Clinical Pathways
Clinical Pathways
Infectious Meningitis and Encephalitis
Infectious Meningitis and Encephalitis

Infectious Meningitis and Encephalitis

Tags
Emerg. Med. Practice
Published
April 1, 2022
Author(s)
Andrew N. Hogan, MD; C. Reece Brockman II, MD, FACEP; Amanda Santa Maria, MD

View The Full Pathway

Action

Patient presents with suspected meningitis/encephalitis

  • Initiate respiratory and circulatory resuscitation

Decision

Is CT indicated before LP?

Background

image
‣
References
  1. *van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016;22:S37-S62. (Practice guideline) DOI: 10.1016/j.cmi.2016.01.007
  2. Brouwer MC, van de Beek D. Epidemiology of community-acquired bacterial meningitis. Curr Opin Infect Dis. 2018;31(1):78-84. (Review)
  3. Durand ML, Calderwood SB, Weber DJ, et al. Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med. 1993;328(1):21-28. (Retrospective; 493 cases, 445 patients)
  4. Bijlsma MW, Brouwer MC, Kasanmoentalib ES, et al. Community-acquired bacterial meningitis in adults in the Netherlands, 2006-14: a prospective cohort study. Lancet Infect Dis. 2016;16(3):339-347. (Prospective observational; 1412 patients)
  5. Thigpen MC, Whitney CG, Messonnier NE, et al. Bacterial meningitis in the United States, 1998-2007. N Engl J Med. 2011;364(21):2016-2025. (Retrospective observational; 3155 patients)
  6. van de Beek D, de Gans J, Spanjaard L, et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med. 2004;351(18):1849-1859. (Retrospective; 696 cases)
  7. Manyelo CM, Solomons RS, Walzl G, et al. Tuberculous meningitis: pathogenesis, immune responses, diagnostic challenges, and the potential of biomarker-based approaches. J Clin Microbiol. 2021;59(3):e01771-e01720. (Review)
  8. van de Beek D, Brouwer MC, Koedel U, et al. Community-acquired bacterial meningitis. Lancet 2021;398(10306):1171-1183. (Review) 
  9. Hasbun R. Update and advances in community acquired bacterial meningitis. Curr Opin Infect Dis. 2019;32(3):233-238. (Review) 
  10. Granerod J, Tam CC, Crowcroft NS, et al. Challenge of the unknown. A systematic review of acute encephalitis in non-outbreak situations. Neurology. 2010;75(10):924-932. (Systematic review; 44 studies) 
  11. Beaman MH. Community-acquired acute meningitis and encephalitis: a narrative review. Med J Aust. 2018;209(10):449- 454. (Review)
  12. * Wright WF, Pinto CN, Palisoc K, et al. Viral (aseptic) meningitis: a review. J Neurol Sci. 2019;398:176-183. (Review) DOI: 10.1016/j.jns.2019.01.050 
  13. Peigue-Lafeuille H, Croquez N, Laurichesse H, et al. Enterovirus meningitis in adults in 1999-2000 and evaluation of clinical management. J Med Virol. 2002;67(1):47-53. (Prospective observational; 30 patients) 
  14. Whitley RJ, Alford CA, Hirsch MS, et al. Vidarabine versus acyclovir therapy in herpes simplex encephalitis. N Engl J Med. 1986;314(3):144-149. (Randomized controlled trial; 208 patients) 
  15. Glaser CA, Honarmand S, Anderson LJ, et al. Beyond viruses: clinical profiles and etiologies associated with encephalitis. Clin Infect Dis. 2006;43(12):1565-1577. (Prospective observational; 1570 patients)
  16. George BP, Schneider EB, Venkatesan A. Encephalitis hospitalization rates and inpatient mortality in the United States, 2000-2010. PLoS One. 2014;9(9):e104169. (Retrospective observational; 238,567 patients) 
