Bacterial meningitis
Summary
Definition
History and exam
Key diagnostic factors
- headache
- neck stiffness
- fever
- altered mental status
- confusion
- photophobia
- vomiting
- seizures
- hypothermia (infants)
- irritability (infants)
- lethargy (infants)
- poor feeding (infants)
- apnea (infants)
- focal neurologic deficit
- abnormal eye movement
- facial palsy
- balance problems/hearing impairment
- bulging fontanel in infants
Other diagnostic factors
- high-pitched cry (infants)
- rash
- papilledema
- Kernig sign
- Brudzinski sign
Risk factors
- age ≤5 or ≥65 years
- crowding
- exposure to pathogens
- nonimmunized infants
- immunodeficiency
- cancer
- asplenia/hyposplenic state
- cranial anatomic defects
- cochlear implants
- contiguous infection
- smoking
Diagnostic tests
1st tests to order
- cerebrospinal fluid (CSF) cell count and differential
- cerebrospinal fluid (CSF) protein
- cerebrospinal fluid (CSF) glucose
- cerebrospinal fluid (CSF) Gram stain
- cerebrospinal fluid (CSF) culture
- antigen detection in cerebrospinal fluid (CSF)
- blood culture
- CBC and differential
- CRP
- electrolytes, calcium (Ca), magnesium (Mg), glucose
- coagulation profile (prothrombin time, INR, activated PTT, fibrinogen, fibrin degradation products)
- CT head
- polymerase chain reaction (PCR)
Emerging tests
- heparin-binding protein (HBP)
- rapid antigen cerebrospinal fluid (CSF) tests
- metagenomic next-generation sequencing (mNGS)
Treatment algorithm
Contributors
Expert advisers
Rodrigo Hasbun, MD, MPH
Professor of Medicine
UT Health Mc Govern Medical School
Houston
TX
Disclosures
RH has received research support and personal fees from Biomeriaux. RH is an author of references cited in this topic.
Omaima El Tahir, MD
PhD Candidate
Department of Pediatric infectious Diseases and Immunology, AI&II
Amsterdam UMC, Vrije Universiteit Amsterdam
Amsterdam
The Netherlands
Disclosures
OET declares that she has no competing interests.
Acknowledgements
Dr Rodrigo Hasbun and Omaima El Tahir would like to gratefully acknowledge Dr Marceline Tutu van Furth, previous contributor to this topic.
Disclosures
AMTvF declares that she has no competing interests.
Peer reviewers
Catherine Derber, MD
Professor
Department of Medicine
Eastern Virginia Medical School
Norfolk
VA
Disclosures
CD declares that she has no competing interests.
Guy Thwaites, MA, MBBS, PhD, MRCP, FRCPath
Wellcome Trust Clinical Research Fellow
Centre for Molecular Microbiology and Infection
Imperial College London
London
UK
Disclosures
GT declares that he has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
Expert advisers: comorbidities
Pankaj Shah, MD
Endocrinologist
Assistant Professor of Medicine
Department of Internal Medicine
Chair, Hospital Diabetes and Endocrinology Core Group
Mayo Clinic
Rochester
MN
Disclosures
As part of his job at his institute, PS provides expert opinion in a physician education tool called "Ask Mayo Expert", where he is one of several "Subject Matter Experts." He also addresses academic educational activities in the US and abroad as part of his institutional duty. PS declares no other competing interests.
Preethi Pirlamarla, MD
Physician (Cardiologist)
Director of Quality Improvement for the Advanced Heart Failure and Cardiac Transplant Department
Heart Institute at University of Washington Medical Center - Montlake
Seattle
WA
Disclosures
PP declares that she has no competing interests.
Lorenzo Azzalini, MD, PhD, MSc, FACC, FSCAI
Associate Professor of Medicine
Division of Cardiology
Department of Medicine
University of Washington
Director of Interventional Cardiology Research, Heart Institute at University of Washington Medical Center - Montlake
Seattle
WA
Disclosures
LA has received consulting fees from Teleflex, Abiomed, GE Healthcare, Reflow Medical, Shockwave, Abbott, and Cardiovascular Systems, Inc.; received a research grant by Abiomed; serves on the advisory board of Abiomed and GE Healthcare; and owns equity in Reflow Medical.
