I.

Pathophysiology
 II. Medical Management:
• Diagnostic procedure:
1. Blood culture
2. Chest x-ray
3. Head CT scan
4. Gram-stain and culture of CSF (cerebral spinal fluid)
5. Lumbar puncyure ("spinal tap") with CSF glucose measurement and CSF cell count

• Laboratory:

• Treatment:

Initial treatment
Meningitis is potentially life-threatening and has a high mortality rate if untreated; delay in treatment
has been associated with a poorer outcome. Thus treatment with wide-spectrum antibiotics should not
be delayed while confirmatory tests are being conducted. If meningococcal disease is suspected in
primary care, guidelines recommend that benzylpenicillin be administered before transfer to hospital.
Intravenous fluids should be administered if hypotension (low blood pressure) or shock are present.
Given that meningitis can cause a number of early severe complications, regular medical review is
recommended to identify these complications early, as well as admission to an intensive care unit if
deemed necessary.
Mechanical ventilation may be needed if the level of consciousness is very low, or if there is evidence
of respiratory failure. If there are signs of raised intracranial pressure, measures to monitor the pressure
may be taken; this would allow the optimization of the cerebral perfusion pressure and various
treatments to decrease the intracranial pressure with medication (e.g. mannitol). Seizures are treated
with anticonvulsants. Hydrocephalus (obstructed flow of CSF) may require insertion of a temporary or
long-term drainage device, such as a cerebral shunt.

Bacterial meningitis

Antibiotics
Structural formula of ceftriaxone, one of the third-generation cefalosporin antibiotics recommended for
the initial treatment of bacterial meningitis.
Empiric antibiotics (treatment without exact diagnosis) must be started immediately, even before the
results of the lumbar puncture and CSF analysis are known. The choice of initial treatment depends
largely on the kind of bacteria that cause meningitis in a particular place. For instance, in the United
Kingdom empirical treatment consists of a third-generation cefalosporin such as cefotaxime or
ceftriaxone. In the USA, where resistance to cefalosporins is increasingly found in streptococci,
addition of vancomycin to the initial treatment is recommended. Empirical therapy may be chosen on
the basis of the age of the patient, whether the infection was preceded by head injury, whether the
patient has undergone neurosurgery and whether or not a cerebral shunt is present. For instance, in
young children and those over 50 years of age, as well as those who are immunocompromised, addition
of ampicillin is recommended to cover Listeria monocytogenes. Once the Gram stain results become
available, and the broad type of bacterial cause is known, it may be possible to change the antibiotics to
those likely to deal with the presumed group of pathogens.
The results of the CSF culture generally take longer to become available (24–48 hours). Once they do,
empiric therapy may be switched to specific antibiotic therapy targeted to the specific causative
organism and its sensitivities to antibiotics. For an antibiotic to be effective in meningitis, it must not
only be active against the pathogenic bacterium, but also reach the meninges in adequate quantities;
some antibiotics have inadequate penetrance and therefore have little use in meningitis. Most of the
antibiotics used in meningitis have not been tested directly on meningitis patients in clinical trials.
Rather, the relevant knowledge has mostly derived from laboratory studies in rabbits.
Tuberculous meningitis requires prolonged treatment with antibiotics. While tuberculosis of the lungs
is typically treated for six months, those with tuberculous meningitis are typically treated for a year or
longer. In tuberculous meningitis there is a strong evidence base for treatment with corticosteroids,
although this evidence is restricted to those without AIDS.

Viral meningitis
Viral meningitis typically requires supportive therapy only; most viruses responsible for causing
meningitis are not amenable to specific treatment. Viral meningitis tends to run a more benign course
than bacterial meningitis. Herpes simplex virus and varicella zoster virus may respond to treatment
with antiviral drugs such as aciclovir, but there are no clinical trials that have specifically addressed
whether this treatment is effective. Mild cases of viral meningitis can be treated at home with
conservative measures such as fluid, bedrest, and analgesics.

