Adult acute bacterial meningitis is an incredibly morbid condition (up to 20%). Often considered on the differential diagnosis down the list for your altered mental status/febrile patients, it is not a rather “common” diagnosis to reach in the emergency department. None the less, emergency physicians must consider it, be able to appropriately evaluate for, and provide treatment for this critical condition. The following video (35 minutes) is a case conference grand rounds lecture given in 2014 and serves as a review for the epidemiology, diagnosis, and key management of adult acute bacterial meningitis. You can find key points to the lecture below, however they only serve to highlight the video and not replace it. Additional #FOAMed references to broaden your study.
On to the video!
Video Key Points:
- Acute bacterial meningitis (adult) mortality, approx 20% vs <1% in viral meningitis (immunocompetent adult)
- Consider CSF lactate levels: Lactate >4 PPV 100%, Lactate <2 NPV 100%
- CTH first if: Age >60, focal neuro finding, confused, seizure in the last 1 wk, immunocompromised, history of CVA, mass.
- Otherwise: Blood Culture > Antibiotics + Dexamethasone > LP
- Everyone: Ceftriaxone 2g IV
- Recent neurosurgical procedure or hospitalization: Add Vancomycin 15mg/kg IV
- Age >60: Add Ampicillin for Listeria coverage
- van de Beek, Diederik, et al. “Clinical features and prognostic factors in adults with bacterial meningitis.” New England Journal of Medicine 351.18 (2004): 1849-1859. [NEJM]
- Hasbun R, et al. ”Computed tomography of the head before lumbar puncture in adults with suspected meningitis.” New England Journal of Medicine 345.24 (2001): 1727-1733. [NEJM]
- Kanegaye J T., Soliemanzadeh P, and Bradley JS. “Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment.” Pediatrics 108.5 (2001): 1169-1174. [Pediatrics]
- Michael, Benedict, et al. “Effect of delayed lumbar punctures on the diagnosis of acute bacterial meningitis in adults.” Emergency Medicine Journal 27.6 (2010): 433-438. [BMJ/EM Journal]
- Cunha BA. “Cerebrospinal fluid lactic acid levels: Accurate, fast, and inexpensive.” Critical care medicine 39.10 (2011): 2383-2384. [J Clin Micro]