people.
Clinical Presentation:
Presenting symptoms include the classic triad of fever, neck stiffness, and altered mental status, but the sensitivity of having all three is low at around 44% (Van de Beek 2006). Other symptoms include:
- Classic Triad: fever, nuchal rigidity, AMS
- Headache
- Focal neurological deficit
- Photophobia
Patients who present with the above symptoms and are also immunocompromised should have a thorough evaluation for meningitis.
Etiology:
| Category | Source |
| Bacterial | Streptococcus pneumoniae*, Neisseria meningitidis, Listeria monocytogenes, Haemophilus influenzae |
| Viral | Enterovirus*, Arbovirus, Herpes virus (HSV, VZV), HIV |
| Fungal | Cryptococcus neoformans, C. immitis, Aspergillus, Zygomycetes |
*Most common
Work-Up
If you have a high suspicion for meningitis, initiate treatment ASAP. The workup should not preclude treatment. With that said, the GOLD STANDARD for diagnosis is Lumbar Puncture. Before lumbar puncture, rule out any intracranial masses or brain shift that could lead to brain herniation during lumbar puncture with a CT head or MRI. Those who have neurological symptoms such as seizures, altered mental status, or are immunocompromised should get head imaging prior to lumbar puncture. Order set:
- Antibiotics +/- Antivirals
- CBC
- CMP
- POC Glucose
- PT/PTT
- CSF studies: Cell count, Gram Stain, Culture, Protein, Glucose
- Other septic workup studies
LUMBAR PUNCTURE TUTORIAL BY EMRAP.
CSF Analysis
Measure opening pressure.
Empiric Treatment
Viral:
IV Acyclovir
Bacterial:
Children:
< 1 month old: Ampicillin + [ Ceftazidime OR Gentamicin ] +/- Vancomycin
> 1 month old: Vancomycin + Ceftriaxone
Adult:
**Consider giving 0.15mg/kg of Dexamethasone with the first dose of antibiotics
Fungal Meningitis
Amphotericin B + Azole
Sources:
- Beek, Diederik Van De, et al. “Community-Acquired Bacterial Meningitis in Adults.” New England Journal of Medicine, vol. 354, no. 1, 2006, pp. 44–53., doi:10.1056/nejmra052116.
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