Meningitis

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
1

Drexel University College of Medicine, Philadelphia, Pennsylvania; 2Weill Cornell Medical Center, New York, New York; 3Baylor College of
Medicine, Houston, Texas; 4MedicalCollege of Wisconsin, Milwaukee; 5Indiana University School of Medicine, Indianapolis; 6University of Virginia
School of Medicine, Charlottesville; and 7University of Alabama at Birmingham

OBJECTIVES

Received 20 August 2004; accepted 25 August 2004; electronically published
6 October 2004.
Reprints or correspondence: Dr. Allan R. Tunkel, Drexel University College of
Medicine, 2900 QueenLane, Philadelphia, PA 19129 (allan.tunkel@drexel.edu).
Clinical Infectious Diseases 2004; 39:1267–84
2004 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2004/3909-0001$15.00

INITIAL MANAGEMENT APPROACH
The initial treatment approach to the patient with suspected acute bacterial meningitis depends on early recognition of the meningitis syndrome, rapiddiagnostic
evaluation, and emergent 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 clinicaldiagnosis. 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 thusorder a CT scan of
the head prior to lumbar 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 givenprior to lumbar puncture or before the patient 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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The objective of these practice guidelines is to provide
clinicians withrecommendations for the diagnosis and
treatment of bacterial meningitis. Patients with bacterial
meningitis are usually treated by 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 bacterialmeningitis is not always
based on randomized, prospective, double-blind clinical trials, but rather on data initially obtained from
experimental 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 andinjection of microorganisms. Frequent sampling of CSF
permits measurement of leukocytes and chemical parameters and quantitation of the relative 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...