Meningitis / Encephalitis

  • CC: Fever, headache, neck stiffness, AMS

  • PP: Photophobia, N/V, seizure, focal neuro deficit, rash, immunocompromised state

  • PN: No alternative toxic/metabolic cause, no focal infection source unless present

  • pertinent SHx: Sick contacts, travel, incarceration/dorm, IVDU, animal/tick exposure

  • Etiology:

    • Meningitis: bacterial/viral/fungal infection of meninges

    • Encephalitis: brain parenchymal inflammation, HSV important not to miss

  • risk factors: Age >50, immunocompromised, HIV, transplant, asplenia, recent neurosurgery, CSF leak

  • initial DATA: CBC, CMP, blood cultures x2, lactate if septic, CT head before LP if indicated, LP with CSF studies

  • pending DATA: CSF cell count/diff, glucose/protein, gram stain/culture, meningitis PCR, HSV PCR, cryptococcal Ag if immunocompromised

  • prior data:

  • MEDS: Anticoagulation, antibiotics, immunosuppression

  • COURSE:

Plan:

  • Neuro/ID consult

  • Droplet precautions until meningococcal disease excluded/treated

  • Blood cultures before antibiotics if possible

  • Do not delay antibiotics for CT/LP if unstable

  • Empiric antibiotics:

    • Vancomycin + Ceftriaxone 2 g IV q12h

    • Age >50/immunocompromised/pregnant: add Ampicillin for Listeria

    • Encephalitis concern: add Acyclovir 10 mg/kg IV q8h

    • Healthcare-associated/neurosurgery: Vancomycin + Cefepime/Meropenem

  • Dexamethasone before/with first antibiotics if bacterial meningitis suspected

  • LP unless contraindicated (CSF (cell count with diff, protien, glucose, gram stain,) serum glucose and blood culture )

  • CT head before LP if focal deficit, papilledema, seizure, severe AMS, immunocompromised, CNS lesion concer

  • Trend neuro checks, fever curve, renal function

  • Seizure precautions if encephalitis/seizure

  • Duration depends organism:

    • Meningococcus: ~7 days

    • Pneumococcus: ~10–14 days

    • Listeria/gram negative: ~21 days

    • HSV encephalitis: ~14–21 days