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Acute bacterial meningitis

What's new

Updated 2023 DGN guidelines for the diagnosis and management of acute bacterial meningitis.

Background

Overview

Definition
ABM is an acute inflammation of the meninges, particularly the arachnoid and the pia mater, associated with the invasion of bacteria into the subarachnoid space.
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Pathophysiology
Bacterial meningitis is mostly caused by S. pneumoniae and Neisseria meningitides.
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Disease course
Bacterial invasion to the CNS through the bloodstream or direct access leads to ABM, which causes clinical manifestations of fever, malaise, headache, meningismus, photophobia, phonophobia, vomiting, altered mental status, focal neurological signs (epileptic seizures, or paresis of a limb), and coma.
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Prognosis and risk of recurrence
Bacterial meningitis is associated with a 34% mortality rate.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute bacterial meningitis are prepared by our editorial team based on guidelines from the German Neurological Society (DGN 2023), the American Cochlear Implant Alliance (ACI Alliance 2022), the Center for Disease Control (CDC 2022,2019), the American Academy of Family Physicians (AAFP 2017), the Infectious Diseases Society of America (IDSA 2017,2011,2004), ...
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Screening and diagnosis

Diagnosis: as per DGN 2023 guidelines, suspect ABM if a combination of headache, meningism, fever, and impaired consciousness is present. Do not rule out bacterial meningitis in the absence of individual symptoms.
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Diagnostic investigations

Brain imaging: as per DGN 2023 guidelines, obtain CT as first-line imaging in the initial phase of the disease if there is a clinical suspicion of increased ICP.
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  • Blood cultures

  • Serum inflammatory markers

  • ENT evaluation

  • Neuropsychologic evaluation

Diagnostic procedures

Lumbar puncture: as per DGN 2023 guidelines, perform lumbar puncture after obtaining blood cultures in adult patients without impaired consciousness, focal neurological deficit, and epileptic seizures.
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  • CSF analysis

Medical management

Setting of care: as per DGN 2023 guidelines, consider managing patients with ABM in an ICU setting because of the frequent occurrence of intracranial and systemic complications. Consider managing patients with pronounced impaired consciousness in an ICU with experience in the treatment of severe CNS diseases.
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  • Antibiotic therapy (timing)

  • Antibiotic therapy (empiric antibiotics)

  • Antibiotic therapy (definitive antibiotics)

  • Antibiotic therapy (routes and duration)

  • Adjunctive corticosteroids

  • Other adjunctive treatments

  • Antiviral therapy

  • Management of sinus vein thrombosis

  • Management of ICP

Inpatient care

Monitoring for complications
As per ESCMID 2016 guidelines:
Obtain monitoring for neurologic and systemic complications in patients with ABM. Obtain ancillary testing in case of deterioration and initiate specific treatment when required.
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Consider obtaining ICP/cerebral perfusion pressure monitoring in selected patients, but not as routine management.
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Therapeutic procedures

Intrathecal antibiotics: as per IDSA 2004 guidelines, consider administering intrathecal vancomycin in patients not responding to parenteral antibiotics.
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  • External ventricular drainage

Surgical interventions

Indications for surgery: as per DGN 2023 guidelines, perform rapid surgery to clear the infectious focus in patients with a parameningeal focus of inflammation (such as sinusitis, mastoiditis) detected clinically (such as otitis media) or on CT as a possible cause of bacterial meningitis.
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Specific circumstances

Patients with cerebral vasculitis: as per DGN 2023 guidelines, consider administering nimodipine and/or corticosteroids in case of vasculopathy. Consider obtaining intra-arterial BP monitoring if nimodipine is administered IV.
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  • Patients with CSF shunt infection (clinical presentation)

  • Patients with CSF shunt infection (evaluation)

  • Patients with CSF shunt infection (shunt removal)

  • Patients with CSF shunt infection (antibiotic therapy)

  • Patients with healthcare-associated ventriculitis and meningitis (clinical presentation)

  • Patients with healthcare-associated ventriculitis and meningitis (diagnostic imaging)

  • Patients with healthcare-associated ventriculitis and meningitis (CSF culture)

  • Patients with healthcare-associated ventriculitis and meningitis (CSF analysis)

  • Patients with healthcare-associated ventriculitis and meningitis (empiric antibiotic therapy)

  • Patients with healthcare-associated ventriculitis and meningitis (definitive antibiotic therapy, Staphylococcus)

  • Patients with healthcare-associated ventriculitis and meningitis (definitive antibiotic therapy, Pseudomonas)

  • Patients with healthcare-associated ventriculitis and meningitis (definitive antibiotic therapy, Acinetobacter)

  • Patients with healthcare-associated ventriculitis and meningitis (definitive antibiotic therapy, Propionibacterium)

  • Patients with healthcare-associated ventriculitis and meningitis (antifungal therapy)

  • Patients with healthcare-associated ventriculitis and meningitis (intraventricular antimicrobial therapy)

Preventative measures

Meningococcal and Hib immunization: as per AAFP 2017 guidelines, offer vaccination for H. influenzae type B and N. meningitidis in individuals in appropriate risk groups to significantly decrease the incidence of bacterial meningitis.
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  • Pneumococcal immunization

  • Post-exposure prophylaxis

Follow-up and surveillance

Repeat lumbar puncture
As per IDSA 2004 guidelines:
Repeat CSF analysis in patients not responding clinically after ≥ 48 hours of appropriate antimicrobial therapy.
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Perform repeated lumbar punctures to document CSF sterilization in neonates with meningitis due to Gram-negative bacilli, because the duration of antimicrobial therapy is determined, in part, by the result.
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  • Rehabilitation

  • Surveillance for long-term sequelae (evaluation)

  • Surveillance for long-term sequelae (management of seizures)

  • Surveillance for long-term sequelae (cochlear implantation)

Quality improvement

Public health reporting: as per EFNS 2008 guidelines, report all cases of suspected meningococcal or H. influenzae type B meningitis to the local public health authorities on an urgent basis.
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