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Treatment of Acute Meningitis

In acutely ill patients, perform an LP (if appropriate) and administer the first dose(s) of antibiotics with or without steroids within 30 minutes of presentation to the ED. Consider instituting ED triage protocol to identify patients at risk. Initiate empiric therapy if LP cannot be performed within 30 minutes. Begin empiric therapy prior to a head CT scan if a focal neurologic deficit is present. If no mass effect is present, perform LP to obtain microbiology studies.

Treat systemic complications of acute bacterial meningitis, including the following:

• Hypotension and/or shock
• Hypoxemia
• Hyponatremia (SIADH)
• Cardiac arrhythmias and ischemia
• Cerebrovascular accident (CVA)
• Exacerbation of chronic diseases

Look for signs of hydrocephalus and increasing ICP. Manage fever and pain, control straining and coughing, avoid seizures, and avoid systemic hypotension. In otherwise stable patients, sufficient care includes elevating the head and monitoring neurologic status. When more aggressive maneuvers are indicated, some authorities favor early use of diuresis (ie, furosemide 20 mg IV, mannitol 1 g/kg IV), provided circulatory volume is protected.

Hyperventilation in intubated patients, with a goal of PaCO₂ of 25-30 mm Hg, may briefly lower ICP; hyperventilation with PaCO₂ of less than 25 mm Hg may decrease CBF disproportionately and lead to CNS ischemia. Consider placing an ICP monitor in comatose patients or in those with signs of increased ICP. With elevated ICP, remove CSF until pressure decreases by 50% and maintain at less than 300 mm water.

Aggressively control seizures if present, since seizure activity increases ICP (ie, lorazepam 0.1 mg/kg IV and IV load with phenytoin 15 mg/kg or phenobarbital 5-10 mg/kg).

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