Suspected bacterial meningitis or meningococcal disease
Suspected bacterial meningitis and meningococcal disease should be treated as emergencies with immediate hospital transfer and immediate initiation of parenteral antibiotics. [1] A history of headache, fever, vomiting, and a rash with tachycardia is compatible with meningococcal disease and should be managed using the meningitis/meningococcal emergency pathway. [1]
Immediate stabilization and diagnostic priorities
Urgent stabilization should be performed in parallel with diagnostic workup. [1] Antibiotics should be started within 1 hour of hospital arrival for suspected bacterial meningitis. [1] Blood tests and lumbar puncture should be performed before starting antibiotics when it is safe and will not cause clinically significant delay. [1] Neuroimaging should not be performed routinely before lumbar puncture. [1] Lumbar puncture should be deferred when features suggest raised intracranial pressure until those factors are resolved. [1]
Transfer and pre-hospital antibiotic administration
Transfer to hospital should be performed as an emergency when bacterial meningitis or meningococcal disease is suspected. [1] Transfer should not be delayed to administer antibiotics. [1] If clinically significant delay in transfer is likely for strongly suspected bacterial meningitis, intravenous or intramuscular ceftriaxone or benzylpenicillin should be given outside of hospital. [1] If clinically significant delay in transfer is likely for strongly suspected meningococcal disease, intravenous or intramuscular ceftriaxone or benzylpenicillin should be given as soon as possible outside of hospital unless this would delay transfer. [1]
Empiric antimicrobial therapy
For suspected bacterial meningitis when the causative organism is not identified, ceftriaxone should be given. [1] If ceftriaxone is contraindicated, cefotaxime should be considered. [1] For suspected meningococcal disease, empiric therapy should include an extended-spectrum cephalosporin such as ceftriaxone or cefotaxime. [2]
Corticosteroid use
For people over 3 months with strongly suspected or confirmed bacterial meningitis, intravenous dexamethasone should be given. [1] The first dose of dexamethasone should be given with or before the first dose of antibiotics if possible. [1] Dexamethasone should not delay antibiotic administration. [1] If dexamethasone is delayed for less than 12 hours after antibiotic start, dexamethasone should be administered as soon as possible. [1]
Diagnostic testing for etiologic confirmation
Blood culture should be obtained. [1] C-reactive protein or procalcitonin should be obtained. [1] Whole-blood diagnostic PCR including meningococcal and pneumococcal targets should be obtained. [1] A bacterial throat swab for meningococcal culture should be performed for suspected bacterial meningitis, preferably before starting antibiotics. [1] Cerebrospinal fluid testing should include cell count and differential, total protein, glucose (for CSF-to-blood glucose ratio), Gram stain, culture with sensitivities, and PCR for relevant pathogens. [1]
Meningococcal disease-specific actions
If meningococcal disease is suspected, hospital transfer should be performed as an emergency. [1] In hospital, intravenous ceftriaxone should be given for suspected or confirmed meningococcal disease. [1] Routine corticosteroids should not be given for meningococcal disease. [1] Ceftriaxone or cefotaxime should be used as part of empiric meningococcal disease therapy. [2]
Treatment follow-up and de-escalation
Antibiotics should be reviewed once microbiologic results are available. [1] For confirmed or recovered meningococcal disease, antibiotics should be stopped after 5 days if the person has recovered. [1]
Public health and infection control considerations
Public health notification and contact management should be pursued due to meningococcal disease transmission risk. [2]