Philip R. Muskin, MD, MA, DLFAPA, LFACLP
Professor of Psychiatry
Columbia University Irving Medical Center
Senior Consultant in Consultation-Liaison Psychiatry
New York-Presbyterian/Columbia University Irving Medical Center
New York
NY
Disclosures
PRM is an Associate Editor of American Psychiatric Association Publishing and on the editorial board for the journal Focus, for which he receives no compensation. At the American Board of Psychiatry and Neurology he is a member of the Article Based Certification Committee for Consultation-Liaison Psychiatry (no compensation), and at the American Psychiatric Association he is a member of the Scientific Program Committee for the Annual Meeting 2025 (no compensation) and will be on this committee in 2026. PRM serves as an expert witness in psychiatric malpractice lawsuits, for which he is compensated. He was grant co-investigator for the proposal “Can hypnosis enhance the ability to regulate behavioral and brain markers of emotion regulation?” (Proposal No. 75037-NS, Department of the Army, US Army Combat Capabilities Development Command, Army Research Office), which ended in 2023. PRM receives royalties from American Psychiatric Association Publishing for The American Psychiatric Publishing Study Guide for the Psychiatry Board Examination (edited by Muskin PR and Dickerman AL, American Psychiatric Publishing, 2016), and makes presentations at the American Psychiatric Association and Academy of Consultation-Liaison Psychiatry Annual Meetings.
Seki Balogun, MD, FACP, AGSF
Professor of Medicine
Geriatrician and Palliative Care Physician
University of Oklahoma Health Sciences Center
Oklahoma City
OK
Disclosures
SB serves on the United States Medical Licensing Examination (USMLE) Step 3 Interdisciplinary Review Committee.
Khalilah Gates, MD
Associate Professor of Medicine (Pulmonary and Critical Care)
Assistant Dean of Learning and Academic Performance
Division of Pulmonary and Critical Care
Department of Medicine
Northwestern University Feinberg School of Medicine
Medical Director, Diversity and Inclusion Education
NM Academy
Chicago
IL
Disclosures
KG is a Board Member of the Respiratory Health Association, where she focuses on communication for COPD and asthma and has no financial agreements or obligations.
Karen Jubanyik, MD
Associate Professor of Emergency Medicine
Director
Emergency Medicine Clerkship
Yale School of Medicine
New Haven
CT
Disclosures
KJ declares that she has no competing interests.
Ziad Zoghby, MD, MBA, FACP
Associate Professor of Medicine
Division of Nephrology and Hypertension
Department of Medicine
Mayo Clinic
Rochester
MN
Disclosures
ZZ received fees for consultancy work in 2022 and 2023 for ChroniSense Ltd, a remote digital health company. He has served since 2018 on the Nephrology Specialty Board for EPIC, an electronic health record vendor, and is the elected Chair of the Board for 2024-2025 (a nonpaid position).
Madeleine Alexeeva, DO
Emergency Medicine Physician
Vituity
Visalia
CA
Associate Program Director of Emergency Medicine Residency
Kaweah Health Medical Center
Visalia
CA
Disclosures
MA declares that she has no competing interests.
Lindsey Phillips, MD
Assistant Professor of Medicine
University of North Carolina School of Medicine
Chapel Hill
NC
Disclosures
LP declares that she has no competing interests.
Michael S. Phipps, MD, MHS
Associate Professor of Neurology and Epidemiology and Public Health
University of Maryland School of Medicine
Director of the Brain Attack Center at the University of Maryland Medical Center
Baltimore
MD
Disclosures
MSP declares that he is a member of the American Academy of Neurology Quality Committee (non-financial), a Liaison, American Heart Association, QCOR Committee (non-financial) and a member of the International Stroke Conference Program Committee (non-financial). No financial disclosures.
References
Key articles
Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. Abstract
van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22(suppl 3):S37-62.Full text Abstract
Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015 Sep 12;(9):CD004405.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available here.
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