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.

References

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