Criteria & Principles
- Obtain blood and CSF cultures prior to initiation of antibiotic therapy whenever possible
- A CT head should be performed before LP in any patients with focal neurologic defects, papilledema, immune compromise or space-occupying lesions
- If lumbar puncture (LP) is delayed, blood cultures should be obtained and appropriate antibiotic and adjunctive therapy may be given prior to LP or CT
- For patients with moderate-to-high clinical suspicion of meningitis, rapid PCR testing is available as part of the LP order set ("Meningitis PCR Panel - CSF") and offers high-sensitivity testing for the following organisms:
- Bacterial: E.coli K1, Haemophilus influenzae, Listeria monocytogenes, Neisseria meningitidis, Streptococcus agalactiae, Streptococcus pneumoniae
- Viral: CMV, Enterovirus, HSV 1/2, HHV-6, VZV, Parechovirus
- Fungal: Cryptococcus
- Expected turnaround time for the PCR panel is about 2 hours after receipt in the laboratory
- The PCR panel should not be ordered in immunocompetent patients with low clinical suspicion for meningitis and normal CSF parameters
- The PCR panel test is imperfect and both false positive and false negative results occur. Therefore, all CSF samples should be sent for culture when meningitis is suspected and Cryptococcal antigen testing should also be performed in immune compromised patients and patients with chronic meningitis symptoms. Scenarios where there is a high level of clinical suspicion may require treatment despite a negative PCR result
Treatment
Duration
Neisseria meningitidis: 7 days
Haemophilus influenzae: 7 days
Streptococcus pneumoniae: 10-14 days
Aerobic GNRs: 21 days
Listeria monocytogenes: >/= 21 days
Severity
All Severity
Mild or No Penicillin Allergy
Immunocompetent:
Age 2-50 years: vancomycin + ceftriaxone 2g IV q12h
Age >50 years: vancomycin + ceftriaxone 2g IV q12h + ampicillin 2g IV q4h
Immunocompromised: vancomycin + cefepime 2g IV q8h + ampicillin 2g IV q4h
Severe Penicillin Allergy: vancomycin + moxifloxacin 400 mg IV q24h + trimethoprim/sulfamethoxazole 5 mg/kg IV q6h
Post-neurosurgery or shunt: See separate “Healthcare or Shunt Associated Meningitis/Ventriculitis” guidelines.
Dexamethasone for Suspected/Proven Pneumococcal Meningitis 0.15 mg/kg q6h for 2-4 days (first dose 10-20 min before or concomitant with first dose of antibiotics). Continue only if CSF gram stain reveals Gram-positive diplococci or blood or CSF cultures or PCR positive for S. pneumoniae. Adjunctive dexamethasone not recommended in adults already receiving/received antibiotics.
Empiric coverage for tick-borne illness: Rocky Mountain Spotted Fever (RMSF) and ehrlichiosis is endemic in North Carolina and can mimic acute bacterial meningitis. For patients at risk (particularly those with outdoor activity or tick bites between April and October), addition of doxycycline 100 mg PO q12h is appropriate.
Viral meningoencephalitis: patients with lymphocytic predominance on CSF cell count and a consistent clinical presentation should be covered empirically for HSV or VZV meningoencephalitis while PCR results are pending. Empiric therapy recommendation is acyclovir IV 10mg/kg q8h
References
1. Tunkel, Allan R. et al. Practice Guidelines for the Management of Bacterial Meningitis. Clinical Infectious Diseases 2004;39:1267–84.
2. DUH CSF Antibiogram 2017