Meningitis (Suspected)
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Population Covered By The Guidance
This pathway provides guidance on the investigation of adult patients with suspected acute bacterial meningitis.
Date reviewed: May 2019
Date of next review: May 2023
Published: July 2019
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Teaching Points
Teaching Points
- Meningitis is a potentially devastating disease associated with a high mortality and morbidity
- In most patients lumbar puncture followed by early initiation of antibiotics is essential
- CT of the brain is recommended before LP in a select group of patients:
- Immunocompromised
- History of CNS disease (e.g. mass lesion, stroke, or focal infection)
- New onset seizure (within one week of presentation)
- Papilloedema
- Abnormal level of consciousness
- Focal neurological deficit
- Treatment should not be delayed while waiting for a CT. Unless contraindicated or an alternate diagnosis is found, an LP should be performed following CT in these patients
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Young N, Thomas M. Meningitis in adults: diagnosis and management. Intern Med J. 2018;48(11):1294-307 (Review article). View the reference
- Salazar L, Hasbun R. Cranial Imaging Before Lumbar Puncture in Adults With Community-Acquired Meningitis: Clinical Utility and Adherence to the Infectious Diseases Society of America Guidelines. Clin Infect Dis. 2017;64(12):1657-62 (Level III evidence). View the reference
- Mount HR, Boyle SD. Aseptic and Bacterial Meningitis: Evaluation, Treatment, and Prevention. Am Fam Physician. 2017;96(5):314-22 (Review article). View the reference
- Piquet AL, Lyons JL. Infectious Meningitis and Encephalitis. Semin Neurol. 2016;36(4):367-72 (Review article). View the reference
- de Campo J, Villanueva EV. Diagnostic Imaging Clinical Effectiveness fact sheet: suspected meningitis - role of lumbar puncture and computed tomography. Australas Radiol. 2005;49(3):252-3 (Clinical guidelines). View the reference
- Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267-84 (Level I evidence). View the reference
- Richie MB, Josephson SA. A Practical Approach to Meningitis and Encephalitis. Semin Neurol. 2015;35(6):611-20 (Review article). View the reference
- van de Beek D, Cabellos C, Dzupova O, Esposito S, Klein M, Kloek AT, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016;22 Suppl 3:S37-62 (Clinical guidelines). View the reference
- Costerus JM, Brouwer MC, van der Ende A, van de Beek D. Repeat lumbar puncture in adults with bacterial meningitis. Clin Microbiol Infect. 2016;22(5):428-33 (Level II evidence). View the reference
- McGill F, Heyderman RS, Michael BD, Defres S, Beeching NJ, Borrow R, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016;72(4):405-38 (Clinical guidelines). View the reference
- Mirrakhimov AE, Gray A, Ayach T. When should brain imaging precede lumbar puncture in cases of suspected bacterial meningitis? Cleve Clin J Med. 2017;84(2):111-3 (Review article). View the reference
- Mellor DH. The place of computed tomography and lumbar puncture in suspected bacterial meningitis. Archives of disease in childhood. 1992;67(12):1417-9 (Review article). View the reference
- Glimaker M, Johansson B, Grindborg O, Bottai M, Lindquist L, Sjolin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-9 (Level III evidence). View the reference
- Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001;345(24):1727-33 (Level II evidence). View the reference
- Rennick G, Shann F, de Campo J. Cerebral herniation during bacterial meningitis in children. Bmj. 1993;306(6883):953-5 (Level III evidence). View the reference
- April MD, Long B, Koyfman A. Emergency Medicine Myths: Computed Tomography of the Head Prior to Lumbar Puncture in Adults with Suspected Bacterial Meningitis - Due Diligence or Antiquated Practice? J Emerg Med. 2017;53(3):313-21 (Review article). View the reference
- Gopal AK, Whitehouse JD, Simel DL, Corey GR. Cranial computed tomography before lumbar puncture: a prospective clinical evaluation. Arch Intern Med. 1999;159(22):2681-5 (Level II evidence). View the reference
- Glimaker M, Johansson B, Bell M, Ericsson M, Blackberg J, Brink M, et al. Early lumbar puncture in adult bacterial meningitis--rationale for revised guidelines. Scand J Infect Dis. 2013;45(9):657-63 (Clinical guidelines). View the reference
- Costerus JM, Brouwer MC, Bijlsma MW, Tanck MW, van der Ende A, van de Beek D. Impact of an evidence-based guideline on the management of community-acquired bacterial meningitis: a prospective cohort study. Clin Microbiol Infect. 2016;22(11):928-33 (Level II evidence). View the reference
- Chia D, Yavari Y, Kirsanov E, Aronin SI, Sadigh M. Adherence to standard of care in the diagnosis and treatment of suspected bacterial meningitis. Am J Med Qual. 2015;30(6):539-42 (Level III evidence). View the reference
- Greig PR, Goroszeniuk D. Role of computed tomography before lumbar puncture: a survey of clinical practice. Journal of Neurology, Neurosurgery, and Psychiatry. 2006;77(7):833- (Level III evidence). View the reference
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