Suspected Meningitis Age > 56 days Clinical Pathway — Emergency Department, Inpatient and ICU

History and Physical Exam

History

Bacterial meningitis is an acute illness. Symptoms typically progress rapidly over several hours to a few days. Prolonged duration of symptoms (more than 5-7 days) suggests another diagnosis, or meningitis due to other causes.

Medications	Pretreatment with antibiotics may complicate CSF result interpretation. Some drugs (e.g., NSAIDs, trimethoprim-sulfamethoxazole, IVIg) can cause aseptic meningitis. Presentation may be less acute and CSF protein and glucose levels may be unreliable.
Immunization Status	Unvaccinated or under-vaccinated patients may have increased susceptibility to Streptococcus pneumoniae and Haemophilus influenzae b.
Indwelling Device	Presence of VP shunt or cochlear implant
Environmental Exposures	A good social history is very important in evaluating possible etiologies of meningitis. For example, consider the following: Fresh water swimming — Naegleria (brain amoeba infection). Tick bites — Lyme, Rickettsial infections. Travel to areas with endemic tuberculosis (TB), exposure to close contacts who have TB or symptoms of TB — tuberculosis. Travel to areas endemic for Coccidioides (Southwestern US) — Histoplasma (Mississippi and Ohio River Valleys).

Physical Exam

Vital Signs	Cushing’s triad (bradycardia, hypertension, irregular breathing) suggests intracranial hypertension and warrants an emergent head CT.
Level of Consciousness	Depressed consciousness may suggest increased intracranial hypertension, mass lesion, encephalitis or seizures/post-ictal state.
Neurologic Examination	Nuchal rigidity and/or bulging fontanelle may suggest meningitis. Focal neurologic findings may suggest one of the following: Parenchymal extension of infection (e.g., abscess, cerebritis or encephalitis) Focal neurologic injury due to ischemia, vasculitis, etc. Recent focal seizure Mass lesion
Kernig and Brudzinski Signs	These signs of meningeal irritation are non-specific but are common in cases of bacterial meningitis. They are less common in viral meningitis.

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