Bacterial Meningitis / Meningococcal Disease

Bacterial meningitis is a medical emergency with a mortality of 20% and significant morbidity. Do NOT wait for CT or LP to give antibiotics if there is clinical suspicion. Meningococcal disease (meningitis + septicaemia) can deteriorate within hours.

Meningitis UK Pathway

The pathway

1 · Recognise

Classic triad: headache + photophobia + neck stiffness (only present in 44% together)
Non-blanching petechial/purpuric rash = meningococcal septicaemia until proven otherwise
Kernig's and Brudzinski's signs

2 · Immediate antibiotics

Ceftriaxone 2g IV immediately. In penicillin-allergic: chloramphenicol 25mg/kg IV. Do NOT delay for CT or LP if meningitis is suspected — every 30 minutes delay increases mortality.

3 · Dexamethasone

0.15mg/kg QDS (max 10mg QDS) IV — given with or before first antibiotic dose. Give for 4 days. Reduces hearing loss and neurological complications in pneumococcal meningitis.

4 · LP — assess safety first

Contraindications to LP:

Reduced GCS
Focal neurology
Papilloedema
Recent seizure
Coagulopathy
Rash of meningococcal septicaemia

If safe: LP before antibiotics ideally, but never delay Abx for LP.

5 · Blood cultures + PCR

Blood cultures before antibiotics if possible (doesn't delay treatment)
Meningococcal PCR on EDTA blood — positive even after antibiotics
Throat swab
LP: CSF MC&S, protein, glucose, lactate, PCR

6 · Supportive care

IV fluids (cautious in cerebral oedema risk)
Seizure management (lorazepam)
Monitor ICP: nurse 30° head-up, avoid hypotonic fluids
Notify Public Health England (PHE) — notifiable disease
Prophylaxis for close contacts (ciprofloxacin)

Drugs

Drug	Dose	Route	Notes
Ceftriaxone	2g	IV	Q12h (Q24h in some protocols). First-line. Administer IMMEDIATELY.
Benzylpenicillin	1.2g	IV	Pre-hospital / GP. Give if meningococcal disease suspected before hospital.
Dexamethasone	0.15mg/kg (max 10mg) QDS	IV	4-day course. Start with or before first antibiotic dose.
Chloramphenicol	25mg/kg	IV	If true penicillin/cephalosporin allergy. Q6h.

When to escalate

GCS <8 or falling — ITU, consider intubation,Purpuric rash spreading — meningococcal septicaemia, full sepsis care + ITU,Refractory seizures — anti-epileptics + ITU,Signs of raised ICP (Cushing's triad, papilloedema) — CT + neurosurgery,Waterhouse-Friderichsen syndrome (adrenal haemorrhage) — hydrocortisone IV

Reference: NICE NG240 Meningitis (bacterial) and meningococcal disease 2024 (replaced CG102) / Meningitis Now

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