Management of bacterial meningitis

Seek expert advice.

Due to the high mortality associated with acute bacterial meningitis, treatment should be started in suspected cases even before the diagnosis can be confirmed.

• empiric antibiotic treatment
  • early antibiotic therapy is associated with lower mortality
    • ideally should be given after both blood and CSF have been obtained for culture
      • if there is a delay in obtaining the sample, antimicrobial therapy should not be withheld, as a delay can result in a higher probability of adverse clinical outcomes
  • NICE state (1):
    • in hospital before the causative organism is known, or when it cannot be identified
      • for suspected bacterial meningitis when the causative organism has not been identified:
        • give ceftriaxone (use the highest doses recommended by the BNF or BNFC or refer to local antimicrobial guidance)
        • if ceftriaxone is contraindicated, consider cefotaxime (see the BNFC for contraindications to ceftriaxone for pre-term babies under 41 weeks corrected gestational age)
        • give intravenous amoxicillin in addition to ceftriaxone or cefotaxime for people with risk factors for Listeria monocytogenes.
        • do not routinely give intravenous aciclovir unless herpes simplex encephalitis is strongly suspected
        • continue initial antibiotic treatment until the results of blood and cerebrospinal fluid tests suggest an alternative treatment is needed or there is an alternative diagnosis. If test results are normal, but bacterial meningitis is still suspected, get advice from an infection specialist
        • if the cerebrospinal fluid results suggest bacterial meningitis, but the blood culture and whole-blood diagnostic polymerase chain reaction are negative:
          • continue antibiotics for 10 days
          • after 10 days, stop antibiotics if the person has recovered, or get advice from an infection specialist if they have not
• adjuvant therapy
  • dexamethasone
  • not recommended – glycerol and therapeutic hypothermia (1,2)
  • NICE state (1)
    • do not routinely use other osmotic agents (such as mannitol or hypertonic sodium chloride) in the management of bacterial meningitis in babies, children, young people and adults
    • if there are signs of raised intracranial pressure and concerns about brain herniation:
      • consider osmotic agents (but not glycerol) as a temporary measure to reduce intracranial pressu
      • for adults, get urgent advice from critical care
      • for babies, children and young people, get urgent advice from paediatric critical care services.

Supportive therapy with hydration, antipyretics, analgesia, and nutritional support may be required (1).

Management in primary and secondary care - see linked items.

For full details of NICE guidance see NICE (March 2024). Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management.

Reference:

• (1) NICE (March 2024). Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management.
• (2) McGill F et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016;72(4):405-38.