western Australian Therapeutics Advisory Group

Early MANAGEMENT OF
ADULT BACTERIAL MENINGITIS
• Does not apply to neurosurgical and immunocompromised patients as different antibiotics are required.
• Discussion with a Clinical Microbiologist or ID Physician is recommended.
• The clinical status may change following initial assessment. In all instances use clinical judgement.

CLINICAL FEATURES SUGGESTIVE OF MENINGITIS If meningococcal septicaemia

q Headache, vomiting, neck stiffness, fever, q No lumbar puncture
photophobia q Blood culture and EDTA blood for
q Petechial/purpuric non-blanching rash PCR
q 2g IV ceftriaxone b.d.
q Intensive monitoring

IMMEDIATE MANAGEMENT
q Airway
q Breathing – respiratory rate, O2 saturation
q Circulation – pulse, BP, urine output INITIAL INVESTIGATIONS
q Mental status q Full blood picture, coagulation profile
q Neurology – focal neurological signs, seizures, q Blood gases
papilloedema q Urea and electrolytes, liver function, glucose level
q Blood cultures, throat swab (bacterial culture),
EDTA blood PCR

SIGNS OF SHOCK/RESPIRATORY FAILURE SIGNS OF RAISED INTRA-CRANIAL OTHER CONTRAINDICATION TO LUMBAR

Warning signs include: PRESSURE PUNCTURE
q Rapidly progressive rash Warning signs include: Includes:
q Poor peripheral circulation, oliguria q Depressed or fluctuating conscious q Anticoagulant therapy
q Acidosis pH < 7.3 or BE worse than -5 level q Bleeding diathesis
q Respiratory rate < 8 or > 30 q Focal neurological signs q Signs of localised spinal sepsis
q Pulse rate < 40 or > 140 q New onset seizure
q White blood cell count < 4x109/L q Bradycardia and hypertension
q Papilloedema

YES NO

DEFER LUMBAR PUNCTURE LUMBAR PUNCTURE* * CSF FINDINGS

GIVE DEXAMETHASONE GIVE DEXAMETHASONE TYPICAL OF BACTERIAL
(UNLESS SEPTIC SHOCK) THEN THEN ANTIBIOTICS MENINGITIS
ANTIBIOTICS q White blood cell
dexamethasone 10mg IV 6hrly count > 500 cells
CONSIDER CT SCAN x106/L
MANAGE IN CRITICAL CARE UNIT THEN q Glucose < 50% of
ceftriaxone 2g IV 12 hourly plasma level
q Raised protein level
AND (> 0.45g/L)
vancomycin 1g IV 12 hourly
AND
ALL PATIENTS REQUIRE CAREFUL Adjust antibiotics and
benzylpenicillin 2.4g IV 4 hourly
MONITORING AND REPEATED REVIEW duration of therapy on
basis of microbiology
results. Refer to
Therapeutic Guidelines:
Antibiotic.
ADDITIONAL INFORMATION Cease dexamethasone
q Do not withhold antibiotics if LP cannot be done immediately if non-pneumococcal
q Contact local Public Health Department if probable/confirmed pathogen identified,
meningococcal disease for prophylaxis of contacts otherwise continue for 4
q Isolate patient for first 24 hours if possible days.

References. Therapeutic Guidelines: Antibiotic, Version 13, 2006.

Early management of suspected bacterial meningitis and meningococcal septicaemia in immunocompetent adults, British
RPH70226014

Infection Society, 2nd Edition 2003.

www.watag.org.au Practice guidelines for the management of bacterial meningitis, Infectious Diseases Society of America, 2004.