Meningitis and encephalitis

a Glucose: 1 mg/dL = 0.0555 mmol/L.

Critical management

  • Antibiotic treatment should not be delayed for CT scan or until lumbar puncture results are available.
  • Empiric antibiotics are based on common organisms by age:

    • 2–50 years old: N. meningitides, S. pneumoniae.
    • >50 years old: S. pneumoniae, N. meningitides, L. monocytogenes.

  • A standard empiric regimen for meningitis in adults is

    • Ceftriaxone 2 g IV every 12 hours and vancomycin 30 mg/kg loading and dosing every 12 hours for trough concentration of 15–20 micrograms/mL.
    • Ampicillin 2 g IV every 4 hours for patients older than 50 years.
    • Acyclovir 10 mg/kg IV every 8 hours for suspected HSV encephalitis.

  • Adjunctive dexamethasone is also recommended at 10 mg IV every 6 hours initiated prior to or concurrent with antibiotic therapy.

Special circumstances

  • Patients with a history of shunt, recent neurosurgery, or penetrating trauma should receive anti-pseudomonal coverage as well.
  • Clinical findings and lumbar puncture results can be much more subtle in immunocompromised patients.

Sudden deterioration

  • The most likely causes of decompensation are hemodynamic or respiratory impairment.
  • Patients should be evaluated for airway protection and those who are at risk of aspiration should be endotracheally intubated.
  • Patients who are hypotensive are likely septic and should be managed aggressively with fluids and pressors according to early goal-directed therapy protocols.
  • Nonconvulsive or convulsive status epilepticus can occur with encephalitis and should be managed with benzodiazepines as first-line agents.

Vasopressor of choice: Hypotensive patients are likely septic and should be managed with norepinephrine as a first-line agent.


Attia J, Hatala R, Cook DJ, et al. Does this adult patient have acute meningitis? JAMA. 1999; 282: 175–81.

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Feb 17, 2017 | Posted by in CRITICAL CARE | Comments Off on Meningitis and encephalitis

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