o Inflammation of the meninges.
o Incidence rates in adults is 1.05 cases per 100,000 population (2004-2011)
• Highest rates between the 45-64 age group.
o Usually caused by an infection, however rare non-infective causes of meningitis can occur.
o Viral meningitis is commonly benign and self-limiting.
o If untreated bacterial meningitis is fatal.
• Average mortality rate of community acquired bacterial meningitis is 20%
o The most common causes of bacterial meningitis in adults include:
• Streptococcus pneumonia, Haemophilus influenza type b (if unvaccinated) and Neisseria meningitides.
• Listeria monocytogenes is common in the elderly and immunocompromised population.
o Fungal and atypical bacterial infections can occur in immunocompromised patients or following acute head trauma.
o Meningitis can lead to meningococcal septicaemia, however sepsis can occur without meningitis.
• This is associated with worse prognosis.



• Triad: Headache, neck stiffness and fever.
• Photophobia
• Vomiting
• Fever
• Seizures
• Altered mental state

Meningococcal septicaemia

• Fever
• Non-blanching rash (purpuric or petechial), however any rash should raise suspicion.
• Shock


o If the patient is unstable then measures to stabilise the patient must be taken initially before a history (including collateral) is taken.
o Source of entry → otitis media

Onset of symptoms

• Acute onset suggests bacterial infection.

Previous history of head trauma → skull fractures.

• Risk for recurrent meningitis.
• Likely to be pneumococcal cause.

HIV status or any history suggestive of immunocompromise.

• Atypical infections

Recent travel

• Toscana virus (Mediterranean).
• Tick Borne Encephalitis Virus (Central and Eastern Europe).
• Other meningococcal (meningitis belt in Africa).
• West Nile Virus (USA).
• Lyme disease (Europe or USA).
• Parasitic meningitis (South America or parts of Africa).

Vital signs

National Early Warning Score

• 5/6 (or a score of 3 in any parameter) – urgent clinician review.
• 7 or more – urgent assessment by critical care team.
• Low scores can be falsely reassuring → meningitis or meningococcal septicaemia can rapidly deteriorate.
o Glasgow coma scale – recorded for prognostic information and monitoring
• GCS ≤8 – poor outcome

Examination findings

o Presence or absence of rash
o Full neurological examination
• Focal signs suggestive of complications such as, venous sinus thrombosis, cerebral oedema e.t.c.

Kernig’s sign – pain leading to resistance on extension of the knee when both the hip and knee are flexed at 90 degrees

Brudzinski’s sign – any positive of the following three medical sign’s

• Cheek sign – pressure on the cheek leads to a reflex rise and flexion of the forearm.
• Symphyseal sign – pressure on the pubic symphysis leads to a reflex abduction of the leg and flexion of the hip and knee.
• Neck sign – forced flexion of the neck leads to reflex flexion of the hips.

Bedside tests

o (see vital signs)

Laboratory investigations

Suspected meningitis (with no signs of shock or severe sepsis)

• Bloods
• Blood cultures (taken within 1 hour of hospital arrival)
• Full blood count
• Urea & Electrolytes
• LFTs
• Procalcitonin (CRP if unavailable)
• Meningococcal and pneumococcal PCR
• Serology sample
• Glucose
• Throat swab
• Bacterial culture

Suspected meningococcal sepsis

• Same as meningitis

Radiological investigations

o Suspected meningitis (with no signs of shock or severe sepsis)
o Suspected meningococcal sepsis

Special investigations

Suspected meningitis (with no signs of shock or severe sepsis)

• Lumbar puncture (LP)
• Opening pressure
• Microscopy, culture and sensitivity
• Meningococcal and pneumococcal PCR
• Protein
• Glucose
• Lactate

Suspected meningococcal sepsis

• Contraindicated

LP is contraindicated in:

• Sepsis
• Respiratory or cardiac compromise
• Anticoagulant therapy/ coagulopathy
• Infection at site of LP
• Focal neurological signs
• Papilloedema
• Continuous or uncontrolled seizures
• GCS ≤12
o If safe LP should be taken within 1 hour of arrival or as soon as safely possible.



• Stabilisation of the patient’s airway, breathing and circulation.
• Decision to admit to intensive care should be made in the first hour.
• Rapidly evolving rash.
• GCS or 12 or less.
• Evidence of severe sepsis.
• Initial investigations (as above).
• If sepsis present:
• Antibiotics should be immediately given after blood cultures.
• Fluid rescuscitation commenced (initial bolus of 500ml crystalloid over 5-10 mins).
• If sepsis not present or suspected then a LP should be carried out prior to the use of antibiotics.
• If this is not possible then a LP should be performed within 4 hours or starting antibiotics.
• All patients (meningitis or meningococcal septicaemia) should be given 2g ceftriaxone intravenously (IV) every 12 hours or 2g cefotaxime IV every 6 hours.
• If allergic (history of anaphylaxis) to penicillins or cephalosporins → IV chloramphenicol 25mg/kg every 6 hours.
• Recent travel (within 6 months) to a country with high rates of penincillin resistant pneumococci → IV vancomycin 15-20mg/kg should be added 12-hourly (or 600mg rifampicin 12-hourly IV or orally)
• Over 60 or Immunocoompromised patients → 2g IV ampicillin/amoxicillin 4-hourly in addition to a cephalosporin.
• Input from Infectious diseases team needed.
o Once the causative organism and antimicrobial sensitivities have been found then definitive antibiotic treatment can commence.
• Definitive treatment can last between 4-21 days depending on the organism.



• Meningitis
• Subdural empyema
• Seizures
• Cerebral venous sinus thrombosis
• Hydrocephalus
• Meningococcal sepsis
• Purpura fulminans
• Septic shock

Long-term sequelae:

• Hearing loss
• Problems with balance
• Dizziness
• Tinnitus
• Cognitive deficits/learning impairments
• Epilepsy
• Movement disorders
• Visual disturbances
• Amputations (sepsis complication only)
• Psychiatric/Psychosocial problems
• Renal impairment

The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults.

Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-ShareAlike 3.0 License