Algorithm for management of suspected bacterial

meningitis in adults and children

Bacterial meningitis suspected

Does patient have any of the following absolute contraindications to lumbar puncture?
• anticoagulant therapy
Yes
• bleeding diathesis
• evidence of localised infection in the lumbar region

No

Does patient have any of the following?

ADULTS CHILDREN
• history of CNS disease • focal neurological signs
• focal neurological signs • papilloedema
• papilloedema • rapidly deteriorating consciousness or obtundation
• new-onset seizure (Glasgow Coma Scale score less than 8)
• abnormal level of consciousness • perforated ear drum
• immunocompromised

None of the above criteria Any of the above criteria

Blood cultures and lumbar

Blood cultures within 30 Blood cultures within 30
puncture within 30 minutes of
minutes of initial assessment minutes of initial assessment
initial assessment

Dexamethasone 10 mg Dexamethasone 10 mg Dexamethasone 10 mg

(child: 0.15 mg/kg up to 10 mg) IV (child: 0.15 mg/kg up to 10 mg) IV (child: 0.15 mg/kg up to 10 mg) IV
PLUS empirical antibiotics IV within PLUS empirical antibiotics IV within PLUS empirical antibiotics IV within
30 minutes of initial assessment 30 minutes of initial assessment 30 minutes of initial assessment
(see empirical therapy) (see empirical therapy) (see empirical therapy)

ADULTS Perform CT scan CHILDREN* Reassess and treat accordingly

Are CSF findings consistent

with bacterial meningitis? CT scan appears normal

No Yes Are clinical signs of raised CT scan shows cerebral oedema or Lumbar puncture
intracranial pressure present?† other intracranial pathology is contraindicated

Reassess Perform lumbar

No Yes
puncture

Is Streptococcus pneumoniae suggested on Gram stain or antigen test, or does the patient have known or
suspected otitis media or sinusitis, or has the patient been recently treated with a beta lactam?

No Yes

Continue empirical therapy Add vancomycin to empirical therapy

* CT scans are not routinely performed in children. Review daily, and perform lumbar puncture as soon as the contraindication(s) have resolved. If lumbar
puncture is still contraindicated, reassess and treat accordingly.

† Clinical contraindications to lumbar puncture and signs of impending herniation include a rapidly deteriorating level of consciousness, brainstem signs and
very recent seizures.

Therapeutic Guidelines Limited (www.tg.org.au) is an independent not-for-profit organisation dedicated to deriving guidelines for therapy from the latest world
literature, interpreted and distilled by Australia’s most eminent and respected experts.

Published in eTG complete, July 2010. ©Therapeutic Guidelines Ltd. www.tg.org.au