Bacterial meningitis and meningococcal septicaemia in adults - Suspected community acquired
|Last review: 30/09/2017|
|Next review: 30/09/2020|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2017|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for the management and prophylaxis of suspected community acquired bacterial meningitis and meningococcal septicaemia in adults
Bacterial meningitis and meningococcal septicaemia in adults
Diagnosis: consider meningitis in patients with any two symptoms of; fever, neck stiffness, headache, or change in mental status.
Empirical antibiotic treatment
Bacterial meningitis: Give antibiotics immediately after the LP. If LP cannot be done within the first hour, antibiotics must be given immediately after blood cultures have been taken
Cefotaxime IV 2g 6hourly.
Beta-lactam allergy - See antibiotic allergy guideline on trust intranet
Severe allergy; i.e. confirmed anaphylaxis, angio-oedema or Stevens-Johnson syndrome:
Chloramphenicol IV 25mg/kg 6 hourly
Please see British infection association algorithm for early management of suspected meningitis and meningococcal septicaemia: http://www.britishinfection.org/files/5414/5674/3289/algorithm.pdf
Duration and directed antimicrobial therapy
Outpatient IV antibiotic therapy (OPAT/CIVAS)
Stabilisation of the patient’s airway, breathing and circulation should be an immediate priority - Link to sepsis pathway
Corticosteroids have potential anti inflammatory effects in bacterial meningitis including decreasing the amount of cytokine released and inhibition of prostaglandins and platelet activating factor . Experimental animal models of infection have shown that subarachnoid inflammatory space inflammation, caused by bacterial products is a major contributory factor to morbidity and mortality  The evidence that dexamethasone has a beneficial effect is based largely on the result of a large multi centre trial in Europe.  A total of 301 adults were randomized to receive dexamethasone (10 mg q6h for 4 days) or placebo, the first dose being administered 15–20 min prior to the first antimicrobial dose. At 8 weeks after enrolment, the percentage of patients with an unfavourable outcome was significantly lower in the dexamethasone group. Among the subgroup of patients with pneumococcal meningitis, benefit was evident in those who received adjunctive dexamethasone, with a lower percentage of unfavourable outcomes and deaths. Benefits were not seen in meningitis caused by other meningeal pathogens, although patient numbers in those groups were small. In all groups, dexamethasone appeared to be the most beneficial in patients with moderate to severe disease on the Glasgow outcome scale. Randomised control trials in Malawi and Vietnam did not show any benefit [19,20]. The most recent Cochrane review concluded there was a small reduction in mortality in patients with pneumococcal meningitis with corticosteroids but not other causes . This review did not show any difference in outcome when comparing whether corticosteroids were given before or after antibiotics.
|Empirical Antimicrobial Treatment|
Empirical treatment 
There is no prospective clinical data on the timing of antibiotic therapy in relation to outcome in patients with bacterial meningitis. The logical approach is to administer antibiotic therapy as soon as the diagnosis is suspected.
Patients with predominantly sepsis or a rapidly evolving rash
Non severe allergy - treat as above
Severe allergy ; i.e. confirmed anaphylaxis, angio-oedema or Stevens-Johnson syndrome
|Directed Antimicrobial Treatment (when microbiology results are known)|
Treatment should be adjusted according to subsequent culture and sensitivity results.
Table. Recommendations for directed antimicrobial therapy 
*Severe beta-lactam allergy includes anaphylaxis, angio-oedema and Stevens-Johnson syndrome
|Duration of Treatment|
|See table 1. If not specified contact Microbiology or infectious diseases
There is little evidence to guide the duration of treatment in adults. The 2016 UK meningitis guidelines recommend that treatment can be stopped after 5 days for meningococcal disease and 10 days in pneumococcal disease if the patient has recovered. If no pathogen has been found antibiotics can be stopped after 10 days if the patient has clinically recovered.
|Switch to oral agent(s)|
Switch to oral antimicrobials is not recommended
|Please contact Infectious diseases or Microbiology if the patient is not responding to the recommended antimicrobial regimens.|
|Objective:||Objective: To improve the diagnosis and management of suspected community acquired bacterial meningitis and meningococcal septicaemia
Aims: To improve the diagnosis and management of suspected community acquired bacterial meningitis and meningococcal septicaemia in adults
Community acquired bacterial meningitis and meningococcal septicaemia
|Target patient group:||All|
|Target professional group(s):||Secondary Care Doctors
Primary Care Doctors
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- Michael B, Sidhu M, Stoeter D, Roberts M, Beeching N, Bonington A, et al. Acute central nervous system infections in adults, a retrospective cohort study in the NHS North West region. QJM 2010;103:10
- Kadurugamuwa JL, Hengstler B, Bray MA, Zak O. Inhibition of complement-factor-5a-induced inflammatory reactions by prostaglandin E2 in experimental meningitis. J Infect Dis 1989;160(4):715e9.
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- de Gans, van de Beek D. Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002; 347:1549–56.
- Mai N, Chau T, Thwaites G, Chuong LV, Sinh D, Nghia H, et al. Dexamethason in Vietnamese adolescents and adults with bacterial meningitis. N Engl J Med 2004;357:2431e40.
- Scarborough M, Gordon S, Whitty C, French N, Njalale Y, Chitani A, et al. Corticosteroids for bacterial meningitis in adults in sub Saharan Africa. N Engl J Med 2007;357:2441e50
- Brouwer MC, McIntyre P, van de Beek D. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev 2013:6.
- Lutsar I, Ahmed A, Friedland IR, Trujillo M, Wubbel L, Olsen K, et al. Pharmacodynamics and bactericidal activity of ceftriax- one therapy in experimental cephalosporin-resistant pneumococcal meningitis. Antimicrob Agents Chemother 1997; 41(11):2414e7.
A. Controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
Improving Antimicrobial Prescribing Group
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