Meningitis refers to inflammation of the meninges surrounding the brain. Meningitis may vary from a benign, self-limited condition to one that may cause disability or death. The most common bacterial pathogens are Streptococcus pneumoniae (pneumococcus), Haemophilus influenzae type B, Neisseria meningitidis (meningococcus), and group B beta-hemolytic streptococci (Streptococcus agalactiae). Adults and older children with meningitis may present with neck stiffness, fever, headache, and altered mentation. Lumbar puncture with cerebrospinal fluid analysis is the mainstay for diagnosis and should include opening pressure, cell count, total protein, glucose, Gram stain, culture, and polymerase chain reaction testing. Empiric, guideline-directed intravenous antibiotic therapy should be started within 1 hour of presentation and continued until a specific organism can be identified. Routine vaccination against the common bacterial pathogens meningococcus, H influenzae type B, and pneumococcus is recommended. Chemoprophylaxis is recommended for close contacts of those infected with H influenzae type B or meningococcus.
Meningitis comprises a range of conditions, from those that are benign and self-limited to those that may cause disability or death. In 2016, across all ages in the United States, 16,869 cases of meningitis were documented, with 1,425 deaths.1 Vaccines have dramatically decreased the incidence of bacterial meningitis and shifted the burden of disease from children to older adults. However, prompt recognition and treatment remain essential.2–4
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Lumbar puncture should be performed when there is concern for bacterial meningitis; neuroimaging should be performed only when there is concern for increased intracranial pressure or space-occupying lesion.19,20,28,31 | C | Expert consensus; US, British, and European clinical practice guidelines |
| Antibiotics should be started within 1 hour when bacterial meningitis is suspected.19,20 | C | Expert consensus; British and European clinical practice guidelines |
| Children should receive vaccines effective against Haemophilus influenzae type B, Streptococcus pneumoniae, and Neisseria meningitidis as part of their routine childhood immunization sequence to reduce the risk of morbidity and mortality associated with these pathogens.1,2 | B | Systematic review and meta-analysis of US and global epidemiologic and surveillance data |
| Adults should receive the vaccine against S pneumoniae at 50 years of age or between ages 19 and 50 if they have risk factors for pneumococcal disease.56 | C | Expert consensus |
| Chemoprophylaxis is recommended for close contacts (household members and roommates, childcare center contacts, or anyone directly exposed to an infected person's oral secretions) of those with N meningitidis and H influenzae type B infection.55,57–59 | C | Expert consensus, systematic review, and meta-analysis demonstrating eradication of carriage of N meningitidis with antibiotics |
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 https://www.aafp.org/afpsort.
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