Patient with Suspected Meningitis Age > 56 days — Inpatient Definitive Management — Clinical Pathway: Emergency, Inpatient

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

Inpatient Definitive Management

There may be considerable variability in inpatient management of patients with acute bacterial meningitis. For patients in whom the suspicion of meningitis is high or for patients who have confirmed meningitis, the following table lists the most common monitoring strategies and consults:

General Management

  Order Frequency Comments
Neurological Monitoring Neuro checks Minimum of every 4 hours on the floor, up to every 1 hour in the ICU Neurologic status should be followed closely for deterioration given high risk of complications, including abscess formation, vasculitis, stroke, cerebral edema with intracranial hypertension.
Head circumference, for age ≤ 2 yrs Daily If head circumference is increasing significantly, consider head imaging
Vital signs Every 4 hours on the floor, up to every 1 hour in the ICU Monitor for Cushing’s triad – bradycardia, hypertension, irregular respirations.
  • If there is concern at any time for a worsening neurologic exam, increasing head circumference (or bulging fontanelle in an infant), and/or other signs or symptoms of increased intracranial pressure, consider the following:
    • If the patient is on a non-ICU floor, notify the CAT (Critical Assessment Team)
    • Call Neurology and/or Neurosurgery consults to discuss potential emergent neuroimaging or other evaluation/management
Imaging Imaging is not routinely indicated
Consider if there is a focal neurologic deficit on exam, or if focal seizures are present
Consider Neurology Consult
Electrolyte Monitoring Monitor BMP ± Mg, Phosphorus Daily for at least 4 days Hyponatremia can occur due to SIADH.
Often occurs on the 2nd and 3rd day of hospitalization
Use isotonic fluids such as D5 normal saline  
Do not fluid restrict   Fluid restriction may lead to cerebral hypoperfusion
Infection Prevention and Control Contact/Droplet Precautions Until 24 hours of effective antibiotics Contact/Droplet Precautions can be discontinued after 24 hours of effective IV antibiotics (Reserve for those in whom there is high suspicion of meningitis)
Repeat LP Repeat LP is not routinely recommended for most organisms. Call ID for specific questions.
Vancomycin Troughs Vancomycin troughs are only recommended for those receiving > 48 hours of vancomycin therapy. Please obtain prior to the 4th dose.

Consults

  Order Frequency Comments
ID Consult Consult Infectious Diseases for all cases of likely or confirmed bacterial meningitis.
Neurology Consult Consult Neurology for patients with seizures, focal neurological deficit or altered mental status out of proportion to their illness; consider an EEG for these patients.
PT, OT, Speech Therapy Consider physical therapy, occupational therapy, and/or speech therapy consult depending on clinical status and as needed.
Audiology Consult Consult Audiology for all confirmed cases of bacterial meningitis. There is a strong association between bacterial meningitis and hearing loss.

Vascular Access

  Order Frequency Comments
Vascular Access Consider PICC placement if a prolonged course of IV antibiotics is anticipated.