Bacterial Meningitis

Severe disease with high mortality (50%)

Unpredictable course of the disease in first 48h


<1 month: E.coli, Listeria, Klebsiella

1-23 months: Pneumococcus, meningococcus, haemophilus, Haemophilus

2-50 years: S. pneumoniae, N.meningitidis

>50 years: S. pneumoniae, N.meningitidis, Listeria

Meningococcus (Neisseria meningitides, gram negative diplococcus)

Pneumococcus (Streptococcus pneumoniae, gram positive diplococcus)

Haemophilus (gram negative) got rare since vaccination available

Clinical presentation

  • Preceded by flu-like symptoms
  • Fever
  • Rash (80%) (meningococcus septicaemia)
  • headache
  • shock
  • signs of meningitis
    • Nuchal rigidity
    • Kernig: pain and spasm when straightening leg with hip bent
    • Brudzinski: Neck flexion causes lower limb flexion
  • Altered concious level > coma
  • seizure (25%)


  • Clinical Presentation
  • Blood culture
  • Throat swab
  • Lumbar Puncture 
    • clody CSF
    • gram stain
    • culture, PCR
    • increased opening pressure (>400mm; Normal range 80-180 mm H2O)
    • pleocytosis (>100 leucocytes/mm3)
    • decreased glucose level
    • protein >0.5g/l

Indications for CTB prior to LP

  • HIV or other immunocompromised state
  • Seizures
  • Focal neurology
  • Evidence of raised ICP (


  • Seizure
  • Stroke
  • tentorial herniation
  • hydrocephalus
  • neurological sequelae

Management / Therapy



Empiric (organism not known)

 Ceftriaxone 4g/day or 2g bd (Children 100mg/kg in one or two doses)


Vancomycin 12.5mg/kg (1g/80kg) 6/24

Neisseria meningitidis

Benzylpenicillin 1.8g 4/24


Ceftriaxone 4g 24/24


Cefotaxime 2g 6/24

Hospital acquired meningitis

Vancomycin 12.5mg/kg (up to 500mg) iv 6/24


Meropenem 2g 8/24


Dexamethasone 0.15mg/kg iv with the first dose of antibiotics, then 0.15mg/kg 6/24 for 4/7

Reduction of antimicrobial agent induced inflammation

Significant reduction in mortality and neurological sequelae

In particular for pneumococcal meningitis

Neuro ICU Management

Consideration of monitoring and management of high ICPs

Repeated lumbat CSF drainage 

EEG to detect seizure activity (in particular nonconvulsive state)