Aseptic and Bacterial Meningitis: Evaluation, Treatment, and Prevention

 

Am Fam Physician. 2017 Sep 1;96(5):314-322.

  Patient information: See related handout on meningitis, written by the authors of this article.

The etiologies of meningitis range in severity from benign and self-limited to life-threatening with potentially severe morbidity. Bacterial meningitis is a medical emergency that requires prompt recognition and treatment. Mortality remains high despite the introduction of vaccinations for common pathogens that have reduced the incidence of meningitis worldwide. Aseptic meningitis is the most common form of meningitis with an annual incidence of 7.6 per 100,000 adults. Most cases of aseptic meningitis are viral and require supportive care. Viral meningitis is generally self-limited with a good prognosis. Examination maneuvers such as Kernig sign or Brudzinski sign may not be useful to differentiate bacterial from aseptic meningitis because of variable sensitivity and specificity. Because clinical findings are also unreliable, the diagnosis relies on the examination of cerebrospinal fluid obtained from lumbar puncture. Delayed initiation of antibiotics can worsen mortality. Treatment should be started promptly in cases where transfer, imaging, or lumbar puncture may slow a definitive diagnosis. Empiric antibiotics should be directed toward the most likely pathogens and should be adjusted by patient age and risk factors. Dexamethasone should be administered to children and adults with suspected bacterial meningitis before or at the time of initiation of antibiotics. Vaccination against the most common pathogens that cause bacterial meningitis is recommended. Chemoprophylaxis of close contacts is helpful in preventing additional infections.

Patients with meningitis present a particular challenge for physicians. Etiologies range in severity from benign and self-limited to life-threatening with potentially severe morbidity. To further complicate the diagnostic process, physical examination and testing are limited in sensitivity and specificity. Advanc`es in vaccination have reduced the incidence of bacterial meningitis; however, it remains a significant disease with high rates of morbidity and mortality, making its timely diagnosis and treatment an important concern.1

WHAT IS NEW ON THIS TOPIC: BACTERIAL MENINGITIS

In 2015, the Advisory Committee on Immunization Practices gave meningococcal serogroup B vaccines a category B recommendation (individual clinical decision making) for healthy patients 16 to 23 years of age (preferred age 16 to 18 years).

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Diagnosis of meningitis is mainly based on clinical presentation and cerebrospinal fluid analysis. Other laboratory testing and clinical decision rules, such as the Bacterial Meningitis Score, may be useful adjuncts.

C

7, 1113, 2530

Lumbar puncture may be performed without computed tomography of the brain if there are no risk factors for an occult intracranial abnormality.

C

7, 22

Appropriate antimicrobials should be given promptly if bacterial meningitis is suspected, even if the evaluation is ongoing. Treatment should not be delayed if there is lag time in the evaluation.

B

7, 22, 36, 37

Dexamethasone should be given before or at the time of antibiotic administration to patients older than six weeks who present with clinical features concerning for bacterial meningitis.

B

7, 3841, 45, 46

Vaccination for Streptococcus pneumoniae, Haemophilus influenzae type B, and Neisseria meningitidis is recommended for patients in appropriate risk groups and significantly decreases the incidence of bacterial meningitis.

B

5861


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Diagnosis of meningitis is mainly based on clinical presentation and cerebrospinal fluid analysis. Other laboratory testing and clinical decision rules, such as the Bacterial Meningitis Score, may be useful adjuncts.

C

7, 1113, 2530

Lumbar puncture may be performed without computed tomography of the brain if there are no risk factors for an occult intracranial abnormality.

C

7, 22

Appropriate antimicrobials should be given promptly if bacterial meningitis is suspected, even if the evaluation is ongoing. Treatment should not be delayed if there is lag time in the evaluation.

B

7, 22, 36, 37

Dexamethasone should be given before or at the time of antibiotic administration to patients older than six weeks who present with clinical features concerning for bacterial meningitis.

B

7, 3841, 45, 46

Vaccination for Streptococcus pneumoniae, Haemophilus influenzae type B, and Neisseria meningitidis is recommended for patients in appropriate risk groups and significantly decreases the incidence of bacterial

The Authors

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HILLARY R. MOUNT, MD, is an assistant professor in the Department of Family and Community Medicine and director of Inpatient Medicine Services at The Christ Hospital/UC Family Medicine Residency Program, University of Cincinnati (Ohio) College of Medicine....

SEAN D. BOYLE, DO, is a volunteer assistant professor in the Department of Family and Community Medicine, The Christ Hospital/UC Family Medicine Residency Program at the University of Cincinnati College of Medicine.

Author disclosure: No relevant financial affiliations.

Address correspondence to Hillary R. Mount, MD, University of Cincinnati College of Medicine, 2123 Auburn Avenue, Ste. 340, Cincinnati, OH 45219 (e-mail: hillary.mount@thechristhospital.com). Reprints are not available from the authors.

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