Menigites

IDSA GUIDELINES

Practice Guidelines for the Management of Bacterial Meningitis
Allan R. Tunkel,1 Barry J. Hartman,2 Sheldon L. Kaplan,3 Bruce A. Kaufman,4 Karen L. Roos,5 W. Michael Scheld,6 and Richard J. Whitley7
Drexel University College of Medicine, Philadelphia, Pennsylvania; 2Weill Cornell Medical Center, New York, New York; 3Baylor College of Medicine, Houston, Texas; 4Medical Collegeof Wisconsin, Milwaukee; 5Indiana University School of Medicine, Indianapolis; 6University of Virginia School of Medicine, Charlottesville; and 7University of Alabama at Birmingham
1

OBJECTIVES The objective of these practice guidelines is to provide clinicians with recommendations for the diagnosis and treatment of bacterial meningitis. Patients with bacterial meningitis are usually treatedby primary care and emergency medicine physicians at the time of initial presentation, often in consultation with infectious diseases specialists, neurologists, and neurosurgeons. In contrast to many other infectious diseases, the antimicrobial therapy for bacterial meningitis is not always based on randomized, prospective, double-blind clinical trials, but rather on data initially obtained fromexperimental animal models of infections. A model commonly utilized is the experimental rabbit model, in which animals are anesthetized and placed in a stereotactic frame. In this procedure, the cisterna magna can be punctured for frequent sampling of CSF and injection of microorganisms. Frequent sampling of CSF permits measurement of leukocytes and chemical parameters and quantitation of therelative penetration of antimicrobial agents into CSF and the effects of meningitis on this entry parameter, the relative bactericidal efficacy (defined as the rate of bacterial eradication) within purulent CSF, and CSF pharmacodynamics. Results obtained from these and other animal models have led to clinical trials of specific agents in patients with bacterial meningitis.

In this guideline, we willreview our recommendations for the diagnosis and management of bacterial meningitis. Recommendation categories are shown in table 1. The guideline represents data published through May 2004. INITIAL MANAGEMENT APPROACH The initial treatment approach to the patient with suspected acute bacterial meningitis depends on early recognition of the meningitis syndrome, rapid diagnostic evaluation, andemergent antimicrobial and adjunctive therapy [1]. Our management algorithm for infants and children is shown in figure 1, and that for adults is shown in figure 2. Once there is suspicion of acute bacterial meningitis, blood samples must be obtained for culture and a lumbar puncture performed immediately to determine whether the CSF formula is consistent with the clinical diagnosis. In some patients,the clinician may not emergently perform the diagnostic lumbar puncture (e.g., secondary to the inability to obtain CSF), even when the diagnosis of bacterial meningitis is considered to be likely, or the clinician may be concerned that the clinical presentation is consistent with a CNS mass lesion or another cause of increased intracranial pressure and will thus order a CT scan of the head prior tolumbar puncture. In those patients in whom lumbar puncture is delayed or a CT scan is performed, however, there may be a significant interval between establishing the diagnosis of bacterial meningitis and initiating appropriate therapy. In these patients, blood samples must be obtained for culture and appropriate antimicrobial and adjunctive therapy given prior to lumbar puncture or before thepatient is sent for CT. Delay in the initiation of therapy introduces the potential for increased morbidity and mortality, if
Practice Guidelines for Bacterial Meningitis • CID 2004:39 (1 November) • 1267

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Received 20 August 2004; accepted 25 August 2004; electronically published 6 October 2004. Reprints or correspondence: Dr....