Bacterial meningitis

Antimicrobial prescribing: NHS Lothian
NHS Lothian

Viral meningitis is more common but peripheral markers such as CRP should not be relied on to differentiate from bacterial infection.

Lumbar puncture should be undertaken at the earliest opportunity to diagnose viral or bacterial meningitis.

All patients with suspected bacterial meningitis or meningococcal sepsis should be respiratory isolated until meningococcal meningitis or sepsis is excluded, the diagnosis is reviewed and thought unlikely, or they have received 24 hours of ceftriaxone.

  • If meningococcal disease/bacterial meningitis is suspected the team caring for the patient must contact the East Region Health Protection Team (0300 790 6264 or eos.eastregionhpt@nhs.scot) to deal with prophylaxis of contacts.
  • Clarify the history of penicillin allergy. If a history of severe penicillin allergy, then all beta-lactams, including cephalosporins, should be avoided. Avoiding ceftriaxone based on a non-urticarial rash with penicillins or minor intolerance can also be harmful.
  • Patients with lymphocytic meningitis, invasive pneumococcal disease or Listeria infection should be offered a HIV test.

Neuroimaging and lumbar puncture

Patients should not have neuroimaging before their LP unless there is a clinical indication suggestive of brain shift

  • Focal neurological signs
  • Presence of papilloedema
  • Continuous, uncontrolled or new-onset seizures
  • GCS ≤12

If prior neuroimaging is indicated an LP should be performed as soon as possible after the neuroimaging unless:

  1. Neuroimaging reveals significant brain shift
  2. An alternative diagnosis is established
  3. The patient’s clinical condition precludes an LP by having continued seizures, rapidly deteriorating GCS or cardiac/respiratory compromise
  4. Regardless of neuroimaging considerations LP should be delayed/avoided in the following situations:
    • Respiratory or cardiac compromise
    • Signs of severe sepsis or a rapidly evolving rash
    • Infection at the site of the LP
    • A coagulopathy

Recommended investigations

For detailed investigations, see CNS infection pathway

  • Blood culture
  • Pneumococcal and meningococcal PCR (EDTA blood sample)
  • Nasopharyngeal swab for meningococcal culture (C+S)
  • Lumbar puncture
    • Opening Pressure
    • Urgent microscopy - contact the laboratory and review the NHS Lothian bacteriology lab page here.
    • Culture and Sensitivity
    • Meningococcal and Pneumococcal PCR
    • Protein
    • Glucose (with paired serum glucose)
    • Viral PCRs
    • CSF lactate
  • HIV screen

Immediate treatment recommendations

Give Dexamethasone 9.9mg every 6 hours IV for 4 days to all patients treated for bacterial meningitis.

Steroids should be given ideally 15-20 minutes before or with first dose of antibiotic, but may be given up to 12 hours after starting antibiotics

 

Antibiotic recommendations

Ceftriaxone  2g every 12 hours IV

If patient >60 years, immunocompromised (including alcohol excess and diabetes), pregnant, or on steroids

ADD

Amoxicillin  2g every 4 hours IV    

Severe penicillin allergy

 

Option below may be considered or contact microbiology for alternative agents.

Chloramphenicol 25 mg/kg (max 2g) every 6 hours IV 

If patient >60 years, immunocompromised (including alcohol excess and diabetes), pregnant, or on steroids

ADD

Co-trimoxazole 30mg/kg (max 2.88g) every 6 hours IV

If patient has recently travelled to an area with a high prevalence of penicillin resistance:

  • Contact Microbiology for advice
  • Consider adding Vancomycin (using NHS Lothian calculator on the intranet) - target trough level 15-20mg/L

Recommended treatment by organism

S. pneumoniae 10-14 days

N. meningitidis 5-7 days

L. monocytogenes 21 days

H.influenza 10 days

Notes

Seek advice from infectious diseases if TB meningitis is considered possible.