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Meningitis

NICE guideline [NG240] Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Published: Mar 2024. NICE BNF Treatment summaries. Central nervous system infections, antibacterial therapy NICE BNF Treatment summaries. Antibacterials, use for prophylaxis Meningococcal disease: prevention of secondary cases.

Primary Care Guidelines

Top piority: transfer immediately to hospital as an emergency.

Antibiotics before transfer:
  • DO NOT delay transfer to hospital to give antibiotics
  • Only if there is likely to be a clinically significant delay in transfer: give IV / IM ceftriaxone or benzylpenicillin outside of hospital

Antibacterial prophylaxis is aimed to eliminate asymptomatic carriage of Neisseria meningitidis from close contacts of the index case, thereby reducing onward transmission and secondary cases
 

Irrespective of vaccination status, the following should be offered antibacterial prophylaxis
  • Contact with the index case in a household type setting during the 7 days before onset of illness.
  • Sexual or other intimate contact during the 7 days before onset of illness.
  • Direct exposure to large particle droplets or secretions from the respiratory tract

  • Ciprofloxacin (alternative or recent travel to Middle East or Asia: rifampicin)
  • Also consider vaccination against Neisseria meningitidis 

Secondary Care Guidelines

Ideally perform the following tests before giving antibiotics:
  • Bacterial throat swab for meningococcal culture
  • Blood tests
    • Blood culture
    • White blood cell count
    • CRP
    • Blood glucose
    • Whole-blood PCR (including meningococcal and pneumococcal)
    • HIV test

Ideally perform lumbar puncture before starting antibitoics


Do not perform lumbar puncture if ANY of the following:

  • Extensive / rapidly spreading purpura
  • Infection at lumbar puncture site
  • Risk factors for an evolving space-occupying lesion
  • Signs of raised ICPIntracranial pressure, any of the following:
    • Wew focal neurological features (including seizures or posturing)
    • Abnormal pupillary reactions
    • GCS ≤9, or a progressive and sustained or rapid fall in level of consciousness
 

If the patient has one of the above reason where lumbar puncture cannot be performed. The management should be 1) take other microbiology samples (i.e. throat swab and blood cultures and PCR), if haven't and then 2) give antibiotics immediately without doing lumbar puncture, or neuroimaging.

CSF Analysis in Meningitis

Parameter Bacterial Viral TB Fungal
Opening pressure ↑ – / ↑ ↑ ↑
Appearance Turbid Clear Slightly turbid Clear/turbid
WCC ↑↑ (neutrophils) ↑ (lymphocytes) ↑ (lymphocytes) ↑ (lymphocytes)
Glucose ↓ – ↓ ↓
Protein ↑ – / ↑ ↑↑ ↑
Gram stain / culture Often +ve – Ziehl-Neelsen stain (may be +ve) India ink (may be +ve)

In addition to the parameters listed above, PCR for relative pathogens should be performed as well.

Do not routinely perform neuroimaging before lumbar puncutre.

Only perform neuroimaging if ANY of the following (NB these overlap with some reasons not to perform lumbar puncture):
  • Risk factors for an evolving space-occupying lesion
  • Signs of raised ICPIntracranial pressure, any of the following:
    • Wew focal neurological features (including seizures or posturing)
    • Abnormal pupillary reactions
    • GCS ≤9, or a progressive and sustained or rapid fall in level of consciousness
 

In these patients, the management should be 1) take other microbiology samples (i.e. throat swab and blood cultures and PCR), if haven't and then 2) give antibiotics immediately, 3) stabilise the patient then perform neuroimaging

IV antibiotic is the top priority in bacterial meningitis, it should be started ASAP, and within 1 hour of arriving at hospital

  • Ideally perform blood tests and lumbar puncture before, then give antibiotics immediately (if safe to do so and will not cause a clinically significant delay to start antibiotic)
 

There are 2 main aspects of initial management:
 

Offer:
  • Ceftriaxone (alternative: cefotaxime)
  • AND amoxicillin only if there are risk factors for Listeria monocytogenes (very young children / >60 y/o / pregnancy / immunosuppression / diabetes / alcohol misuse / cancer / kidney or liver disease)

Do not routinely give intravenous aciclovir unless herpes simplex encephalitis is strongly suspected

 

 Disclaimer: the exact wording of NICE is 'risk factors for Listeria monocytogenes' but helpful enough they did not define the risk factors. The above listed risk factors were instead listed in the BNF treatment summary for Central nervous system infections, antibacterial therapy.

IV dexamethasone should also be given with or before first dose of antibiotic if  >3 months age and bacterial meningitis is strongly suspected or confirmed 
  • Do not give dexamethasone in meningococcal disease
  • Do not delay antibiotics to wait for dexamethasone to be started
  • Only continue dexamethasone if meningitis found caused by pneumococcus or Haemophilus influenzae type b

NICE gudieline covered the choice of antibitoic for 6 organisms, but there are actually only 2 antibiotic regimens one need to learn:

  • In terms of the guidelines, there are some discrepency in terms of the duration to continue the antibiotic but the author deem of excessive details and is unlikely important for exams.
  • Clinically, the choice of antibiotic would be guided by local microbiology guidelines and culture sensitivities
 
Causative organism 1st line antibiotic 2nd line antibiotic Severe penicillin allergy*
Neisseria meningitidis (including meningococcal disease) Ceftriaxone Ceftotaxime Chloramphenicol
Streptococcus pneumoniae
Haemophilus influenzae type b
Group B streptococcus
Enterobacterales (coliforms)
Listeria monocytogenes Amoxicillin / ampicillin Co-trimoxazole Chloramphenicoil + co-trimoxazole
*NICE recommends to consdier the same penicillin-contianing antibiotics if the reaction was not severe allergy.

References

Author: Adams Lau
Reviewer:
Last edited: 17/07/25