Fungal meningitis
Fungal meningitis, such as cryptococcal meningitis, is treated with long courses of highly dosed
antifungals, such as amphotericin B and flucytosine. Raised intracranial pressure is common in fungal
meningitis, and frequent (ideally daily) lumbar punctures to relieve the pressure are recommended, or
alternatively a lumbar drain.

• IVF:
1. PNSS

• Surgical procedures:
LUMBAR PUNCTURE
There are different ways to get a sample of CSF. Lumbar puncture, commonly called a spinal tap, is the
most common method. The test is usually done like this:
• The patient lies on his or her side, with knees pulled up toward the chest, and chin tucked
downward. Sometimes the test is done with the person sitting up, but bent forward.
• After the back is cleaned, the health care provider will inject a local numbing medicine
(anesthetic) into the lower spine.
• A spinal needle is inserted, usually into the lower back area.
• Once the needle is properly positioned, CSF pressure is measured and a sample is collected.
• The needle is removed, the area is cleaned, and a bandage is placed over the needle site. The
person is often asked to lie down for a short time after the test.
Occasionally, special x-rays are used to help guide the needle into the proper position. This is called
fluoroscopy.
Lumbar puncture with fluid collection may also be part of other procedures, particularly a myelogram
(x-ray or CT scan after dye has been inserted into the CSF).
Alternative methods of CSF collection are rarely used, but may be necessary if the person has a back
deformity or an infection.
Cisternal puncture uses a needle placed below the occipital bone (back of the skull). It can be
dangerous because it is so close to the brain stem. It is always done with fluoroscopy.
Ventricular puncture is even more rare, but may be recommended in people with possible brain
herniation. This test is usually done in the operating room. A hole is drilled in the skull, and a needle is
inserted directly into one of brain's ventricles.
CSF may also be collected from a tube that's already placed in the fluid, such as a shunt or a
venitricular drain. These sorts of tubes are usually placed in the intensive care unit.

BLOOD CULTURE
A blood sample is needed. Blood is typically drawn from a vein, usually from the inside of the elbow or
the back of the hand. The site is cleaned with germ-killing medicine (antiseptic). The health care
provider wraps an elastic band around the upper arm to apply pressure to the area and make the vein
swell with blood.
Next, the health care provider gently inserts a needle into the vein. The blood collects into an airtight
vial or tube attached to the needle. The elastic band is removed from your arm.
Once the blood has been collected, the needle is removed, and the puncture site is covered to stop any
bleeding.
In infants or young children, a sharp tool called a lancet may be used to puncture the skin and make it
bleed. The blood collects into a small glass tube called a pipette, or onto a slide or test strip. A bandage
may be placed over the area if there is any bleeding.
It is very important that the blood sample does not become contaminated. The sample is sent to a
laboratory, where it is placed in a special dish and watched to see if microorganisms grow. This is
called a culture. Most cultures check for bacteria. If bacteria does grow, further tests will be done to
identify the specific type.
A gram stain may also be done. A gram stain is a method of identifying microorganisms (bacteria)
using a special series of stains (colors). For example, see skin lesion gram stain.

HEAD CT-SCAN
You will be asked to lie on a narrow table that slides into the center of the CT scanner. Depending on
the study being done, you may need to lie on your stomach, back, or side.
A cranial CT scan produces images from your upper neck to the top of your head.
You must be still during the exam, because movement causes blurred images. If you can't stay still,
pillows or cushions may be placed around your head to hold it in place.
Once inside the scanner, the machine's x-ray beam rotates around you. (Modern "spiral" scanners can
perform the exam in one continuous motion.) You may be told to hold your breath for short periods of
time.
Small detectors inside the scanner measure the amount of x-rays that make it through the part of the
body being studied. A computer takes this information and uses it to create several individual images,
called slices. These images can be stored, viewed on a monitor, or printed on film. Three-dimensional
models of your head can be created by stacking the individual slices together.
Special dye, called contrast, may be used to help highlight blood vessels and look for a mass (tumor). If
this is needed, the health care provider will inject the dye into a vein.
Generally, complete scans take only a few minutes. The newest multidetector scanners can image your
entire body, head to toe, in less than 30 seconds.