Meningitis

Acute bacterial meningitis is a medical emergency. A compatible syndrome, particularly fever, headache, neck stiffness, and altered cognition or consciousness, should trigger urgent evaluation; the absence of all four manifestations reduces the probability of bacterial disease, but individual meningeal signs have limited sensitivity. PubMedPubMedIntroduction - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf Stabilize airway, ventilation, circulation, seizures, and shock while obtaining blood cultures and preparing for lumbar puncture (LP). PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf

In hospital, administer empiric intravenous antimicrobials as early as possible. The WHO guideline identifies the first hour as the usual target window; LP and blood tests should precede therapy only when they can be completed safely without delaying treatment. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf Observational evidence associates earlier in-hospital antibiotic treatment with lower adult mortality, although a precise evidence-based cutoff remains uncertain. BMJBMJMeningitis (bacterial) and meningococcal disease: recognition, diagnosis and management—summary of updated NICE guidance

When LP can proceed, send CSF for Gram stain, white blood cell count and differential, protein, glucose with a paired blood glucose and CSF-to-blood glucose ratio, culture with antimicrobial susceptibility testing, and PCR-based testing for relevant pathogens. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf CSF lactate may assist differentiation of bacterial from viral meningitis before antibiotic exposure, but its value is limited after antibiotics or with competing central nervous system disorders. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf

A neutrophilic pleocytosis with low CSF glucose or low CSF-to-serum glucose ratio and increased protein is the classic pyogenic pattern, but no individual CSF measure confirms or excludes meningitis. Interpret the integrated profile alongside presentation, Gram stain, cultures, and molecular testing. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf Send blood cultures as soon as possible, preferably before antibiotics. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf Peripheral leukocyte count, C-reactive protein, and procalcitonin may contribute to diagnostic probability where available but must not defer LP or treatment. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf

Perform cranial imaging before LP when readily accessible if the patient has GCS below 10, focal neurologic signs, cranial nerve deficits, papilledema, new-onset seizure in an adult, or severe immunocompromise. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf If imaging is not readily accessible, defer LP in patients with these features until they resolve; obtain blood cultures and start antimicrobials immediately. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf

New-onset isolated seizure in a child does not independently require pre-LP cranial imaging when no other high-risk feature is present. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf Conversely, concern for hydrocephalus, mass lesion, cerebral edema, or altered consciousness should prompt neurocritical assessment and imaging once treatment has begun. PubMedPubMedIntroduction - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf

For suspected or probable acute bacterial meningitis, use intravenous ceftriaxone or cefotaxime as empiric therapy. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf Add intravenous ampicillin or amoxicillin when Listeria risk is present: age over 60 years, pregnancy, immunocompromise, transplantation, malignancy, advanced HIV disease, diabetes, end-stage kidney disease, cirrhosis, or alcohol use disorder. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf Consider intravenous vancomycin where local pneumococcal resistance to penicillin or third-generation cephalosporins is high. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf

Once culture and susceptibility results are available, narrow and optimize therapy. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf The supplied sources do not provide U.S. agent dosing, renal-adjustment specifications, or organism-specific treatment durations; use current local susceptibility data, institutional pathways, and prescribing references for these details.

Viral meningitis is commonly self-limited, but severe disease and immunocompromise require heightened attention. In the United States, enteroviruses are leading causes; herpesviruses and influenza may have actionable antiviral treatment considerations. Most mild viral meningitis improves within 7 to 10 days, whereas severe illness or high-risk patients may require hospitalization. CDCCDCAbout Viral Meningitis

Fungal meningitis is uncommon but life-threatening. Consider it with advanced immune compromise, relevant endemic fungal exposure, or recent epidural anesthesia, injection, or invasive procedure. Fungal cultures can be negative and may take up to 2 weeks to turn positive; CDC advises immediate treatment after CSF acquisition when fungal meningitis is suspected and not withholding therapy because culture or beta-D-glucan is negative. CDCCDCClinical Overview of Fungal Meningitis | Meningitis | CDC

Tuberculous meningitis is outside routine acute bacterial pathways and often needs empiric treatment despite nondiagnostic testing. No single negative test excludes disease; CSF Xpert MTB/RIF Ultra is preferred when available, but should be paired with mycobacterial culture and clinical-imaging assessment. PubMedPubMedA Clinical Practice Guideline for Tuberculous Meningitis

Before discharge, assess for neurologic, sensory, functional, psychosocial, and care-support needs, and establish a documented follow-up plan. WHO recommends a clinician review for all children and adults before discharge and at least once within 4 weeks after discharge. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf Formal audiologic screening should occur before discharge or, if not feasible, within 4 weeks; even those with an initially normal screen should have repeat formal assessment because delayed hearing loss can occur. PubMedPubMedExecutive summary - WHO guidelines on meningitis diagnosis, treatment and care - NCBI Bookshelf

A 2026 systematic review and meta-analysis found meningitis-related sequelae in 18% of assessed adults and 24% of assessed children. In adults, pooled sequelae prevalence was 24.8% at discharge, 41.5% within 3 months, and 31.9% beyond 3 months; in children, pooled prevalence was 28.9% at discharge, 29.9% within 3 months, and 38.2% beyond 3 months. PubMedPubMedDetection of sequelae from acute meningitis during clinical review by a healthcare provider: a systematic review and meta-analysis - PMC These data support both discharge assessment and longitudinal reassessment rather than a single follow-up encounter.