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Approach Considerations

The challenges for emergency physicians when treating meningitis are as follows:

• Early identification and treatment of patients with acute bacterial meningitis
• Assessing whether a treatable CNS infection is present in those with suspected subacute or chronic meningitis
• Identifying the causative organism

Bacterial meningitis must be first and foremost in the differential diagnosis of patients with headache, neck stiffness, fever, and change in mental status. Acute bacterial meningitis is a medical emergency, and delays in instituting effective antimicrobial therapy result in increased morbidity and mortality.

The cornerstone in the diagnosis of meningitis is examination of the CSF. The diagnosis of bacterial meningitis is made by culture to isolate the bacteria in the CSF sample. Other laboratory tests, which may include other culture of blood specimens, are needed to complement the CSF culture. These bacterial cultures are used for identification of the offending bacteria and occasionally its serogroup, as well as for determination of the organism’s susceptibility to antibiotics.

In general, whenever the diagnosis of meningitis is strongly considered, a lumbar puncture should be promptly performed.

The opening pressure should be measured and the fluid sent for cell count (and differential count), chemistry (ie, CSF glucose and protein), and microbiology (ie, Gram stain and cultures).

A computed tomography (CT) scan of the brain may be performed prior to lumbar puncture in some patient groups with a higher risk of herniation. These groups include those made up of patients with the following risk factors:

• Newly onset seizures
• An immunocompromised state
• Signs suspicious for space-occupying lesions (such as papilledema and focal neurologic signs)
• Moderate to severe impairment in consciousness

Special studies, such as serology and nucleic acid amplification, may also be performed, depending on clinical suspicion of an offending organism.

In the absence of focal neurologic deficit, radiographic imaging of the head should not preclude performing a lumbar puncture.

Neurosurgical procedures are performed in consultation with a neurosurgical service in the presence of severe intracranial hypertension, evidence of paranasal and mastoid infection that requires surgical drainage, skull fractures, foreign body–associated infections (eg, ventriculoperitoneal shunts), or an associated abscess formation.

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