G00.0-3/G00.8-9/G03.0-2/G03.8-9/A32.1
*N. meningitidis, H. influenzae Type B and listeriosis are notifiable medical conditions.
DIAGNOSIS
Computed tomography should be done before lumbar puncture in patients with:
- focal neurological signs,
- new seizures,
- papilloedema, or
- reduced level of consciousness.
In cases where lumbar puncture is delayed or cannot be done (e.g. uncontrolled significant bleeding tendency), commence empiric antibiotic therapy after taking samples for blood cultures. Attempt the lumbar puncture later, if possible.
GENERAL MEASURES
Observe patient closely with regular monitoring of vital signs and neurological state.
Pay close attention to hydration status.
Nurse patients in a quiet, semi-dark surrounding.
Repeated lumbar punctures are of no benefit in uncomplicated bacterial meningitis.
Prompt initiation of antibiotic therapy is associated with improved outcomes in patients with bacterial meningitis.
MEDICINE TREATMENT
All patients require sufficient analgesia:
- Paracetamol, oral, 1 g 4–6 hourly when required.
- Maximum dose: 15 mg/kg/dose.
- Maximum daily dose: 4 g in 24 hours.
AND/OR
- NSAID, e.g.:
- Ibuprofen, oral, 400 mg then 8 hourly with meals, if needed.
Severe pain:
- Tramadol, oral, 50–100 mg 4–6 hourly.
Antibiotic therapy
Empiric therapy for bacterial meningitis, until sensitivity results are available:
- Ceftriaxone, IV, 2 g 12 hourly for 10 days.
Adjunctive corticosteroids are not recommended as trials in low-middle income countries have not demonstrated benefit.
Meningococcal meningitis A39.0 + (G01*)
For confirmed meningococcal disease only:
- Benzylpenicillin (penicillin G), IV, 20–24 MU daily in 4–6 divided doses for one week.
Eradicate nasopharyngeal carriage with a single dose of ciprofloxacin 500 mg after completing course of benzylpenicillin. This is not required if the patient received an initial, pre-referral dose of ceftriaxone.
- Ciprofloxacin, oral, 500 mg immediately as a single dose.
Severe penicillin allergy: (Z88.0)
- Meropenem, IV, 2 g 8 hourly for 7 days. LoEIII [52]
Prophylaxis of contacts:
Only for close household contacts.
Only for healthcare workers who resuscitate patients before they received appropriate treatment.
- Ciprofloxacin, oral, 500 mg immediately as a single dose.
Pneumococcal meningitis G00.1
This organism may be associated with CSF leaks.
If sensitive to penicillin: (Z88.0)
- Benzylpenicillin (penicillin G), IV, 20–24 MU daily in 4–6 divided doses for 10 days.
If resistant to penicillin:
- Ceftriaxone, IV, 2 g 12 hourly for at least 10 days.
Severe penicillin allergy: (Z88.0)
- Meropenem, IV, 2 g 8 hourly for 10 days.
Note: Consult a microbiologist/infectious diseases specialist.
Haemophilus influenzae G00.0
- Ceftriaxone, IV, 2 g 12 hourly for 10 days.
Severe penicillin allergy: (Z88.0)
- Meropenem, IV, 2 g 8 hourly for 10 days.
Note: Consult a microbiologist/infectious diseases specialist.
Listeria monocytogenes meningitis A32.1
- Ampicillin, IV, 3 g 6 hourly for 21 days. LoEIII [53]
AND
- Gentamicin, IV, 5 mg/kg daily for 7 days (may be prolonged if response is poor). See Appendix II for guidance on prescribing.
Severe penicillin allergy: (Z88.0)
Consult a specialist.
TUBERCULOUS MENINGITIS
A17.0 + (G01*)
CSF findings are extremely variable. Generally, lymphocytes predominate, however, polymorphs predominate initially in about a third of patients.
Protein is usually >1 g/L and glucose is usually low.
In cases where the differential diagnosis between bacterial and tuberculous meningitis is in doubt, lumbar puncture should be repeated 2–3 days later while still on ceftriaxone. If the aetiology is bacterial, considerable improvement in CSF findings may be expected, but with untreated tuberculous meningitis the cell counts and protein levels will be the same or higher; and the glucose level will be the same or lower.
Standard combination tuberculosis therapy according to National protocol. See section 16.9: Tuberculosis, Pulmonary.
Duration of therapy: 9 months.
In HIV non-infected individuals:
Corticosteroid use may be of benefit in reducing neurological deficit in patients with grade II to III disease (focal neurological disease, depressed levels of consciousness Glasgow Coma Scale of 14 or less.
- Dexamethasone, IV,
- 0.3–0.4 mg/kg/day for 2 weeks.
- Followed by 0.2 mg/kg daily during week 3.
- Then 0.1 mg/kg/day during week 4, then 4 mg per day during week 5, and therafter, taper 1 mg off the daily dose each week.
- Total duration approximately 8 weeks.
- Corticosteroids (intermediate-acting) e.g.:
- Prednisone, oral, 60 mg daily for 2 weeks. LoEIII [55]
- Then taper gradually over the next 6 weeks (See Appendix II for an example of a dose reduction regimen).
In HIV-infected individuals:
Note: There is uncertainty whether the use of corticosteroids is beneficial in
HIV-infected patients with TBM.
CRYPTOCOCCAL MENINGITIS
HIV-infected patients (see section 10.2.4: Cryptococcosis)
- In HIV infection the aim is to suppress the infection until immune restoration occurs with antiretroviral therapy.
HIV-uninfected patients
- In HIV-uninfected patients the aim is to cure the infection.
Cryptococcal Meningitis, HIV-Infected
See Cryptococcosis.
Cryptococcal Meningitis, HIV-Uninfected
B45.1 + (G02.1*)
MEDICINE TREATMENT
Initial therapy:
- Amphotericin B, IV, 1 mg/kg daily.
- Ensure adequate hydration to minimise nephrotoxicity. (See Appendix II for preventing, monitoring and management of toxicity).
- Duration of initial IV therapy:
- Treat intravenously for 4 weeks, provided that there are no neurological complications and follow up CSF culture at 2 weeks is negative. In patients with neurological complications or persistent positive culture: increase the initial phase of therapy to 6 weeks in consultation with a specialist.
AND
- Fluconazole, oral, 800 mg daily for 2 weeks, followed by 400 mg daily for 2 months.
Maintenance therapy:
- Fluconazole, oral, 200 mg daily for a minimum of 1 year.
Follow all patients closely for relapses.
Therapeutic lumbar puncture:
This should be considered as the intracranial pressure is often elevated with a communicating hydrocephalus. See Cryptococcosis.