  17. * Venkatesan A, Tunkel AR, Bloch KC, et al. Case definitions, diagnostic algorithms, and priorities in encephalitis: consensus statement of the International Encephalitis Consortium. Clin Infect Dis. 2013;57(8):1114-1128. (Practice guideline) DOI: 10.1093/cid/cit458
  18. Huo L, Xu KL, Wang H. Clinical features of SARS-CoV-2-associated encephalitis and meningitis amid COVID-19 pandemic. World J Clin Cases. 2021;9(5):1058-1078. (Case series; 32 patients) 
  19. Antoniello D, Milstein MJ, Dardick J, et al. Altered mental status in COVID-19. J Neurol. 2022;269(1):12-18. (Retrospective; 166 patients) 
  20. Aksamit AJ. Treatment of viral encephalitis. Neurol Clin. 2021;39(1):197-207. (Review) 
  21. Park BJ, Wannemuehler KA, Marston BJ, et al. Estimation of the current global burden of cryptococcal meningitis among persons living with HIV/AIDS. AIDS. 2009;23(4):525-530. (Review) 
  22. * Attia J, Hatala R, Cook DJ, et al. The rational clinical examination. Does this adult patient have acute meningitis? JAMA. 1999;282(2):175-181. (Systematic review; 10 studies) DOI: 10.1001/jama.282.2.175 
  23. Gaieski DF, O’Brien NF, Hernandez R. Emergency neurologic life support: meningitis and encephalitis. Neurocrit Care. 2017;27(Suppl 1):124-133. (Practice guideline) 
  24. Seymour CW, Cooke CR, Heckbert SR, et al. Prehospital intravenous access and fluid resuscitation in severe sepsis: an observational cohort study. Crit Care (London). 2014;18(5):533. (Prospective; 15 centers, 1350 patients) 
  25. * Julián-Jiménez A, Morales-Casado MI. Usefulness of blood and cerebrospinal fluid laboratory testing to predict bacterial meningitis in the emergency department. Neurologica (Engl Ed). 2019;34(2):105-113. (Review) DOI: 10.1016/j.nrl.2016.05.009 
  26. Sakushima K, Hayashino Y, Kawaguchi T, et al. Diagnostic accuracy of cerebrospinal fluid lactate for differentiating bacterial meningitis from aseptic meningitis: a meta-analysis. J Infect. 2011;62(4):255-262. (Meta-analysis; 33 studies, 1885 patients)
  27. * McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016;72(4):405-438. (Practice guideline) DOI: 10.1016/j.jinf.2016.01.007
  28. Briere EC, Rubin L, Moro PL, et al. Prevention and control of Haemophilus influenzae type B disease: recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm Rep. 2014;63(Rr-01):1-14. (Guidelines) 
  29. U.S. Centers for Disease Control and Prevention. Updated recommendations for use of VariZIG --United States, 2013. MMWR Recomm Rep. 2013;62(28):574-576. (Practice guideline) 
  30. Cohn AC, MacNeil JR, Clark TA, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Reomm Rep. 2013;62(RR-2):1-28. (Practice guideline) 
  31. Bardak-Ozcem S, Sipahi OR. An updated approach to healthcare-associated meningitis. Expert Rev Anti Infect Ther. 2014;12(3):333-342. (Review) 
  32. Tyler KL. Acute viral encephalitis. N Engl J Med. 2018;379(6):557-566. (Review) 
  33. Kenfak A, Eperon G, Schibler M, et al. Diagnostic approach to encephalitis and meningoencephalitis in adult returning travellers. Clin Microbiol Infect. 2019;25(4):415-421. (Review) 
  34. Brody IA, Wilkins RH. The signs of Kernig and Brudzinski. Arch Neurol. 1969;21(2):215-218. (Editorial) 
  35. Nakao JH, Jafri FN, Shah K, et al. Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014;32(1):24-28. (Prospective observational; 197 patients) 
