Signs and Symptoms:
- Brudzinski sign and Kernig Sign
- Symptoms include fever, neck pain/stiffness, and photophobia. More non-specific symptoms include headache, dizziness, confusion, delirium, irritability, and nausea/vomiting. Signs of increased intracranial pressure have a worse prognosis.
- Can present with a rash. An erythematous macular and petechial rash in the extremities is associated with 3: Rocky Mountain Spotted Fever, syphilis, and meningococcus, but others can cause rashes too.
Tsai J, Nagel MA, Gilden D. Skin rash in meningitis and meningoencephalitis. Neurology. 2013 May 7;80(19):1808-11. doi: 10.1212/WNL.0b013e3182918cda. PMID: 23650233; PMCID: PMC3719428.
Treatment:
- Cover pseudomonas in penetrating trauma, post-surgical and shunts
- There is insufficient evidence to support the widespread use of steroids in bacterial meningitis. Some studies report a reduction in mortality for Streptococcus pneumoniae meningitis, but not in Haemophilus influenzae or Neisseria meningitidis meningitis. In children, steroids were associated with a reduction of severe hearing impairment only in cases of Haemophilus influenzae meningitis. Only continue if S. pneumonia. If used, administer the first dose of dexamethasone within 10-20 minutes before or concomitant with first antimicrobial dose.
- Bactrim can replace ampicillin in penicillin allergy
- Cefotaxime is more or less equivalent to ceftriaxone, but safe in neonates (ceftriaxone may case hyperbilirubinemia, and cannot be given with calcium containing solutions)
| Age | Antimicrobial Therapy | |
| < 1 month | Ampicillin plus cefotaxime; OR ampicillin plus an aminoglycoside Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes | |
| 1-23 months | Vancomycin + Ceftriaxone 100 mg/kg/day IV divided every 12 to 24 hours Streptococcus pneumoniae, Neisseria meningitidis, S. agalactiae, Haemophilus influenzae, E. coli | |
| 2-50 years | Vancomycin + Ceftriaxone 2g IV every 12h N. meningitidis, S. pneumoniae | |
| > 50 years | Vancomycin + Ceftriaxone 2g IV every 12h + Ampicillin 2g IV every 4h S. pneumoniae, N. meningitidis, Listeria monocytogenes, aerobic gram-negative bacilli | |
| Head traumas | ||
| Basilar skull fracture | Vancomycin + Ceftriaxone 2g IV every 12h S. pneumoniae, H. influenzae, group A beta-hemolytic streptococci | |
| Penetrating trauma | Vancomycin plus cefepime; OR vancomycin plus ceftazidime; OR vancomycin plus meropenem Staphylococcus aureus, coagulase-negative staphylococci (especially Staphylococcus epidermidis), aerobic gram-negative bacilli (including Pseudomonas aeruginosa) | |
| Post neurosurgery | Vancomycin plus cefepime; OR vancomycin plus ceftazidime; OR vancomycin plus meropenem Staphylococcus aureus, coagulase-negative staphylococci (especially Staphylococcus epidermidis), aerobic gram-negative bacilli (including Pseudomonas aeruginosa) | |
| Immunocompromised | Vancomycin plus ampicillin plus cefepime; OR vancomycin plus meropenem Staphylococcus aureus,S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gram-negative bacilli (including P. aeruginosa) | |
***Remember always treat for S. pneumoniae, N. meningitidis, vanc, except in newborns + a cephalosporin), listeria for the old and young (ampicillin)***
Cerebrospinal fluid makeup:
| Normal CSF | Syphilis* | Bacterial | Viral | |
| Does it Gram’s stain | No | Maybe | Yes | No |
| WBC (cells/mm3) | <5 | >20 | >1000 | <100 |
| Neutrophils | All monos | All monos | >80% | 1-50% |
| Glucose (mg/dL) | >40 | <40* | <40 | >40 |
| CSF:Serum Glucose | >0.4 | <0.4 | <0.4 | >0.4 |
| Protein (mg/dL) | <50 | >50 | >200 | >50 |
Cover pseudomonas in penetrating trauma, post-surgical and shunts: use vancomycin and cefepime 2 g IV every 8 hours or meropenem 2 g IV every 8 hours
Increased Intracranial Pressure:
If the patient develops clinical signs of increased intracranial pressure (altered mental status, neurologic deficits, non-reactive pupils, bradycardia), interventions to maintain cerebral perfusion include:
- Elevating the head of the bed to 30 degrees
- Inducing mild hyperventilation in the intubated patient
- Osmotic diuretics such as 25% mannitol or 3% saline
Prophylaxis:
If H. influenzae or N. meningitidis are cultured, household contacts and direct contacts should get prophylaxis.
N. meningitidis
- Rifampin 5-10 BID for 2 days in kids
- Rifampin 600 mg BID for 2 days in adults
- Ceftriaxone 125 mg IM times 1 < 15 years old
- Ceftriaxone 250 mg IM times 1 >15 years old
- Ciprofloxacin 20 mg/kg up to 500 mg times 1
H. influenzae
- Rifampin 20 mg/kg per dose up to 600 mg times 4 days
Factors affecting drug entry into the CSF:
