Diagnosis, Initial Management,

and Prevention of Meningitis

DAVID M. BAMBERGER, MD, University of MissouriKansas City School of Medicine, Kansas City, Missouri

Although the annual incidence of bacterial meningitis in the United States is declining, it remains a medical emergency with a potential for high morbidity and mortality. Clinical signs and symptoms are unreliable in distinguishing
bacterial meningitis from the more common forms of aseptic meningitis; therefore, a lumbar puncture with cerebrospinal fluid analysis is recommended. Empiric antimicrobial therapy based on age and risk factors must be started
promptly in patients with bacterial meningitis. Empiric therapy should not be delayed, even if a lumbar puncture
cannot be performed because results of a computed tomography scan are pending or because the patient is awaiting
transfer. Concomitant therapy with dexamethasone initiated before or at the time of antimicrobial therapy has been
demonstrated to improve morbidity and mortality in adults with Streptococcus pneumoniae infection. Within the
United States, almost 30 percent of strains of pneumococci, the most common etiologic agent of bacterial meningitis,
are not susceptible to penicillin. Among adults in developed countries, the mortality rate from bacterial meningitis is
21 percent. However, the use of conjugate vaccines has reduced the incidence of bacterial meningitis in children and
adults. (Am Fam Physician. 2010;82(12):1491-1498. Copyright 2010 American Academy of Family Physicians.)

Patient Information:
A handout on the pneumococcal conjugate vaccine is
available at http://family
doctor.org/691.xml.

cute meningitis is a medical emergency with a potential for high morbidity and mortality. Bacterial
meningitis is life threatening,
and must be distinguished from the more
common aseptic (viral) meningitis. With
increased use of conjugate vaccines, the
annual incidence of bacterial meningitis in
the United States declined from 1.9 to 1.5
cases per 100,000 persons between 1998
and 2003, with an overall mortality rate of
15.6 percent.1-3 Incidence rates in developing
countries remain significantly higher.
Etiology
Age, immunosuppression, and neurosurgical
procedures increase the likelihood of infection from specific pathogens (Table 1).3,4 In
persons with community-acquired meningitis, aseptic meningitis is significantly
more common than bacterial meningitis;
96 percent of children with cerebrospinal fluid
(CSF) pleocytosis have aseptic meningitis.5
The most common etiologies of aseptic meningitis are enterovirus, herpes simplex virus
(HSV), and Borrelia burgdorferi infections. In
adults, the incidence of aseptic meningitis is
7.6 cases per 100,000 persons, and the most
common etiologies are enterovirus, HSV,
and varicella-zoster virus infections.6 Other

pathogens and diseases associated with aseptic meningitis include Treponema pallidum,
Mycoplasma pneumoniae, Rocky Mountain
spotted fever, ehrlichiosis, mumps, lymphocytic choriomeningitis virus, and acute retroviral syndrome associated with human
immunodeficiency virus (HIV) infection.
Patients with mosquito-borne arboviral
infections (e.g., West Nile virus, St. Louis
encephalitis, the California encephalitis group) often present with encephalitis;
however, they may present with meningeal
involvement alone and no neurologic manifestations. Seasonality is important in
predicting the likelihood of aseptic meningitis, because most enteroviral and arboviral infections occur in the summer or fall in
temperate climates. Tuberculous and fungal
meningitis are less common in the United
States, and usually produce more chronic
symptoms. Cryptococcal meningitis is common in patients with altered cellular immunity, especially in those with advanced HIV
infection (e.g., CD4 cell count of less than
200 cells per mm3 [200 109 per L]).
Clinical Presentation
In adults with community-acquired bacterial meningitis, 25 percent have recent otitis
or sinusitis, 12 percent have pneumonia, and

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Meningitis
Table 1. Common Etiologies of Bacterial Meningitis and Recommended Empiric Therapy*
Population

Likely pathogen

Empiric therapy

Infants younger than one month

Streptococcus agalactiae (group B streptococcus), Listeria

monocytogenes, Escherichia coli, other gram-negative bacilli

Ampicillin and cefotaxime

(Claforan)

Children one to 23 months of age

Streptococcus pneumoniae, Neisseria meningitidis, S. agalactiae,

Haemophilus influenzae, E. coli

Vancomycin and ceftriaxone

(Rocephin)

Children and adults two to

50 years of age

N. meningitidis, S. pneumoniae

Vancomycin and ceftriaxone

Adults older than 50 years, with

altered cellular immunity, or
with alcoholism

S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gramnegative bacilli

Vancomycin, ceftriaxone,
and ampicillin

Patients with basilar skull fracture

or cochlear implant

S. pneumoniae, H. influenzae, group A beta-hemolytic streptococci

Vancomycin and ceftriaxone

Patients with penetrating trauma

or postneurosurgery

Staphylococcus aureus, coagulase-negative staphylococci, aerobic

gram-negative bacilli (including Pseudomonas aeruginosa)

Vancomycin and cefepime

(Maxipime)

Patients with cerebrospinal fluid

shunt

Coagulase-negative staphylococci, S. aureus, aerobic gram-negative

bacilli (including P. aeruginosa), Propionibacterium acnes

Vancomycin and cefepime

*In 2002-2003 among all age groups in the United States, 61 percent of bacterial meningitis was caused by S. pneumoniae, 16 percent by
N. meningitidis, 14 percent by S. agalactiae (group B streptococcus), 7 percent by H. influenzae, and 2 percent by L. monocytogenes.3
Adapted with permission from Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect
Dis. 2004;39(9):1275, with additional information from reference 3.

16 percent are immunocompromised.7 Typical clinical

features are listed in Table 2.7 At least one of the cardinal
features of fever, neck stiffness, and altered mental status
is present in 99 to 100 percent of patients with meningitis; when headache is included, two of the four features
are observed in 95 percent of patients with meningitis.7,8
The Kernig and Brudzinski signs are poorly sensitive but

Table 2. Clinical and Laboratory Findings

in Adults with Bacterial Meningitis

Clinical or laboratory feature

Sensitivity
(%)

Two of the following features: fever, neck

stiffness, altered mental status, and headache

95

Cerebrospinal fluid white blood cell count

100 per L (0.10 109 per L)

93

Headache

87

Neck stiffness

83

Fever 100.4F (38C)

77

Nausea

74

Altered mental status (Glasgow Coma Scale

score < 14)

69

Growth of organism in blood culture

66

Triad of fever, neck stiffness, and altered

mental status

44

Focal neurologic signs

33

Seizure

Papilledema

Information from reference 7.

1492 American Family Physician

highly specific for bacterial meningitis.9 Sixty-three percent of patients with meningococcal meningitis present
with a rash that is usually petechial.7 Petechial rash may
also be caused by Haemophilus influenzae or Streptococcus pneumoniae infection. Pneumococcal meningitis is
more likely than meningococcal meningitis to be associated with seizures, focal neurologic findings, and altered
consciousness.
Compared with younger adults, persons 65 years and
older with bacterial meningitis are less likely to have
headache, nausea, vomiting, and nuchal rigidity, and
are more likely to have seizures and hemiparesis.10 Similarly, the classical features of bacterial meningitis are not
observed as often in younger children, who may present
with subtle findings, such as lethargy and irritability.11
A recent history of upper respiratory tract infection is
common in children with bacterial meningitis; children are also more likely than adults to experience a seizure.12 The illness course varies, with progression over
hours to several days. The clinical features are nonspecific. For example, in a study of 297 adults who underwent a lumbar puncture for suspected meningitis, only
80 (27 percent) had any degree of CSF pleocytosis, only
20 (6.7 percent) had a white blood cell count of 100 cells
per L [0.10 109 per L] or higher, and only three (1 percent) had culture-confirmed bacterial meningitis.9
Initial Evaluation
Given the lack of specificity of clinical findings, the key
to the diagnosis of meningitis is the evaluation of CSF.13
The peripheral white blood cell count alone is not helpful in distinguishing bacterial from aseptic meningitis,

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Meningitis

Initial Management of Suspected Acute Meningitis

Patient presents with suspected meningitis

Initiate droplet precautions

Adequate respiratory and circulatory status,

and likely normal coagulation status based
on history and physical examination?

No

Go to A

Initiate therapy for respiratory,

circulatory, and coagulation status

Yes
Central nervous system disease*; adult with
a new-onset seizure or moderately to severely
impaired level of consciousness; or delay in
ability to perform lumbar puncture?4,16-18

No

Perform lumbar puncture

and blood cultures

Spinal fluid cloudy?

Yes

No

A Obtain blood cultures and initiate antimicrobial therapy

If patient is an adult with likely pneumonococcal meningitis,
initiate concomitant dexamethasone

Yes
CSF suggestive of
bacterial meningitis?

Perform computed tomography or magnetic resonance imaging

Scan reveals mass effect

or cerebral edema?
Yes
Reconsider diagnosis based
on clinical, laboratory, and
radiographic findings

No

No

Perform lumbar puncture

No
CSF suggestive of
bacterial meningitis?
Yes

Yes
Suspicion of bacterial meningitis
remains high based on young age,
neutropenia, immunosuppression, or
evidence of meningococcal meningitis?
No

Continue therapy
Meningitis likely?
Yes

No

Yes

Reconsider
diagnosis

Reconsider diagnosis

Initiate (or continue)

antimicrobial therapy
Initiate concomitant
dexamethasone in
an adult with likely
pneumonococcal
meningitis

Continue therapy
*Includes CSF shunts, hydrocephalus, trauma, space-occupying lesions or recent neurosurgery, immunocompromised state, papilledema, or focal
neurological signs.

Figure 1. Algorithm for the initial management of suspected acute meningitis. (CSF = cerebrospinal fluid.)
Information from references 4, and 16 through 18.

particularly in young children (i.e., a normal white blood

cell count does not rule out bacterial meningitis).14 Meningitis should be suspected in patients with those features
previously noted that cannot be fully explained by other
diagnoses. Lumbar puncture is a safe procedure, although
postprocedure headache occurs in about one third of
patients.15 (A video of a lumbar puncture is available at
http://content.nejm.org/cgi/content/short/355/13/e12.)
The concern with lumbar puncture is the poorly quantified risk of herniation in patients with a space-occupying
lesion or severe diffuse cerebral swelling, and the degree to
which the risk can be recognized by a previous computed
tomography scan. Life-threatening herniation from lumbar puncture has not been reported in patients who are
neurologically unremarkable before the procedure.16
Based on patient series17 and guidelines,4,18 patients with
risk factors for occult intracranial abnormalities should
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Volume 82, Number 12

undergo computed tomography of the brain before

lumbar puncture. This includes patients with central
nervous system disease (including CSF shunts, hydrocephalus, trauma, space-occupying lesions or recent
neurosurgery, immunocompromised state, papilledema,
focal neurologic signs) and adults with new-onset seizures or moderately to severely impaired consciousness
(Figure 14,16-18). During the initial evaluation of a patient
with suspected meningitis, diagnostic and therapeutic
maneuvers should begin concomitantly. If a computed
tomography scan is required before a lumbar puncture,
blood cultures should be obtained, followed by prompt
initiation of empiric antimicrobial therapy before the
scan. Adjunctive therapy with dexamethasone should be
added in adults with suspected S. pneumoniae infection.19
After CSF is obtained, the Gram stain results, white
and red blood cell counts, glucose levels, and protein

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American Family Physician 1493

Meningitis
Table 3. Typical CSF Parameters in Patients with Meningitis
White blood cells
per L ( 109 per L)

Percentage
of neutrophils

Glucose
level

Protein level in
mg per dL (g per L)

Likelihood of observing
organism on CSF stain

Pyogenic (not Listeria

monocytogenes)

> 500 (0.50)

> 80

Low

> 100 (1.00)

~70 percent

L. monocytogenes

> 100 (0.10)

~50

Normal

> 50 (0.50)

~30 percent

Partially treated pyogenic

> 100

~50

Normal

> 70 (0.70)

~60 percent

Aseptic, often viral

10 to 1,000
(0.01 to 1.00)

Early: > 50

Normal

< 200 (2.00)

Not applicable

Tubercular

50 (0.05) to 500

< 30

Low

> 100

Rare

Fungal

50 to 500

< 30

Low

Varies

Often high in cryptococcus

Pathogen

Late: < 20

CSF = cerebrospinal fluid.

Table 4. Clinical Decision Rules to Distinguish Bacterial from Aseptic Meningitis

in Children with CSF Pleocytosis*
Rule

Bacterial Meningitis Score5

Meningitest21

Exclusion criteria

Neurosurgical history

Neurosurgical history

Immunosuppression

Immunosuppression

CSF red blood cell count 0.01 10 6 per L

(0.01 1012 per L)

CSF red blood cell count 0.01 10 6 per L

Antibiotic use in the previous 48 hours

Antibiotic use in the previous 48 hours

Purpura
Criteria (further evaluation,
including lumbar puncture, is
needed in patients with one or
more findings)

Positive CSF Gram stain

Positive CSF Gram stain

Seizure

Seizure

Blood neutrophil count 10,000 per L

(10.00 109 per L)

Purpura

CSF neutrophil count 1,000 per L

(1.00 109 per L)
Sensitivity (95% confidence interval)

Toxic appearance (irritability, lethargy, or low

capillary refill)
CSF protein level 50 mg per dL (0.50 g per L)

CSF protein level 80 mg per dL (0.80 g per L)

Serum procalcitonin level 0.5 ng per mL

99 percent (99 to 100)

100 percent (96 to 100)

CSF = cerebrospinal fluid.

*White blood cell count 10 per L (0.01 109 per L).
Adapted with permission from Dubos F, Martinot A, Gendrel D, Brart G, Chalumeau M. Clinical decision rules for evaluating meningitis in children.
Curr Opin Neurol. 2009;22(3):292, with additional information from reference 5.

levels should be evaluated immediately. Although no

single measure is diagnostic, a combination of abnormal
CSF findings is highly suggestive of meningitis and helpful in determining the likely etiology (Table 3). Rarely,
patients with bacterial meningitis may present with normal or near-normal white blood cell counts, glucose levels, and protein levels. This has been observed in young
children with neutropenia and other immunocompromised states, and very early in the course of meningococcal meningitis.20 Lack of CSF leukocytosis and normal
CSF glucose levels are also common in patients with
HIV infection and cryptococcal meningitis, but the CSF
cryptococcal antigen test is highly sensitive and specific.
Patients with partially treated bacterial meningitis and
1494 American Family Physician

those with Listeria infection may have a CSF profile that

is similar to aseptic meningitis. In children who have not
received previous antimicrobial agents, clinical decision
rules are useful in identifying those at low risk of bacterial meningitis and, if otherwise clinically stable, who
are eligible for careful observation without antimicrobial
therapy (Table 4).5,21
Bacterial Meningitis
Initial empiric therapy of bacterial meningitis is based
on the patients age, risk factors, and clinical features
(Table 1).3,4 In patients with suspected bacterial meningitis, empiric therapy should not be delayed for more
than one hour while awaiting diagnostic testing or

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Meningitis
Table 5. Pathogen-Specific Therapy for Common Causes of Bacterial Meningitis

Pathogen*

Recommended therapy

Adult dosage
(intravenous)

Streptococcus pneumoniae
Penicillin MIC:
< 0.1 mcg per mL

Penicillin

4 million units every

four hours

Penicillin MIC: 0.1 to

1 mcg per mL

Ceftriaxone (Rocephin)

2 g every 12 hours

Penicillin MIC:
2 mcg per mL

Vancomycin

15 to 22.5 mg per
kg every 12 hours

Ceftriaxone MIC:
1 mcg per mL

plus
Ceftriaxone

2 g every 12 hours

Vancomycin

15 to 22.5 mg per
kg every 12 hours

plus

Days of therapy

Alternative therapy

10 to 14

Meropenem (Merrem),
moxifloxacin (Avelox), or
chloramphenicol

Ceftriaxone

2 g every 12 hours

Neisseria meningitidis

Ceftriaxone

2 g every 12 hours

Five to seven

Chloramphenicol, meropenem,
or moxifloxacin

Haemophilus influenzae

Ceftriaxone

2 g every 12 hours

Seven to 10

Chloramphenicol or moxifloxacin

Streptococcus agalactiae
(group B streptococcus)

Ampicillin

Usually in children

14 to 21

Vancomycin or cefotaxime
(Claforan)

2 g every four hours

21

Trimethoprim/sulfamethoxazole
(Bactrim, Septra)

plus
Gentamicin

Listeria monocytogenes

Ampicillin
with or without

Enterobacteriaceae

Gentamicin

1 to 2 mg per kg
every eight hours

Ceftriaxone, ceftazidime
(Fortaz), or cefepime
(Maxipime)

Varies

21 to 28

Ciprofloxacin (Cipro),
meropenem, or trimethoprim/
sulfamethoxazole

Seven to 10 days
after shunt removal
or cerebrospinal
fluid sterilization

Daptomycin (Cubicin) or
linezolid (Zyvox), consider
adding rifampin

with or without
Gentamicin
Staphylococci
Methicillin susceptible

Nafcillin

2 g every four hours

Methicillin resistant

Vancomycin

15 to 22.5 mg per
kg every 12 hours

MIC = minimal inhibitory concentration.

*Listed in order of most likely to least likely.
Cefotaxime may be used instead.
Consider adding rifampin. Vancomycin penetration into cerebrospinal fluid may be diminished with concomitant dexamethasone, but adequate
levels are achieved with continuous infusion at 60 mg per kg.27
For the first seven to 10 days.
Information from references 4, 11, 16, 18, 26, and 27.

transfers.4,18,22,23 Although no prospective comparative

trials have been performed, observational studies have
found that delays in therapy of as little as two to six hours
are associated with adverse outcomes.22,23 Factors associated with a delay in antimicrobial therapy include failure
to receive antimicrobials before transfer from another
facility; performance of head computed tomography
before lumbar puncture and antimicrobial administration; and the absence of the cardinal features of fever,
neck stiffness, and altered mental status. When administered just before antimicrobial therapy is initiated, concomitant use of dexamethasone for four days has been
shown to reduce mortality and improve neurologic outcomes in adults with S. pneumoniae infection.19 It has not
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Volume 82, Number 12

been shown to improve outcomes in other patient groups.

Studies of patients in the developing world who have a
high likelihood of HIV infection have not shown a clear
benefit with adjunctive dexamethasone for pyogenic bacterial meningitis.24,25 Fluid management includes treatment for possible dehydration or hyponatremia from the
syndrome of inappropriate antidiuretic hormone.
After the results of the Gram stain, culture, and susceptibility tests are available, specific therapy targeting
the pathogen should be administered (Table 54,11,16,18,26,27).
Blood cultures drawn before antimicrobial administration are positive in 61 to 66 percent of patients.5,7 Initiation of antimicrobials before lumbar puncture decreases
the yield of CSF culture, the likelihood of a low CSF

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American Family Physician 1495

Meningitis

glucose level, and the degree of elevation of CSF protein;

however, it does not markedly influence the results of
CSF Gram stain, which is positive in 60 to 70 percent of
patients.26,28
Polymerase chain reaction testing of CSF is more
sensitive than CSF culture, particularly in patients who
received previous antimicrobials.29,30 However, antimicrobial susceptibility testing, which is important in the
treatment and prevention of meningitis, can be performed only when the organism is grown in culture. In
one series in the United States, 28 percent of pneumococci from patients with meningitis were not susceptible
to penicillin, 6 percent were not susceptible to chloramphenicol, 17 percent were not susceptible to meropenem
(Merrem), and 12 percent were not susceptible to cefotaxime (Claforan).1 Because of this degree of resistance,
the administration of empiric therapy with vancomycin and a third-generation cephalosporin (cefotaxime
or ceftriaxone [Rocephin]) is recommended until the
results of susceptibility tests are known.
Aseptic Meningitis
Enteroviruses are the most common etiologic pathogens
in persons with aseptic meningitis and do not require
specific antimicrobial therapy. They can be diagnosed
by CSF polymerase chain reaction testing,6 which is not
always needed, but a positive test may be useful in discontinuing antimicrobials initiated presumptively for
bacterial meningitis. If suggested by the patients sexual
or substance use history, it is appropriate to order serum
reactive plasma reagin (RPR), CSF Venereal Disease
Research Laboratory (VDRL), serum HIV antibody, and
serum HIV polymerase chain reaction tests. In acute
HIV seroconversion, the serum HIV antibody test may
be negative at the time of clinical presentation.
HSV aseptic meningitis is usually a self-limited infection that must be distinguished from HSV encephalitis
based on clinical and radiographic features; therapy with
acyclovir (Zovirax) can be lifesaving in patients with
HSV encephalitis. In contrast with HSV encephalitis,
most patients with HSV aseptic meningitis have normal
mental status and neurologic function, and do not have
enhancement observed on magnetic resonance imaging
of the temporal lobe. Both forms of HSV central nervous
system disease are diagnosed by CSF HSV polymerase
chain reaction testing. Infection with HSV may cause
recurrent disease (e.g., Mollaret meningitis). Varicellazoster virus infection may cause aseptic meningitis in
the absence of cutaneous manifestations.6 Although it
has not been studied in clinical trials, therapy with acyclovir at 10 mg per kg every eight hours is suggested,
1496 American Family Physician

based on expert opinion. Central nervous system Lyme

disease is treated with ceftriaxone for 14 to 28 days, and
central nervous system syphilis is treated with intravenous penicillin for 10 to 14 days.
Tuberculous and Cryptococcal Meningitis
A high index of suspicion is needed to diagnose tuberculous meningitis because culture results are often delayed
and stains are often negative. Empiric therapy may be
lifesaving. Polymerase chain reaction testing may be useful. Initial treatment is a combination of isoniazid (5 mg
per kg per day in adults, 10 mg per kg per day in children,
up to 300 mg); rifampin (10 mg per kg per day in adults,
10 to 20 mg per kg per day in children, up to 600 mg); pyrazinamide (15 to 30 mg per kg per day, up to 2 g); and ethambutol (15 to 25 mg per kg per day). Streptomycin (20 to
40 mg per kg per day, up to 1 g) should be used in lieu of
ethambutol in young children.31 Adding dexamethasone
to the treatment regimen improves mortality in patients
older than 14 years with tuberculous meningitis.32
Cryptococcal meningitis is the most common fungal
meningitis, and usually occurs in patients with altered
cellular immunity. Initial treatment includes amphotericin B (0.7 to 1.0 mg per kg per day intravenously) plus flucytosine (Ancobon; 25 mg per kg every six hours orally).33
Prognosis
The mortality rate in adults with bacterial meningitis in
developed countries is 21 percent; it is higher in patients
with pneumococcal disease than in those with meningococcal disease.7 Neurologic sequelae include hearing loss
in 14 percent of patients and hemiparesis in 4 percent.7
Risk factors for adverse outcomes include advanced age,
alteration of mental status on admission, bacteremia,
and a CSF white blood cell count of less than 1,000 per L
(1.00 109 per L).7 The mortality rate in children with
bacterial meningitis is 3 percent; the incidence of stroke
in children with bacterial meningitis is 3 percent.34
Prevention
Conjugate vaccines for H. influenzae type B and S. pneumoniae initiated in early childhood have been highly effective in reducing the incidence of bacterial meningitis, not
only in children but also in adults.1,2 Although the overall
incidence of pneumococcal meningitis has declined with
the use of the conjugate vaccine, the percentage of meningitis cases caused by nonvaccine serotypes has increased,
as did the percentage of isolates that were not susceptible
to penicillin and cefotaxime.1 A newer conjugate vaccine
for Neisseria meningitidis (active against serogroups A, C,
W135, and Y, but not serogroup B) is recommended in all

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Meningitis
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
rating

References

Evaluation of cerebrospinal fluid is key to the diagnosis of meningitis. Decision rules using clinical and
laboratory findings are highly sensitive in diagnosing meningitis in children.