  36. Uchihara T, Tsukagoshi H. Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache. 1991;31(3):167-171. (Prospective; 54 patients) 
  37. Iguchi M, Noguchi Y, Yamamoto S, et al. Diagnostic test accuracy of jolt accentuation for headache in acute meningitis in the emergency setting. Cochrane Database Syst Rev. 2020;6:CD012824. (Cochrane review and meta-analysis; 9 studies, 1161 patients) 
  38. Nigrovic LE, Malley R, Macias CG, et al. Effect of antibiotic pretreatment on cerebrospinal fluid profiles of children with bacterial meningitis. Pediatrics. 2008;122(4):726-730. (Retrospective; 245 patients)
  39. * Costerus JM, Brouwer MC, Bijlsma MW, et al. Community-acquired bacterial meningitis. Curr Opin Infect Dis. 2017;30(1):135-141. (Review) DOI: 10.1097/QCO.0000000000000335 
  40. Bonadio WA. The cerebrospinal fluid: physiologic aspects and alterations associated with bacterial meningitis. Pediatr Infect Dis J. 1992;11(6):423-431. (Review) 
  41. Ellis J, Luintel A, Chandna A, et al. Community-acquired acute bacterial meningitis in adults: a clinical update. Br Med Bull. 2019;131(1):57-70. (Review) 
  42. Arevalo CE, Barnes PF, Duda M, et al. Cerebrospinal fluid cell counts and chemistries in bacterial meningitis. South Med J. 1989;82(9):1122-1127. (Retrospective; 428 patients) 
  43. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267-1284. (Practice guideline) 
  44. Dumaidi K, Al-Jawabreh A. Molecular detection and genotyping of enteroviruses from CSF samples of patients with suspected sepsis-like illness and/or aseptic meningitis from 2012 to 2015 in West Bank, Palestine. PloS One. 2017;12(2):e0172357. (Prospective; 356 patients) 
  45. Mazor SS, McNulty JE, Roosevelt GE. Interpretation of traumatic lumbar punctures: who can go home? Pediatrics. 2003;111(3):525-528. (Retrospective; 57 patients) 
  46. Dougherty JM, Roth RM. Cerebral spinal fluid. Emerg Med Clin N Amer. 1986;4(2):281-297. (Review)
  47. Tamune H, Takeya H, Suzuki W, et al. Cerebrospinal fluid/ blood glucose ratio as an indicator for bacterial meningitis. Am J Emerg Med. 2014;32(3):263-266. (Retrospective; 144 patients) 
  48. Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment. Pediatrics. 2001;108(5):1169-1174. (Retrospective; 128 patients) 
  49. Baheerathan A, Pitceathly RD, Curtis C, et al. CSF lactate. Pract Neurol. 2020;20(4):320-323. (Review)
  50. Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America’s clinical practice guidelines for healthcare-associated ventriculitis and meningitis. Clin Infect Dis. 2017;64(6):e34-e65. (Practice guideline) 
  51. Buch K, Bodilsen J, Knudsen A, et al. Cerebrospinal fluid lactate as a marker to differentiate between community-acquired acute bacterial meningitis and aseptic meningitis/encephalitis in adults: a Danish prospective observational cohort study. Infect Dis (Lond). 2018;50(7):514-521. (Prospective; 176 patients) 
  52. Verstrepen WA, Kuhn S, Kockx MM, et al. Rapid detection of enterovirus RNA in cerebrospinal fluid specimens with a novel single-tube real-time reverse transcription-PCR assay. J Clin Microbiol. 2001;39(11):4093-4096. (Prospective; 70 patients) 
  53. Bahr NC, Meintjes G, Boulware DR. Inadequate diagnostics: the case to move beyond the bacilli for detection of meningitis due to Mycobacterium tuberculosis. J Med Microbiol. 2019;68(5):755-760. (Review) 
