Emergency Department Management of Meningitis and Encephalitis

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Bacterial meningitis and viral encephalitis are infectious disease emergencies that can cause significant patient morbidity and mortality. Clinicians use epidemiologic, historical, and physical examination findings to identify patients at risk for these infections, and central nervous system (CNS) imaging and lumbar puncture (LP) may be needed to further evaluate for these diagnoses. The diagnosis of bacterial meningitis can be challenging, as patients often lack some of the characteristic findings of this disease with presentations that overlap with more common disorders seen in the emergency department. This article addresses considerations in clinical evaluation, need for CNS imaging before LP, interpretation of cerebrospinal fluid results, standards for and effects of timely antibiotic administration, and recommendations for specific antimicrobial therapy and corticosteroids.

Section snippets

History and physical exam to diagnose central nervous system infections

Clinical suspicion of a CNS infection begins with patient history. Conditions that may increase a patient's risk of contracting an infection, such as asplenia or CNS prosthetic device, should be initially considered along with epidemiologic factors (eg, a household contact of an index meningococcal infection case, or a newborn in the setting of maternal genital herpes) when assessing risk. Nonspecific symptoms such as headache, nausea, and vomiting are poor predictors of meningitis [17], which

Cerebrospinal fluid cytology and chemistry studies

Once LP is successfully completed, CSF analysis will help the clinician to make the diagnosis of meningitis or encephalitis on the basis of increased CSF white blood cell (WBC) counts. Typical CSF findings for viral CNS infection include WBC counts fewer than 300 cells per mm3, less than 20% of which are neutrophils, and normal protein and glucose levels. HSV encephalitis is characterized by temporal lobe hemorrhage, edema, and necrosis with inflammation, which, in addition to CSF lymphocytic

Bacterial meningitis

Bacterial meningitis in developed countries is estimated to occur in 2.6 to 6 per 100,000 adults per year, and can be many times higher in some undeveloped countries [2], [3], [4], [5]. The most common pathogens causing meningitis are Streptococcus pneumoniae and Neisseria meningitidis[2], [4], [6]. The median age of patients with meningitis in the United States went up from 15 months in 1986 (before the introduction of the H influenzae type b vaccination) to 25 years in 1995 [2]. Childhood

Empiric antibiotics for bacterial meningitis

Bacterial meningitis is a life-threatening infection, and empiric administration of broad-spectrum antibiotics (Table 1) is indicated for patients suffering from this disease until bacterial identification is made [1], [5], [62], [78], [91]. Third-generation cephalosporins ceftriaxone and cefotaxime have excellent CSF penetration, provide coverage for the most common bacterial pathogens (including N meningitidis and S pneumoniae), and are recommended for initial therapy [92]. Vancomycin should

Patient disposition

Patients who are presumptively diagnosed with bacterial meningitis or encephalitis based on clinical findings, CSF results, and CNS imaging should be admitted to the hospital for monitoring, intravenous antimicrobial therapy, and adjunctive corticosteroids. However, some variability remains regarding patient disposition decisions in clinically well-appearing patients with mildly elevated levels of CSF WBCs but with other CSF findings suggestive of viral meningitis. The introduction of rapid CSF

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    Dr. Fitch received faculty funding support for his work on this project from the Brooks Scholars in Academic Medicine award at the Wake Forest University School of Medicine.

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