5, 8, 13, 21

Patients with risk factors for occult intracranial abnormalities should undergo computed tomography of the
brain before lumbar puncture.

17

If bacterial meningitis is suspected, empiric therapy with antimicrobials should not be delayed for more than
one hour in patients awaiting diagnostic testing or transfers.

4, 18, 22, 23

Adults with Streptococcus pneumoniae or Mycobacterium tuberculosis infection should receive concomitant
dexamethasone with antimicrobial therapy to reduce mortality and improve neurologic outcomes.

19, 25, 32

Conjugate vaccines for S. pneumoniae and Haemophilus influenzae type B are recommended for patients
in appropriate risk groups to reduce the incidence of bacterial meningitis.

1, 2

Clinical recommendation

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.xml.

Table 6. Chemoprophylaxis for Bacterial Meningitis

Pathogen

Indication

Neisseria
meningitidis
(postexposure
prophylaxis)

Close contact (for more than

eight hours) with someone with
N. meningitidis infection

Antimicrobial
agent
Rifampin
or

Dosage

Comments

Adults: 600 mg every 12 hours for two

days

Not fully
effective and
rare resistant
isolates

Children one month or older: 10 mg per

kg every 12 hours for two days

Contact with oral secretions of

someone with N. meningitidis
infection

Children younger than one month: 5 mg

per kg every 12 hours for two days
Ciprofloxacin
(Cipro)

Adults: single dose of 500 mg

Rare resistant
isolates

Ceftriaxone
(Rocephin)

Single intramuscular dose of 250 mg

(125 mg if younger than 15 years)

or

Haemophilus
influenzae
(postexposure
prophylaxis)

Living in a household with

one or more unvaccinated or
incompletely vaccinated children
younger than 48 months

Rifampin

20 mg per kg per day, up to 600 mg per

day, for four days

Streptococcus
agalactiae
(group B
streptococcus;
women in the
intrapartum
period)

Previous birth to an infant with

invasive S. agalactiae infection

Penicillin G

Initial dose of 5 million units intravenously,

then 2.5 to 3 million units every four
hours during the intrapartum period

Colonization at 35 to 37 weeks
gestation
Bacteriuria during pregnancy
High risk because of fever,
amniotic fluid rupture for more
than 18 hours, or delivery
before 37 weeks gestation

or
If allergic to
penicillin:
Cefazolin

2 g followed by 1 g every eight hours

or
Clindamycin
(Cleocin)

900 mg every eight hours

or
Vancomycin

Clindamycin
susceptibility
must be
confirmed by
antimicrobial
susceptibility
test

15 to 20 mg per kg every 12 hours

Information from references 11, 18, and 36.

children 11 to 18 years of age; freshmen entering college

dormitories; travelers to regions in which meningococcal disease is endemic (e.g., sub-Saharan Africa; Mecca,
Saudi Arabia, during the Hajj); and persons with complement component deficiencies.35 Patients with functional
or anatomic asplenia should receive the meningococcal,
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Volume 82, Number 12

pneumococcal, and H. influenzae vaccines. Patients hospitalized with N. meningitidis infection or meningitis of
uncertain etiology require droplet precautions for the
first 24 hours of treatment, or until N. meningitidis can
be ruled out. Chemoprophylaxis recommendations are
listed in Table 6.11,18,36

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American Family Physician 1497

Meningitis

The Author
DAVID M. BAMBERGER, MD, is a professor of medicine at the University of
MissouriKansas City School of Medicine.
Address correspondence to David M. Bamberger, MD, 2411 Holmes St.,
Kansas City, MO 64108 (e-mail: bambergerd@umkc.edu). Reprints are
not available from the author.

the management of community-acquired bacterial meningitis: report of

an EFNS Task Force on acute bacterial meningitis in older children and
adults [published correction appears in Eur J Neurol. 2008;15(8):880].
Eur J Neurol. 2008;15(7):649-659.
19. de Gans J, van de Beek D; European Dexamethasone in Adulthood
Bacterial Meningitis Study Investigators. Dexamethasone in adults with
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www.aafp.org/afp

Volume 82, Number 12

December 15, 2010