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. 


BacterialStreptococcus pneumoniae*, Neisseria meningitidis, Listeria monocytogenes, Haemophilus influenzae
ViralEnterovirus*, Arbovirus, Herpes virus (HSV, VZV), HIV
FungalCryptococcus neoformans, C. immitis, Aspergillus, Zygomycetes

*Most common


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


CSF Analysis

Measure opening pressure. 

Empiric Treatment


IV Acyclovir



< 1 month old: Ampicillin + [ Ceftazidime OR Gentamicin ] +/- Vancomycin

> 1 month old: Vancomycin + Ceftriaxone


Source: 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.

**Consider giving 0.15mg/kg of Dexamethasone with the first dose of antibiotics

Fungal Meningitis

Amphotericin B + Azole


Leave a Reply