Management of community-acquired bacterial meningitis

Acute bacterial meningitis (ABM) is a potentially life-threatening neurological emergency. An agreed protocol for early, evidence-based and effective management of community-acquired ABM is essential for best possible outcome. A literature search of peer-reviewed articles on ABM was employed to collect data on the management of ABM in older children and adults. Based on the robustness of published evidence, a consensus guideline was developed for initial management, investigations, antibiotics and supportive therapy of community-acquired ABM. Patients with ABM should be rapidly hospitalized and assessed for consideration of lumbar puncture (LP) if clinically safe. Ideally, patients should have fast-track brain imaging before LP, but initiation of antibiotic therapy should not be delayed beyond 3 h after the first contact of the patient with health services. In every case, a blood sample must be sent for culture before initiating antibiotic therapy. Laboratory examination of cerebrospinal fluid is the most definitive investigation for ABM and, whenever possible, the choice of antibiotics and the duration of therapy should be guided by the microbiological diagnosis. Parenteral therapy with a third-generation cephalosporin is the initial antibiotic of choice in the absence of penicillin allergy and bacterial resistance; amoxicillin should be used in addition if meningitis due to Listeria monocytogenes is suspected. Vancomycin is the preferred antibiotic for penicillin-resistant pneumococcal meningitis. Dexamethasone should be administered in both adults and children with or shortly before the first dose of antibiotic in suspected cases of Streptococcus pneumoniae and H. influenzae meningitis. In patients presenting with rapidly evolving petechial skin rash, antibiotic therapy must be initiated immediately on suspicion of Neisseria meningitidis infection with parenteral benzyl penicillin in the absence of a known history of penicillin allergy