Meningitis (Bacterial)ICU / resuscitation

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Fever, stiff neck, headache, photophobia, ΔMS

ABCDE

A-B-C; blood cultures then antibiotics + dexamethasone without delay; treat shock/seizures; LP when safe.

Calculators:
  1. First (do NOT delay): Blood cultures + Dexamethasone + empiric antibiotics
  2. Head CT before LP only if: focal deficit / ↑ICP signs / immunocompromised
  3. Then LP (bacterial CSF: ↑neutrophils, ↑protein, ↓glucose)
  4. Empiric antibiotics: Ceftriaxone 2 g IV q12h + Vancomycin; add Ampicillin if >50 y (IDSA — kept; WHO 2025 uses >60 y) / immunocompromised (Listeria); acyclovir if HSV
Decision tree
Signs of raised ICP / focal deficit / immunocompromised?
Yes
Blood cultures → antibiotics + dexamethasone NOW → CT → LP when safe
No
Blood cultures → LP → antibiotics + dexamethasone without delay

Order set

  • Blood cultures
  • Dexamethasone + empiric antibiotics NOW
  • LP (after CT if indicated)
  • FBC, coags, glucose

Escalate / ICU

  • ↓GCS / seizures
  • Septic shock
  • Raised-ICP signs / focal deficits

Criteria

AdmitAll bacterial meningitis
ICU↓GCS, seizures, shock, raised ICP
Intubate↓GCS / status epilepticus / shock
VasopressorsSeptic shock
DischargeAfebrile, neurologically recovering, antibiotic course defined, notified

Key

  • Give antibiotics as soon after LP as possible — never wait on CT/LP to treat.
  • Do NOT routinely restrict fluids; glycerol not recommended (WHO 2025).
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
  • ↓GCS
  • Petechial rash/shock
  • Seizures/focal signs
Differentials
  • Viral meningitis
  • Encephalitis
  • SAH
  • Abscess
Common mistakes
  • Delaying antibiotics for CT/LP
  • Missing Listeria cover in >50/immunocompromised
Disposition & follow-up

ICU if unstable; notify public health; contact prophylaxis.

Discharge package
MedicationsComplete antibiotic course
Follow-upAudiology + neuro review; public health done
VaccinationMeningococcal/pneumococcal per organism/risk
Warning symptomsRecurrent fever, headache, hearing loss, seizures
💊 Treatment detail — doses & preparation
Ceftriaxone3rd-gen cephalosporin
Dose2 g IV OD (meningitis 2 g q12h); gonorrhoea 500 mg–1 g IM once
PreparationIV: 2 g in 50–100 mL NS over 30 min; IM: reconstitute with lidocaine 1%
MonitorBiliary sludging; avoid with calcium-containing IV fluids in same line
Vancomycin IVglycopeptide
DoseLoad 25–30 mg/kg (critically ill), then 15–20 mg/kg q8–12h by levels (AUC 400–600)
PreparationDilute to ≤5 mg/mL in NS/D5W; infuse ≥60 min per 500 mg (red-man if fast)
MonitorTrough/AUC before 3rd–4th dose, creatinine, ototoxicity
Ampicillinaminopenicillin
Dose2 g IV q4h (Listeria cover in meningitis age >50/immunocompromised)
Preparation2 g vial in 50–100 mL NS over 30 min
MonitorRash (EBV), sodium load
Dexamethasone (meningitis)adjunct corticosteroid
Dose10 mg IV q6h ×4 d — start with/before first antibiotic dose (pneumococcal)
Preparation10 mg/2 mL vial slow push
MonitorStop if pneumococcus excluded; glucose
Aciclovir IVantiviral
Dose10 mg/kg IV q8h (HSV encephalitis ×14–21 d)
PreparationReconstitute 500 mg, dilute in 100 mL NS, infuse over 1 h + hydrate (crystalluria)
MonitorCreatinine, urine output; neurotoxicity in CKD
📖 IDSA / ESCMID + WHO Meningitis Guidelines 2025Reviewed July 2026

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