  54. Hernandez AV, de Laurentis L, Souza I, et al. Diagnostic accuracy of Xpert MTB/RIF for tuberculous meningitis: systematic review and meta-analysis. Trip Med Int Health. 2021;26(2):122- 132. (Meta-analysis; 30 articles, 3972 cases) 
  55. Morales-Casado MI, Julián-Jiménez A, Moreno-Alonso F, et al. [Diagnostic usefulness of procalcitonin and C-reactive protein in the emergency department for predicting bacterial meningitis in the elderly]. Enferm Infecc Microbiol Clin. 2016;34(1):8-16. (Prospective; 220 patients) 
  56. Chalupa P, Beran O, Herwald H, et al. Evaluation of potential biomarkers for the discrimination of bacterial and viral infections. Infection. 2011;39(5):411-417. (Prospective; 81 patients) 
  57. Vikse J, Henry BM, Roy J, et al. The role of serum procalcitonin in the diagnosis of bacterial meningitis in adults: a systematic review and meta-analysis. Int J Infect Dis. 2015;38:68-76. (Meta-analysis; 9 studies, 725 patients) 
  58. Newcombe J, Cartwright K, Palmer WH, et al. PCR of peripheral blood for diagnosis of meningococcal disease. J Clin Microbiol. 1996;34(7):1637-1640. (Prospective; 80 patients) 
  59. Temfack E, Rim JJB, Spijker R, et al. Cryptococcal antigen in serum and cerebrospinal fluid for detecting cryptococcal meningitis in adults living with human immunodeficiency virus: systematic review and meta-analysis of diagnostic test accuracy studies. Clin Infect Dis. 2021;72(7):1268-1278. (Meta-analysis; 11 studies, 3600 patients) 
  60. Venkatesan A, Jagdish B. Imaging in encephalitis. Semin Neurol. 2019;39(3):312-321. (Review) 
  61. Glimåker M, Johansson B, Bell M, et al. Early lumbar puncture in adult bacterial meningitis--rationale for revised guidelines. Scand J Infect Dis. 2013;45(9):657-663. (Review)
  62. Costerus JM, Brouwer MC, Sprengers MES, et al. Cranial computed tomography, lumbar puncture, and clinical deterioration in bacterial meningitis: a nationwide cohort study. Clin Infect Dis. 2018;67(6):920-926. (Retrospective; 1533 patients) 
  63. Bertrand A, Leclercq D, Martinez-Almoyna L, et al. MR imaging of adult acute infectious encephalitis. Med Mal Infect. 2017;47(3):195-205. (Review) 
  64. Aronin SI, Peduzzi P, Quagliarello VJ. Community-acquired bacterial meningitis: risk stratification for adverse clinical outcome and effect of antibiotic timing. Ann Intern Med. 1998;129(11):862-869. (Retrospective; 269 patients) 
  65. Proulx N, Fréchette D, Toye B, et al. Delays in the administration of antibiotics are associated with mortality from adult acute bacterial meningitis. QJM. 2005;98(4):291-298. (Retrospective case record study; 119 patients) 
  66. Perfect JR, Dismukes WE, Dromer F, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(3):291-322. (Practice guideline) 
  67. van de Beek D, Brouwer MC, Thwaites GE, et al. Advances in treatment of bacterial meningitis. Lancet. 2012;380(9854):1693- 1702. (Review) 
  68. Poulsen KP, Czuprynski CJ. Pathogenesis of listeriosis during pregnancy. Anim Health Res Rev. 2013;14(1):30-39. (Review) 
  69. Pelegrín I, Moragas M, Suárez C, et al. Listeria monocytogenes meningoencephalitis in adults: analysis of factors related to unfavourable outcome. Infection. 2014;42(5):817-827. (Retrospective; 59 patients) 
  70. Kitonsa J, Nsubuga R, Mayanja Y, et al. Determinants of two-year mortality among HIV positive patients with cryptococcal meningitis initiating standard antifungal treatment with or without adjunctive dexamethasone in Uganda. PLoS Negl Trop Dis. 2020;14(11):e0008823. (Retrospective; 211 patients) 
