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Bacterial Meningitis - CCS Case Guide

Key Takeaway: Bacterial meningitis is a medical emergency with high mortality if treatment is delayed. Empiric antibiotics and dexamethasone should be administered immediately, even before lumbar puncture if imaging is required first.

Bacterial meningitis is a medical emergency with high mortality if treatment is delayed. Empiric antibiotics and dexamethasone should be administered immediately, even before lumbar puncture if imaging is required first. CCS cases test the ability to act quickly while obtaining necessary diagnostics.

Recognizing the Meningitis Presentation

  • History: Severe headache, fever, neck stiffness, photophobia, altered mental status, nausea/vomiting, possible recent URI or otitis media
  • Physical Exam: Nuchal rigidity, positive Kernig and Brudzinski signs, petechial or purpuric rash (meningococcal), altered consciousness, papilledema (rare)
  • Vital Signs: Fever, tachycardia, possible hypotension in meningococcal sepsis

Immediate Actions (First 5 Minutes)

These orders should be placed immediately — timing is scored:

Critical First Orders

  • ✓ IV access immediately
  • ✓ Blood cultures x2
  • ✓ Dexamethasone 0.15 mg/kg IV before or with first dose of antibiotics
  • ✓ Empiric IV antibiotics immediately (do NOT wait for LP if any delay)
  • ✓ CT head before LP ONLY if focal deficits, papilledema, immunocompromised, or altered consciousness

Complete Workup

After initial stabilization, complete the diagnostic workup:

  • Blood cultures x2 (before antibiotics if possible)
  • Lumbar puncture with CSF analysis (cell count, glucose, protein, Gram stain, culture)
  • CSF opening pressure
  • CT head before LP (only if indicated)
  • CBC with differential
  • BMP
  • Coagulation studies
  • Procalcitonin
  • CSF PCR (HSV, enterovirus, bacterial panel)
  • Latex agglutination or multiplex PCR if Gram stain negative

Treatment

Empiric Antibiotics (adult)

  • Vancomycin 15-20 mg/kg IV + ceftriaxone 2 g IV q12h
  • Add ampicillin 2 g IV q4h if age > 50, immunocompromised, or alcoholic (Listeria coverage)
  • Administer within 30 minutes of presentation

Dexamethasone

  • Dexamethasone 0.15 mg/kg IV q6h for 4 days
  • Give before or with first dose of antibiotics
  • Most beneficial for pneumococcal meningitis
  • Discontinue if non-pneumococcal etiology confirmed

Supportive Care

  • IV fluids for hydration
  • Seizure precautions
  • Head of bed elevation to 30 degrees
  • Monitor for signs of increased ICP
  • Droplet precautions until meningococcal ruled out

Targeted Therapy

  • Narrow antibiotics based on culture and sensitivity results
  • Typical duration 7-21 days depending on organism
  • Add acyclovir if HSV encephalitis suspected

Common Pitfalls

Scoring Tip: These are the most commonly missed actions for Meningitis cases.

  • Delaying antibiotics for LP or CT
  • Omitting dexamethasone or giving it after antibiotics
  • Performing LP without checking for contraindications (focal deficits, papilledema)
  • Forgetting Listeria coverage in elderly or immunocompromised patients
  • Not initiating droplet precautions
  • Missing the diagnosis by not considering meningitis in elderly patients with altered mental status and fever

Disposition

  • Admit to ICU for close neurological monitoring
  • Telemetry floor once stable and improving
  • Complete full antibiotic course
  • Hearing evaluation before discharge (aminoglycoside toxicity and meningitis sequelae)
  • Close contacts of meningococcal cases need chemoprophylaxis (rifampin or ciprofloxacin)

Key Orders Checklist

  • ☐ Blood cultures x2
  • ☐ Dexamethasone IV before antibiotics
  • ☐ Vancomycin + ceftriaxone IV (± ampicillin)
  • ☐ Lumbar puncture with CSF studies
  • ☐ CT head (if indicated before LP)
  • ☐ Droplet precautions
  • ☐ Seizure precautions

Practice Meningitis Cases

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