Last Updated on February 16, 2019 by FRCEM Intermediate

Causes

• Neisseria meningitis, Streptococcus pneumoniae, and Haemophilus influenza type b (Hib) are the most common causative organisms of acute bacterial meningitis in children aged 3 months or older and adults.
• In neonates (younger than one month of age), Streptococcus agalactiae, Escherichia coli, S. pneumoniae, and Listeria monocytogenes are the most common causative organisms

Clinical features

History

• malaise
• fever
• headache
• vomiting
• stiff neck
• risk factors

Examination

• non-blanching rash
• normal -> altered LOC -> coma
• meningism
• head jolt accentuation test (lateral head rotation worsens headache = very sensitive)
• Kernig’s sign
• Brudzinski’s sign
• papilloedema (indicates raised ICP)
• tense fontanelle in babies
• focal neurological deficit
• shock

Investigations

• Bloods – FBC and CRP
• Blood cultures
• Blood PCR testing for N. meningitidis and S. pneumoniae
• CT Head first if:
  • Abnormal mental states
  • new onset seizures
  • immunocompromised
  • GCS < 10 focal neurological signs in keeping with a space occupying lesion.
  • Signs suggesting raised intracranial pressure.
• Perform a lumbar puncture unless contraindicated.do not delay antibiotics
  • Contraindications for LP
    • GCS 8 or less or deteriorating
    • Focal neurological signs or abnormal posture
    • Prolonged seizure lasting 10 minutes or more and a GCS of 12 or less
    • Shock
    • Systemic meningococcal disease
    • Signs of raised intracranial pressure: unilateral or bilateral dilated pupils or sluggish pupillary reaction
    • Bradycardia or hypertension Abnormal breathing pattern

Treatment

• out of the hospital, a single dose of benzylpenicillin (IM or IV)
• Empirical antibiotics for suspected bacterial meningitis (ideally following LP, but do not delay > 30 minutes):
  • All adult patients should receive their first dose of 2G Ceftriaxone
  • For adults aged over 50 years or immunocompromised, add IV ampicillin PLUS Gentamicin
  • Children < 3 months – Cefotaxime 80 mg/kg IV + amoxicillin/ampicillin
  • Children ≥ 3 months – Ceftriaxone 80 mg/kg IV
• If herpes simplex meningoencephalitis is part of the differential diagnosis give appropriate antiviral treatment
• Give dexamethasone (0.15 mg/kg to a maximum dose of 10 mg)-with or before the first dose of antibiotics.
  • If dexamethasone was not given before or with the first dose of antibiotics, but was indicated, try to administer the first dose within 4 hours of starting antibiotics, but do not start dexamethasone more than 12 hours after starting antibiotics.
  • Do not use corticosteroids in children younger than 3 months with suspected or confrmed bacterial meningitis.

Control of Infection Action

• The patient should be admitted to a side-room and barrier nursed
• requires droplet precautions
• Contact the Hospital Control of Infection team.
• Arrange for treatment of patient and prophylaxis of appropriate contacts
• Contact Community Health Service appropriate to the residence of your patient

Prophylaxis

Prophylaxis is recommended for

• Family contacts.
• Kissing contacts.
• Children under five who have attended a party at which a child was incubating the infection.
• Children under five in the same crèche (not school) class.
• Health care workers only recommended chemoprophylaxis if “mouth or nose is directly exposed to respiratory droplets and/or secretions from a case of meningococcal disease”.

Prophylactic Drugs: Either rifampicin or ciprofloxacin

Complications

• Hearing loss
• Seizures
• Motor deficit
• Cognitive impairment
• Hydrocephalus
• Visual disturbance