AKT · Acute care/Neurological

Bacterial meningitis

Meningococcus, pneumococcus (adults); also Listeria, Hib

Overview

Infection of the meninges — a medical emergency. In the community a non-blanching rash (meningococcaemia) warrants immediate benzylpenicillin; in hospital, do not let an LP delay antibiotics. Empirical IV ceftriaxone (± amoxicillin for Listeria cover) is given fast.

Recognise

Fever, severe headache, neck stiffness, photophobia, vomiting; reduced GCS
Non-blanching petechial/purpuric rash (meningococcal septicaemia)
Kernig/Brudzinski signs; in infants: bulging fontanelle, poor feeding, irritability

Red flags

Non-blanching rash, septic shock, reduced GCS, focal signs/seizures → do not delay antibiotics; signs of raised ICP

Differentials & how to tell them apart

Subarachnoid haemorrhagethunderclap headache, no fever; CT/LP xanthochromia

Encephalitis (HSV)confusion/behaviour change, seizures → add aciclovir

Migraineno fever/meningism/rash

Septicaemia of other sourceno meningism; identify focus

Investigations

Blood cultures + LP (CSF microscopy/culture/PCR, glucose, protein) — but do not delay antibiotics; CT before LP only if raised-ICP/focal signs; meningococcal PCR.

Management

Community + non-blanching rash: benzylpenicillin now; hospital: IV ceftriaxone (± amoxicillin) ± dexamethasone

1Recognise meningism/rash. Community with suspected meningococcal disease → IM/IV benzylpenicillin immediately, transfer. Hospital → blood cultures then empirical IV ceftriaxone without delay.Gate: Do NOT delay antibiotics for the LP; perform CT before LP only if raised ICP/focal neurology/reduced GCS — otherwise LP can wait until after antibiotics
2Add amoxicillin if Listeria risk (>50/immunocompromised/pregnant); dexamethasone for suspected pneumococcal; notify public health; ciprofloxacin prophylaxis for close contacts.

IM/IV benzylpenicillin — community, if meningococcal disease suspected (non-blanching rash) — give immediately before transfer

IV ceftriaxone — empirical hospital treatment

IV amoxicillin — add if Listeria risk (>50y, immunocompromised, pregnant)

Dexamethasone — with/just before antibiotics in suspected pneumococcal meningitis (reduces complications)

Key points

Antibiotics before LP if it would cause delay. Notifiable disease — public health + contact prophylaxis. Dexamethasone helps in pneumococcal meningitis.

Monitor & prognosis

GCS, haemodynamics, repeat exam; CSF/PCR results; complications (hearing, seizures).

Meningococcal septicaemia can be rapidly fatal; early antibiotics are key.

Source: NICE NG240 (meningitis); notifiable disease