Bacterial meningitis is an infection of the membranes around the brain and spinal cord, most often caused by Streptococcus pneumoniae or Neisseria meningitidis. It is a medical emergency, and antibiotics must not be delayed while waiting for tests.
Key symptoms
- Fever and severe headache
- Stiff neck
- Confusion, drowsiness or seizures
- Nausea, vomiting and discomfort with bright light
- Infants: poor feeding, irritability, bulging fontanelle
What you find on exam
- Vital signs; look for sepsis and shock
- Neck stiffness; Kernig and Brudzinski signs
- Level of consciousness with the Glasgow Coma Scale
- Petechial or purpuric rash (meningococcus)
- Focal neurologic signs and papilledema before lumbar puncture
Tests
- Blood cultures right away, before antibiotics
- Lumbar puncture: high opening pressure, many neutrophils, low glucose, high protein, Gram stain and culture
- CT head first if focal signs, papilledema, seizure, immunosuppression or reduced consciousness
- Blood count, lactate, coagulation tests, glucose
Treatment basics
- Empiric IV ceftriaxone plus vancomycin as soon as possible
- Add ampicillin if over 50, pregnant or immunocompromised (Listeria)
- Dexamethasone before or with the first antibiotic dose
- Supportive care: fluids, airway, seizure control
- Droplet precautions and prophylaxis for close contacts of meningococcal cases
Red flags
- Falling level of consciousness or seizures
- Spreading purple rash or signs of shock
- Any delay in antibiotics while waiting for CT or lumbar puncture
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; NASEMSO National Model EMS Clinical Guidelines. Written by Making Synapses. Making Synapses is not affiliated with these organizations.