Meningitis

key points in management of suspected bacterial meningitis and meningococcal sepsis

If a non-blanching rash is present, give benzylpenicillin 1.2g IM/IV before admitting. investigations and treatment proceed in parallel.

Investigations

• Perform LP
  • without waiting for CT (not if GCS ≤12 or focal neurology).
  • Wait for clotting screen only if suspect coagulopathy.
  • Record opening pressure: 7–18cm CSF normal but increased in meningitis.
  • Send CSF for MC&S, protein, lactate, glucose, virology/PCR.
• Urea, Creatinine
• Electrolytes,
• CBC (low WBC ≈ immunocompromise: get help)
• LFT
• Glucose
• Coagulation
• Throat swabs (1 for bacteria, 1 for virology).
• CXR.
• Consider HIV, TB tests.

Management

• ABCs: IVI + fluid resus. Check and correct blood glucose

If Meningitic: (e.g. neck stiffness; photophobia) without shock

• Take blood cultures
• If Signs of increased ICP/shift of brain (papilledema, uncontrolled seizures, focal neurology, GCS ≤12)
• Get ICU help
• IV antibiotics (see below)
• Dexamethasone 10mg/6h IV
• Airway support
• Fluid resuscitation
• Delay LP until stable
• Nurse at 30°
• If No Signs of increased ICP/shift of brain
• Get senior help
• Perform LP ≤1h
• IV antibiotics (pre-LP, if LP delayed >1h) (see below)
• Dexamethasone 10mg/6h IV

If Septicemic: e.g. shock (prolonged capillary refill time; cold hands + feet; increased BP), evolving rash

• Get ICU help
• Take blood cultures
• IV antibiotics (see below)
• Airway support /pre-emptive intubation
• Fluid resuscitation/ionotropes/vasopressors (aim for: MAP >70mmHg; urine output >30mL/h)
• Delay LP until stable

Careful monitoring in both cases

Subsequent therapy: Discuss antibiotic (see below) therapy with microbiology and adjust based on organism and local sensitivities. Maintain normovolemia with IVI if needed. Isolate for 1st 24h. Inform Public Health.

Antibiotics

• Initiate early antibiotics.
• Take blood cultures first. Then perform LP prior to antibiotics only in patients where no evidence of shock, petechial rash or increased ICP and where able to obtain LP within 1h.
• Empirical options include ceftriaxone 2g/12h IV; add e.g. amoxicillin 2g/4h IV if >60yrs age or immunocompromised.

Prophylaxis

• Discuss with public health/ID
• Household contacts in droplet range
• Those who have kissed the patient’s mouth. Give ciprofloxacin (500mg oral, 1 dose; child 5–12yrs: 250mg; child <5yrs: 30mg/kg to max 125mg)