Adult Bacterial Meningitis — Empiric Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Is CT needed before LP?
   Are there indications for a head CT before lumbar puncture? (Suspected bacterial meningitis is a neurological emergency — start treatment within 1 h and do not delay for imaging/LP; draw blood cultures immediately. Indications for CT before LP (any): immunocompromise, seizure within the past week, focal neurological signs, altered consciousness/coma, papilledema, known CNS disease.)
   • CT-before-LP indication present → CT then LP (treat first)
   • None (LP can be done first) → LP then treat immediately
2. [End] CT then LP (treat first)
   Sequence: 1) draw blood cultures immediately; 2) give dexamethasone + empiric antibiotics (do not wait for CT/LP); 3) head CT to exclude a mass/herniation; 4) lumbar puncture for CSF once safe. Never delay antibiotics for CT/LP. (Note: Empiric antibiotics (adults): ceftriaxone 2 g IV q12h (or cefotaxime) + vancomycin 15–20 mg/kg q8–12h; add ampicillin if >50 years or immunocompromised (cover Listeria); add acyclovir if HSV encephalitis is suspected. Dexamethasone 0.15 mg/kg q6h × 2–4 days, given 10–20 min before or with the first antibiotic dose; continue 4 days if pneumococcus confirmed, otherwise stop.)
3. [End] LP then treat immediately
   Sequence: 1) immediate LP + blood cultures (obtain CSF promptly if no contraindication); 2) immediately give dexamethasone + empiric antibiotics (do not delay treatment for the LP). (Note: Empiric antibiotics (adults): ceftriaxone 2 g IV q12h (or cefotaxime) + vancomycin 15–20 mg/kg q8–12h; add ampicillin if >50 years or immunocompromised (cover Listeria); add acyclovir if HSV encephalitis is suspected. Dexamethasone 0.15 mg/kg q6h × 2–4 days, 10–20 min before or with the first antibiotic dose.)

Source guidelines & references

• IDSA Practice Guideline for bacterial meningitis. Clin Infect Dis 2004
• de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. NEJM 2002

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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