Treatment Guideline Chart

Acute meningitis is the infection of the subarachnoid space and cerebrospinal fluid by bacteria that may cause local and systemic inflammatory response.
There is the classic triad of symptoms of fever, neck stiffness and altered level of consciousness.
Other symptoms include chills, myalgia, photophobia, severe headache, focal neurologic symptoms, nausea, vomiting, seizures and some patients may present with rash.


Meningitis%20-%20acute,%20bacterial Diagnosis


  • Perform a complete neurologic exam, including a mental status exam

Look for Signs of Meningeal Irritation

Neck Stiffness

  • Examine the neck for rigidity by gentle forward flexion with the patient in supine position

Kernig Sign

  • Position of patient: Supine with the hip flexed at 90o
  • Positive when extension of the knee from this position elicits resistance or pain in the lower back or posterior thigh

Brudzinski Sign

  • Position of patient: Supine
  • Positive when passive neck flexion results in spontaneous flexion of the knees and hips

Contralateral Reflex

  • Position of patient: Supine
  • Positive when passive flexion of one hip and knee causes flexion of the contralateral leg

Look for Signs of Increased Intracranial Pressure (ICP)

  • Altered level of consciousness (eg stupor or coma)
  • Dilated, poorly reactive, or nonreactive pupils
  • Ocular movement disorders (eg abducens nerve palsy)
  • Cushing reflex: Bradycardia, hypertension and irregular breathing
  • Papilledema on fundoscopic exam
  • Projectile vomiting
  • Decerebrate posturing

Other Signs and Symptoms

  • Some patients may not present with the classic signs, eg alcoholics, patients who are immunocompromised and who had meningitis after surgery


  • Neonates with bacterial meningitis usually do not have meningismus
  • They can present with temperature instability, jaundice, vomiting, diarrhea, respiratory distress, high-pitched crying, lethargy, refusal to eat and changes in affect and state of alertness
  • Bulging fontanelle may occur late in the illness
  • Seizures commonly reported among those with group B streptococcal meningitis

Children 1-4 Years Old

  • Fever, chills, vomiting, photophobia, severe headache and nuchal rigidity are the most common initial symptoms


  • May present with lethargy or obtundation, no fever and variable signs of meningeal inflammation; they may also suffer antecedent or concurrent respiratory infections

Laboratory Tests

Lumbar Puncture (LP) and Cerebrospinal Fluid (CSF) Exams
  • A diagnostic mainstay, perform a LP promptly and send cerebrospinal fluid specimens for exams, to facilitate initiation of appropriate therapy
    • If signs of increased ICP or a mass are present, consider treating the condition first then do neuroimaging before doing LP to decrease risk of brain herniation (Please see Non-Pharmacological Therapy section)
    • Presence of the following should prompt delay in performing LP:
      • Presence of signs of severe sepsis or rapidly evolving rash
      • Respiratory or cardiac compromise
      • Treatment with an anticoagulant, antiplatelet, or if with known thrombocytopenia or clotting abnormality
      • Infection at lumbar puncture site
  • CSF formula:
    • Cell count
    • Glucose <40 mg/dL
    • Protein >50 mg/dL
Findings Suggestive of Bacterial/Purulent Meningitis
  • Elevated opening pressure (>100-200 mmHg)
  • Neutrophilic pleocytosis
  • Decreased glucose levels (hypoglycorrachia) and CSF/serum glucose ratio
  • Elevated protein levels [100-500 mg/dL indicates injury to the blood-brain barrier (BBB)]
  • Elevated lactate levels
Gram Stain and Culture
  • 105 CFU/mL of bacteria should be present for Gram stain to be reliable
  • Gram stain is a cheap and important tool for diagnosis, however, sensitivity varies by age group, type of pathogen and antibiotic used previously
  • CSF culture is the gold standard in the diagnosis of bacterial meningitis, however, results may take time

Antigen/Antibody Tests

  • Eg pneumococcal bacterial antigen tests (BAT), latex agglutination test, cryptococcal antigen latex agglutination system (CALAS), immunochromatographic antigen test
    • Make use of serum containing bacterial antibodies or commercially available antisera directed against capsular polysaccharides of meningeal pathogens
  • BAT is reserved for patients whose initial CSF Gram stain is negative or CSF culture is negative after 48 hours of incubation
    • Pneumococcal BAT have a sensitivity for pneumococcal meningitis between 67-100% and a specificity of >95%
  • Latex agglutination is a rapid diagnostic tool to determine the causative pathogen
    • Sensitivity varies for each causative pathogen: 78-100% for H influenzae, 22-93% for N meningitidis, and 59-100% for S pneumoniae
    • Sensitivity decreases when empiric treatment is started before lumbar puncture
  • Rapid immunochromatographic antigen test (eg S pneumoniae BinaxNOW®) has 99-100% sensitivity and specificity for pneumococcal meningitis
Other Tests (As Warranted)
  • Acid-fast bacilli (AFB) smear and tuberculosis culture, India ink, polymerase chain reaction (PCR), tissue culture, Limulus lysate test, counter immunoelectrophoresis, metagenomic next-generation sequencing (mNGS)
  • Multiplex PCR is a rapid, non-culture based method with sensitivity of 90% and specificity of 97%
Blood Cultures (BCs)
  • Used to detect causative organism and establish susceptibility patterns when the cerebrospinal fluid cultures are negative or not available
  • Obtain blood culture before instituting empiric antibiotic therapy is recommended
Other Exams
  • Complete blood count (CBC), fibrin degradation products (FDP)
  • C-reactive protein (CRP) and serum procalcitonin
  • Urine osmolality and sodium (Na), plasma osmolality
  • Blood sugar


Head Computed Tomography (CT) Scan
  • If a patient has the following: focal neurologic findings (excluding cranial nerve palsies), new-onset seizures, severely immunocompromised state, papilledema or presents with coma, perform a head CT scan prior to doing a lumbar puncture (LP) to rule out the presence of intracranial mass lesions because of the potential risk for herniation
  • CT prior to LP is also recommended in immunocompromised patients [human immunodeficiency virus (HIV), acquired immune deficiency syndrome (AIDS), patients on immunosuppressive therapy, after transplantation], patients with history of central nervous system disease and those with new-onset seizure within 1 week prior to presentation
  • Blood cultures should be sent and empirical antimicrobial therapy should be initiated prior to CT scan
    • Starting antimicrobial therapy 1-2 hours prior to LP is not thought to decrease the diagnostic sensitivity of the cerebrospinal fluid (CSF) study
    • Blood cultures, test for bacterial antigens and CSF formula will still provide evidence for or against the presence of meningitis
Other Exams
  • Magnetic resonance imaging (MRI) with gadolinium enhancement and diffusion-weighted imaging may be used for patients with meningitis secondary to medical devices (eg CSF shunt, CSF drain, intrathecal drug therapy)
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