  71. Tenforde MW, Shapiro AE, Rouse B, et al. Treatment for HIV-associated cryptococcal meningitis. Cochrane Database Syst Rev. 2018;7:CD005647. (Cochrane review, meta-analysis; 13 studies, 2426 patients) 
  72. Bradshaw MJ, Venkatesan A. Herpes simplex virus-1 encephalitis in adults: pathophysiology, diagnosis, and management. Neurotherapeutics. 2016;13(3):493-508. (Review) 
  73. Tunkel AR, Glaser CA, Bloch KC, et al. The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2008;47(3):303-327. (Practice guidelines) 
  74. * Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015(9):CD004405. (Cochrane review, meta-analysis; 25 studies, 4121 patients) DOI: 10.1002/14651858.CD004405.pub5 
  75. Prasad K, Singh MB, Ryan H. Corticosteroids for managing tuberculous meningitis. Cochrane Database Syst Rev. 2016;4:CD002244. (Cochrane review, meta-analysis; 9 studies, 1337 patients) 
  76. Glimåker M, Brink M, Naucler P, et al. Betamethasone and dexamethasone in adult community-acquired bacterial meningitis: a quality registry study from 1995 to 2014. Clin Microbiol Infect. 2016;22(9):814.e811-e814. (Retrospective; 1746 patients) 
  77. Armangue T, Spatola M, Vlagea A, et al. Frequency, symptoms, risk factors, and outcomes of autoimmune encephalitis after herpes simplex encephalitis: a prospective observational study and retrospective analysis. Lancet. Neurol. 2018;17(9):760-772. (Prospective; 99 patients) 
  78. Joubert B, Dalmau J. The role of infections in autoimmune encephalitides. Rev Neurol (Paris). 2019;175(7-8):420-426. (Review) 
  79. McLean HQ, Fiebelkorn AP, Temte JL, et al. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(RR-04):1-34. (Practice guideline) 
  80. Garg RK, Mahadevan A, Malhotra HS, et al. Subacute sclerosing panencephalitis. Rev Med Virol. 2019;29(5):e2058. (Review) 
  81. Wall EC, Ajdukiewicz KM, Bergman H, et al. Osmotic therapies added to antibiotics for acute bacterial meningitis. Cochrane Database Syst Rev. 2018;2:CD008806. (Cochrane review, meta-analysis; 5 studies, 1451 patients)
  82. Mourvillier B, Tubach F, van de Beek D, et al. Induced hypothermia in severe bacterial meningitis: a randomized clinical trial. JAMA. 2013;310(20):2174-2183. (Randomized controlled trial; 98 patients) 
  83. Fan S-J, Tan H-K, Xu Y-C, et al. A pooled analysis of the LAMP assay for the detection of Neisseria meningitidis. BMC Infect Dis. 2020;20(1):525. (Systematic review; 14 studies, 3185 patients) 
  84. Tansarli GS, Chapin KC. Diagnostic test accuracy of the BioFire® FilmArray® meningitis/encephalitis panel: a systematic review and meta-analysis. Clin Microbiol Infect. 2020;26(3):281- 290. (Meta-analysis; 8 studies, 3059 patients) 
  85. Nigrovic LE, Kuppermann N, Macias CG, et al. Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA. 2007;297(1):52-60. (Retrospective; 20 centers, 3295 patients)

Want more?

Get the full article 👇

Full Infectious Meningitis and Encephalitis Pathway
Full Infectious Meningitis and Encephalitis Pathway
CT is indicated before LP
CT is indicated before LP
CT is not indicated before LP
CT is not indicated before LP

FacebookTwitterLinkedInInstagramYouTubePinterest

EB Medicine

FOAMed

Podcast

© EB Medicine. All rights reserved