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<< Adult Acute Bacterial Meningitis In The United States: 2009 Update
Risk Management Pitfalls For Meningitis
- “Bacterial meningitis was at the top of my list, but I wanted to wait for the CT scan and LP results before I initiated antibiotics.” Waiting for a CT scan to be completed and then interpreted, followed by an LP and an additional wait for the laboratory results, can cause significant delays of up to several hours. In a sick patient with altered mental status, focal neurologic deficits, or hypotension, time to antibiotics may be of critical importance. Parenteral antibiotics and steroids should be administered before CT scanning or the LP is complete (with blood cultures ideally obtained beforehand).
- “I knew the patient had AIDS and was posturing. I thought I should perform the LP as quickly as possible to evaluate for infectious meningitis.” Although an LP has critical value in the diagnosis of meningitis, do not overlook the fact that this patient may have a contraindication to LP (ie, evidence of increased ICP) or an alternative diagnosis (eg, brain abscess, toxoplasmosis) that would be picked up by cranial CT scan. There are established recommendations for performing a CT scan prior to an LP in patients with compromised immune systems.
- “I can’t believe that older man had bacterial meningitis. Although he did have a headache and was mildly confused, he did not have fever or neck stiffness.” Elderly patients may not present with the typical signs and symptoms of meningitis. Although fever commonly occurs, a temperature in the reference range or hypothermia is also possible. A study of 84 afebrile elderly patients with altered mental status found that 15 of these patients (18%) had abnormal LP results (95% CI, 10%-26%). A final diagnosis of meningitis was made for 10 of the 15 patients (bacterial meningitis, 2 patients; aseptic meningitis, 6 patients; lymphomatous meningitis, 2 patients).172
- “There is no way she could have bacterial meningitis. Her symptoms have persisted for 5 days. If she has had untreated bacterial meningitis for that long, she’d be dead." In a large review of adult patients with ABM, only 50% of the patients reported a symptom duration of less than 24 hours.39 Many patients will describe flulike symptoms for several days preceding the onset of worsening headache and neck pain. Unfortunately, there is currently no reliable way to distinguish a viral syndrome from early meningitis other than doing an LP with CSF analysis. Although some lawyers and medical experts may argue that a WBC count should be obtained in these patients, no guidelines recommend use of this test in adults to determine if they will benefit from an LP.
- “I got the antibiotics on as quickly as possible. I left the decision to give corticosteroids to the admitting doctor.” Corticosteroids are thought to work by suppressing the inflammatory response that occurs with antibiotic-induced bacterial cell lysis. Their use in immunocompetent adults with ABM is associated with a favorable survival benefit and neurologic outcome. Corticosteroids are ideally given immediately before the first dose of antibiotics in the ED.
- “I can’t believe that patient was admitted for bacterial meningitis. He did not have nuchal rigidity, and I thought I had excluded this diagnosis with negative Kernig and Brudzinski test results.” The absence of nuchal rigidity or other specific signs of meningeal irritation does not exclude the possibility of ABM. Although the specificity of Kernig and Brudinski signs is high, the sensitivity of these signs is extremely low. Similarly, the sensitivity of nuchal rigidity is only 30% for the detection of ≥ 6 WBC/mL in the CSF.
- “I thought for sure that patient had ABM. He had a fever, headache, and an altered mental status. The tap was atraumatic, but his CSF showed an RBC count of 2500 cells/mL and a WBC count of 200 cells/mL. His glucose and protein levels were normal. I gave him antibiotics and steroids, but I was surprised when his CSF Gram stain came back negative.” Don’t be surprised. The presentation of encephalitis can greatly overlap with that of meningitis. For patients with a negative Gram stain and a CSF analysis that is consistent with viral meningitis, think about the possibility of HSV or encephalitis. Our approach in the ED is to give empiric acyclovir to these patients.
- “Did you just admit that patient for meningococcal meningitis? I saw his wife a few days ago and admitted her for the same thing." If only you had contacted the patient’s family and told them to come to the ED for chemoprophylaxis with ciprofloxin or rifampin after you made the initial diagnosis! Remember that household contacts, intimate nonhousehold contacts, and health care workers who have direct mucosal contact with the patient’s secretions (eg, during endotracheal intubation, respiratory suctioning) are at risk of developing meningococcal disease after exposure to a patient with meningococcal meningitis.
- “That older man I admitted had gram-positive rods in his CSF. I wonder what he will grow out.” Don’t forget that immunocompromised patients and patients older than 50 years are susceptible to infection with L monocytogenes. In these patients, empiric antibiotic coverage should include ampicillin 50 mg/kg IV every 6 hours (maximum dose, 3 gm) as well as ceftriaxone and vancomycin.
- “My colleague just went to trial over a missed case of bacterial meningitis. She told me that the plaintiff’s expert witness testified that antibiotics should be given to everybody remotely suspected of having meningitis.” Although antibiotics are generally considered benign, there are far-reaching consequences to their indiscriminate use in every patient who may have a serious infection. Severe morbidity―and even death―can result from allergic reactions and antibiotic-associated colitis. Haphazard antibiotic administration is also blamed for the increased prevalence of multidrug-resistant bacteria in the United States.
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