Meningitis

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This is an infection of the coverings of the brain, and is most commonly caused by bacteria, viruses, fungi and protozoa. One type, Cerebrospinal Meningitis (CSM), caused by Neisseria meningitides, is common in the Northern and Upper Regions of Ghana, and usually occurs in epidemics during the harmattan season. The presentation may  sometimes be confused with cerebral malaria. Meningitis is a medical emergency. Failure to recognise and adequately manage meningitis results in serious complications.

Inform regional or district health authorities immediately in epidemic meningitis.

Cause

• Bacterial
  • Neisseria meningitides 
  • Streptococcus pneumoniae
  • Haemophilus influenza
  • Mycobacterium tuberculosis
  • Staphylococcus aureus
  • Escherichia coli (neonates)
• Viruses e.g. Herpes viruses
• Protozoa e.g. Toxoplasma in HIV-AIDS
• Fungi e.g. Cryptococcus neoform

Symptoms

For Adults and Children > 5 years

• Fever
• Neck pains
• Severe headaches
• Photophobia
• Change in behaviour
• Convulsions
• Vomiting

Children < 1 year 

• Fever
• Irritability
• Refusal to eat
• Poor sucking
• Vomiting
• Drowsiness and weak cry
• Focal or generalized convulsions after which the child is sleepy
• Lethargy
• Bulging fontanelle

Signs

For Adults and Children > 5 years

• Fever
• Neck stiffness
• Positive Kernig’s sign
• Altered consciousness
• Coma

Children < 1 year

• Neck retraction  
• Presence or absence of neck stiffness 
• Presence or absence of fever
• Bulging fontanelle
• Coma
• Hypotonia or hypertonia
• Convulsion

Investigations

• FBC
• Rapid diagnostic test (to exclude cerebral malaria)
• Blood film for malarial parasites (to exclude cerebral malaria)
• Lumbar puncture (only after excluding raised intracranial pressure)
• Blood culture and sensitivity

TreatmentTreatment Objectives

• To identify and eradicate the causative organisms 
• To prevent complications
• To prevent spread to contacts 
• To maintain good nutrition

Non-pharmacological treatment

• Tepid sponging
• Keep the airway clear 
• Nasogastric tube feeding if applicable

Pharmacological treatment 

Bacterial Meningitis

1^st Line Treatment

Evidence Rating: [A]

• Ceftriaxone, IV/deep IM, 

Adults 

2-4 g daily for 7-10 days 

Children

> 12 years; 2-4 g daily for 7-10 days

< 12 years; 50-80 mg/kg for 10-14 days

Neonates;

20-50 mg/kg once daily for 21 days

And

• Vancomycin, IV, 

Adults 

15 mg/kg 12 hourly for 7-10 days 

Children

> 12 years; 15 mg/kg 12 hourly for 7-10 days 

2-12 years 15 mg/kg 12 hourly for 7-10 days

1 month-2 years; 15 mg/kg 8 hourly for 10-14 days

< 1 month; not recommended 

Or

Evidence Rating: [B]

• Benzylpenicillin, IV,

Adults

4 MU 4 hourly for 14 days

Children

0.2 MU/kg 6 hourly for 14 days 

And

• Chloramphenicol, IV, 

Adults

1 g 6 hourly for 14 days

Children

25 mg/kg 6 hourly for 14 days

This may be subsequently changed to oral therapy with significant clinical improvement

Or

• Chloramphenicol, IM, (oily preparation)

Adults 

100 mg/kg as a single dose

Children 

100 mg/kg as a single dose

Note: Not recommended for children below 2 months, and also for pregnant and lactating mothers. 

For penicillin allergy 

• Clindamycin, IV, 

Adults

600-900 mg 8 hourly for 14 days

Children

13 mg/kg 8 hourly for for 14 days

And

• Chloramphenicol, IV, 

Adults

1 g 6 hourly for 14 days

Children

25 mg/kg 6 hourly for 14 days

2^nd Line Treatment

Evidence Rating: [B]

• Cefotaxime, IV, 

Adults

2g 6 hourly for 7 days

Children 

> 12 years or body weight > 50kg; 2 g 6 hourly

< 12 years or body weight < 50kg; 50 mg/kg 6 hourly 

And

• Vancomycin, IV, 

Adults 

15 mg/kg 12 hourly for 7-10 days 

Children

> 12 years; 15 mg/kg 12 hourly for 7-10 days 

2-12 years; 15 mg/kg 12 hourly for 7-10 days

1 month-2 years; 15 mg/kg 8 hourly for 10-14 days

< 1 month; not recommended 

Prophylaxis for CSM

Prophylactic treatment is recommended for patients 2 days prior to discharge and also for their close contacts

• Ciprofloxacin, oral,

Adults 

500 mg as a single dose (Avoid in Pregnancy)

Children

5-12 years; 250 mg as a single dose

Or

• Ceftriaxone, IM,

Adults 

250 mg as a single dose

Children

< 12 years; 125 mg as a single dose

Note: Role of steroids: Dexamethasone started together with the first dose of the appropriate antibiotic has been found to lead to major reduction in hearing loss and death in both children and adults.  

• Dexamethasone, IV, 4-10 mg 6 hourly for 5-7 days 

 

Summary of treatment options for Bacterial Meningitis
Age	Pathogens	1st line Empirical treatment	Alternatives (Specialist care)
< 50 years	Meningococcus,  Pneumococcus, Haemophilus Influenza	Ceftriaxone And Vancomycin	Cefotaxime Meropenem  Fluoroquinolones
> 50 years	Pneumococcus, Listeria, Gram-negative bacilli	Ceftriaxone  Or Ampicillin And  Vancomycin	Fluoroquinolone
Hospital  Acquired	Staphylococci, Gram-negative bacilli, Pneumococcus Pseudomonas	Ceftazidime +/- Gentamycin	Meropenem Vancomycin

Referral Criteria

• Refer all patients not responding to treatment within the first 48 hours for specialist care.