Diagnostics

1. A complete and detailed history and physical examination with details of length of illness
and details of presenting symptoms, preceding illness, past medical history. Also history
of exposure: travel, sick contact, insect bites, sexual activities, animal contacts.

2. Initial labs:

CBC, CRP, UA, PCR, LAT, Blood cultures; CSF: with opening
pressure, Procalcitonin and serology

Cerebrospinal fluid (CSF) culture is the gold standard for the diagnosis of acute
bacterial meningitis.

CBC should not be used solely as a basis for starting antibiotics. Signs and symptoms
of bacterial meningitis associated with neutrophilia and increased serum CRP are highly
suggestive of bacterial meningitis.

In patients suspected to have bacterial meningitis, blood culture should be performed

prior to starting antibiotic therapy.

Serum and CSF CRP are useful in confirming and excluding bacterial meningitis.

PCR may be utilized to amplify DNA from patients with meningitis caused by common
meningeal pathogens (S. pneumonia meningitidis and H. influenzae) especially if the
CSF culture is negative.

Procalcitonin may be used differentiate bacterial from viral meningitis. In situations

wherein a CSF analysis cannot be performed immediately, it may be used as a basis to
start antibiotics. However, it should not replace CSF analysis and culture in the
diagnosis of bacterial meningitis.

Latex agglutination test detects bacterial antigens in the CSF. Studies have shown that
the sensitivity of CSF bacterial antigen detection test ranges from 0-25%, and this is for
cases where culture results are negative.

Initial imaging: CT head without contrast to rule out space-occupying lesions,

hemorrhage or trauma. MRI of brain and spine if concern for myelitis/encephalitis.
Imaging can be added to evaluate for abscess, inflammation but is not necessarily
sensitive to make diagnosis. Cerebral edema is often not demonstrated on scans.
Neuroimaging is used to identify the presence of complications of bacterial meningitis
 and to rule out contraindications in doing a lumbar tap. Neuroimaging is not used to
diagnose the presence or absence of a CNS infection.

CSF cellular parameters in normal individuals and in patients with different types of
meningitis

Management

1. Neuro assessment: airway protection for severe altered mental status (GCS below 8).
Take precautions for increased intracranial pressure during intubation. Consider ICP
monitoring for evidence of elevated ICP. Treat seizure activity: 50% of patients who
presented with seizures progress to status epilepticus, which is hard to control and
correlates with poor neuro outcomes.

2. Cardiovascular support as needed; cerebral perfusion pressure is directly affected by

mean blood pressure.
3. Antibiotics early; do not withhold antibiotics awaiting lumbar puncture. Start antiviral if
high suspicion of herpes infection.

Electrolyte and fluid derangements are common:

 Diabetes insipidus: monitor urine output and check sodium level for spike in UOP (Na in
the 150s-160s).

 SIADH: late onset of electrolyte derangements with oliguria and relative hyponatremia
(Na can be below 125), increased risk of seizure activity. Correct hyponatremia acutely
to bring Na level above 125 with 3% saline if necessary (seizure threshold), then slow
correction to normal level (Na 140-145) over the next 36-48 hrs.

Treatment
Ampicillin 50-100 mg/kg Q6 hrs; max 12 gm/day.
Vancomycin15-20 mg/kg Q8 hrs; max 1 gm/dose; follow level, adjust dose for renal
insufficiency.
Gentamycin 2.5 mg/kg Q8 hrs; max 120 mg/dose; follow level, adjust dose with renal
insufficiency.
Cefotaxime 50 mg/kg Q6 hrs; max 2 gm/dose.
Ceftriaxone 100 mg/kg Q24 hrs; max 4 gm/day.
Acyclovir10-20 mg/kg Q8 hrs.

Expected response to treatment

With appropriate treatment: CSF culture and gram stain will become negative in 24-48
hours, glucose will normalize in 72 hrs. Cell counts and proteins will take days to
normalize.
APPENDIX – 1