COMMUNITY-ACQUIRED MENINGITIS

• Interval between patient's arrival and commencement of lumbar puncture (if indicated) and antimicrobial treatment (‘door-to-needle time’) should not exceed 1hr
• If bacterial meningitis strongly suspected, contact a consultant in infectious diseases

Symptoms and signs

• Headache, neck stiffness, photophobia
• Fever
• Impaired consciousness, coma and fits
• Clinical features of septicaemia or severe sepsis

Alert

• In the elderly, confusion can occur as the only symptom of meningitis in the absence of meningism or even of fever

Life-threatening features

• Altered consciousness
• Focal neurological deficit
• Raised intracranial pressure
• Convulsions
• Concurrent evidence of sepsis

Differential diagnosis

• Subarachnoid haemorrhage
• Other intracranial sepsis
• Systemic sepsis
• Other causes of confusion or of raised intracranial pressure
• Encephalitis
• look for symptoms of confusion, seizures, dysphasia or reduced conscious level
• Malaria in travellers

Penicillin Allergy

• True penicillin allergy is rare
• Ask the patient and record what happened when they were given penicillin
• If any doubt about whether patient is truly allergic to penicillin, seek advice from a microbiologist or consultant in infectious diseases

Infection Control alerts

• Check for IC alert.
• If IC alert not available, check previous 12 months of microbiology reports
• If MRSA present, treat as tagged for MRSA. See MRSA management
• If ESBL, MGNB, CARB present, treat as tagged for ESBL. See ESBL/MGNB/CARB management

Immediate management

Immediate management tool

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Investigations

• CSF
• if there are no clinical contraindications, perform lumbar puncture immediately. See Lumbar puncture guideline
• if there are no clinical contraindications to LP, CT scan is not indicated
• FBC, differential WBC and coagulation screen
• U&E, glucose and CRP
• Chest X-ray

Microbiology

• Throat swab (Include suspected meningococcal meningitis in clinical details. Take separate swabs for MRSA screening)
• Blood culture
• Meningococcal/pneumococcal PCR (EDTA tube)
• Urinary pneumococcal antigen

CSF results

CSF acellular

• Stop antimicrobials and corticosteroids and seek alternative diagnosis

CSF shows neutrophil predominance

• Continue dexamethasone (Hameln brand) 3.3 mg IV or 4 mg oral 6-hrly
• Continue antimicrobials
• if anaphylaxis to penicillin/ cephalosporin, contact consultant microbiologist/ ID
• if no anaphylaxis to penicillin/ cephalosporin, continue ceftriaxone 2 g by IV infusion 12-hrly. If aged >60 yr, pregnant or with impaired cellular immunity, add amoxicillin 2 g by IV infusion 4-hrly

CSF shows lymphocyte predominance

• Consider stopping antimicrobials and dexamethasone
• Consider other diagnoses (e.g. viral meningitis, tuberculous meningitis). Discuss with consultant +/- infectious disease team

Notification

• Notify cases of suspected community-acquired meningitis immediately to consultant in communicable disease control to discuss need for prevention of secondary cases

• Neurological observations, including GCS, every 15 min in severe cases initially, then at decreasing intervals as recovers

• If bacterial meningitis proven or probable, continue antimicrobial treatment for 7 days, then review
• if meningococci isolated, treat for 7 days, then review
• if pneumococci isolated, treat for 14 days, then review
• if other organisms isolated contact consultant microbiologist/ ID
• Withdraw dexamethasone after 48 hr unless specific indication to continue (e.g. TB meningitis)
• If encephalitis is not/no longer suspected, it is not necessary to continue aciclovir until a negative HSV PCR test result has been received

• Follow-up in clinic to check for hearing loss
• Refer patients with persisting neurological deficit to appropriate specialist for rehabilitation:
• aged <65 yr – rehabilitation department
• aged ≥65 yr – consultant geriatrician linked to medical firm