EFNS guideline on the management of community‐acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults

Abstract

Acute bacterial meningitis (ABM) is a potentially life-threatening neurological emergency. An agreed protocol for early, evidence-based and effective management of community-acquired ABM is essential for best possible outcome. A literature search of peer-reviewed articles on ABM was used to collect data on the management of ABM in older children and adults. Based on the strength of published evidence, a consensus guideline was developed for initial management, investigations, antibiotics and supportive therapy of community-acquired ABM. Patients with ABM should be rapidly hospitalized and assessed for consideration of lumbar puncture (LP) if clinically safe. Ideally, patients should have fast-track brain imaging before LP, but initiation of antibiotic therapy should not be delayed beyond 3 h after first contact of patient with health service. In every case, blood sample must be sent for culture before initiating antibiotic therapy. Laboratory examination of cerebrospinal fluid is the most definitive investigation for ABM and whenever possible, the choice of antibiotics, and the duration of therapy, should be guided by the microbiological diagnosis. Parenteral therapy with a third-generation cephalosporin is the initial antibiotics of choice in the absence of penicillin allergy and bacterial resistance; amoxicillin should be used in addition if meningitis because of Listeria monocytogenes is suspected. Vancomycin is the preferred antibiotic for penicillin-resistant pneumococcal meningitis. Dexamethasone should be administered both in adults and in children with or shortly before the first dose of antibiotic in suspected cases of Streptococcus pneumoniae and H. Influenzae meningitis. In patients presenting with rapidly evolving petechial skin rash, antibiotic therapy must be initiated immediately on suspicion of Neisseria meningitidis infection with parenteral benzyl penicillin in the absence of known history of penicillin allergy. ObjectivesThe primary objective of this guideline is to assist neurologists with the diagnosis and treatment of community-acquired acute bacterial meningitis (ABM) in older children and adults based on literature evidence and expert consensus. Here, we propose early diagnosis and treatment of ABM, as soon as possible, and a target time of no longer than 3 h from door-to-first antibiotic therapy based on secured diagnosis supported by clinical and cerebrospinal fluid (CSF) findings. The management of hospital acquired ABM and chronic meningitis, tuberculous meningitis inclusive, is not considered in this document. Search strategy and selection criteriaData for this guideline were identified by searches of MEDLINE, EMBASE, the Cochrane databases and references from relevant articles. Search terms used were (alone and in combination): bacterial meningitis, Correspondence: Dr Abhijit Chaudhuri, Department of Neurology, Essex Centre for Neurological Sciences, QueenÕs Hospital, Romford, UK (tel.: 01708 435000; fax: 01708 503756; e-mail: chaudhuria@ gmail.com).Short Version: This is an abridge...

Is the diagnosis and treatment of childhood acute bacterial meningitis in Turkey evidence-based?

“…A third-generation cephalosporin is recommended as the first-line agent in children older than 1 month of age with community-acquired bacterial meningitis (4). The use of ceftriaxone or cefotaxime in 90% of the patients is in accordance with literature.…”

“…In a multicenter study including 27 tertiary care children's hospitals located in 18 US states and the District of Columbia, adjuvant corticosteroid therapy was not associated with time to death or time to hospital discharge (23). Despite opposite results in several metaanalyses, dexamethasone is advised in the European guideline (4). Dexamethasone administered before the first parenteral antibiotic dose was shown to decrease nitric oxide production in CSF during bacterial meningitis (24).…”

“…The use of ceftriaxone or cefotaxime in 90% of the patients is in accordance with literature. If penicillin-or cephalosporinresistant pneumococcus is suspected, in geographic regions or in patients with a recent travel history to countries with high rates of penicillin and ceftriaxone resistance (e.g., the United States), the use of ceftriaxone or cefotaxime plus vancomycin is recommended (4,19,20). Resistance to cefotaxime was reported as 4% in isolates from children with invasive pneumococcal disease in Turkey (21).…”

“…International guidelines providing clinicians with recommendations are presented for several diseases including bacterial meningitis (2,4). Several studies determining the etiology and prognostic factors in children with bacterial meningitis have been performed in Turkey (5,6).…”

Bacterial Meningitis in Patients using Immunosuppressive Medication: a Population-based Prospective Nationwide Study

“…Resistance to infection is predominantly mediated by cellular immunity and their elimination requires T lymphocytes mediated cytotoxicity (Horta-Baas et al 2013). Guidelines advise the use of a third generation cephalosporin combined with ampicillin or amoxicillin if L. monocytogenes is suspected (Chaudhuri et al 2008;Tunkel et al 2004). Based on the high frequency of L. monocytogenes as causative organism in patients using immunosuppressive medication identified in our cohort, empiric treatment for patients using immunosuppressive medication should be broad and include ampicillin or amoxicillin for listeria coverage in combination with an extended spectrum cephalosporin.…”