German guidelines on community-acquired acute bacterial meningitis in adults

Abstract

Introduction: The incidence of community-acquired acute bacterial meningitis has decreased during the last decades. However, outcome remains poor with a significant proportion of patients not surviving and up to 50% of survivors suffering from long-term sequelae. These guidelines were developed by the Deutsche Gesellschaft für Neurologie (DGN) under guidance of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) to guide physicians through diagnostics and treatment of adult patients with acute bacterial meningitis.

Recommendations: The most important recommendations are: (i) In patients with suspected acute bacterial meningitis, we recommend that lumbar cerebrospinal fluid (with simultaneous collection of serum to determine the cerebrospinal fluid-serum glucose index and blood cultures) is obtained immediately after the clinical examination (in the absence of severely impaired consciousness, focal neurological deficits, and/or new epileptic seizures). (ii) Next, we recommend application of dexamethasone and empiric antibiotics intravenously. (iii) The recommended initial empiric antibiotic regimen consists of ampicillin and a group 3a cephalosporin (e.g., ceftriaxone). (iv) In patients with severely impaired consciousness, new onset focal neurological deficits (e.g. hemiparesis) and/or patients with newly occurring epileptic seizures, we recommend that dexamethasone and antibiotics are started immediately after the collection of blood; we further recommend that -if the imaging findings do not indicate otherwise -a lumbar CSF sample is taken directly after imaging. (v) Due to the frequent occurrence of intracranial and systemic complications, we suggest that patients with acute bacterial meningitis are treated at an intensive care unit in the initial phase of the disease. In the case of impaired consciousness, we suggest that this is done at an intensive care unit with experience in the treatment of patients with severe CNS diseases.

Conclusions: The German S2k-guidelines give up to date recommendations for workup, diagnostics and treatment in adult patients with acute bacterial meningitis.

Keywords: Acute bacterial meningitis; Central nervous system infection; Guideline; Listeria monocytogenes; Meningitis; Neisseria meningitidis; Streptococcus pneumoniae.

Fig. 1

Workup in suspected bacterial meningitis (1) Other contraindications for lumbar puncture (such as manifest coagulation disorders, oral anticoagulation) need to be considered. (2) The beginning of antibiotic therapy plus dexamethasone is to be started within 1 h after arrival of the patient at the emergency department. A delay of more than 3 h should be strictly avoided. In case of any delay of the lumbar puncture, antibiotic therapy and adjunctive dexamethasone should be started before CSF is obtained. (3) Imaging signs that can hint at increased intracranial pressure are e.g. generalized brain oedema, hydrocephalus or space occupying brain abscess