eMedicine Specialties > Emergency Medicine > Infectious Diseases

Meningitis: Follow-up

Author: Marjorie Lazoff, MD, Editor-in-Chief, Medical Computing Review
Contributor Information and Disclosures

Updated: Jul 28, 2009

Follow-up

Further Inpatient Care

  • Admit to appropriate service.
  • If meningococcal meningitis is suspected, arrange for respiratory isolation for the first 24 hours and ensure appropriate ED personnel receive prophylaxis (see Patient Education).

Deterrence/Prevention

  • One vaccine protects against 4 strains of N meningitidis. As of February 2008, the Advisory Committee on Immunization Practices no longer recommends routine immunization of children, but they continue to recommend routine immunization of teenagers and all children/adults at increased risk.7
  • It is not known whether the adult use of conjugate pneumococcal vaccine decreases the incidence of S pneumoniae meningitis.  
  • There is no standard recommendation for H influenzae vaccination in adults.  

Complications

  • Immediate -Septic shock, including DIC, coma with loss of protective airway reflexes, seizures (30-40% of children, 20-30% of adults), cerebral edema, septic arthritis, pericardial effusion, and hemolytic anemia (H influenzae)
  • Subdural effusions - Reported in 39% of children aged 1-18 months with bacterial meningitis
    • Risk factors include young age, rapid onset of illness, low peripheral WBC count, and high CSF protein.
    • Seizures occur more commonly during the acute course of the disease, although long-term sequelae of promptly treated subdural effusions are similar to those of uncomplicated meningitis.
  • Delayed - Decreased hearing or deafness, other cranial nerve dysfunction, multiple seizures, focal paralysis, subdural effusions, hydrocephalus, intellectual deficits, ataxia, blindness, Waterhouse-Friderichsen syndrome, and peripheral gangrene

Prognosis

  • Prognosis depends on the pathogen, patient's age and condition, and severity of acute illness.
  • Patients with severe neurologic impairment on presentation or with extremely rapid onset of illness, even if treated immediately, have a 50-90% mortality rate and an even higher rate of morbidity.
  • Pneumococcal meningitis has the highest rates of mortality (21%) and morbidity (15%).

Patient Education

  • Health professionals recommend vaccinating all US college students against N meningitis.
  • See Treatment for recommended prophylaxis for close contacts of patient with (suspected) N meningitidis or H influenzae type b meningitis.
    • Instruct all contacts to return to ED immediately at the first sign of fever, sore throat, rash, or symptoms of meningitis.
    • Rifampin prophylaxis only eradicates the organism from the nasopharynx; it is ineffective against invasive disease.
  • For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education articles Meningitis in Adults and Meningitis in Children.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose bacterial meningitis among the top 5 ED malpractice claims
  • Failure to promptly institute treatment or failure to educate regarding follow-up care in previously discharged patient

Special Concerns

  • Neonate: Query the mother regarding intrapartum antibiotic prophylaxis and, if none, risk factors (eg, delivery <37 wk gestation, ruptured membranes 18 h or more, previously delivered child with group B streptococcal (GBS) infection, GBS bacteruria during pregnancy, intrapartum temp 100.4°F [38°C] or higher).
  • Travelers - Elicit recent travel history, as some third world countries have outbreaks of meningococcal epidemics.
  • Geriatric patients - Elicit history of pneumococcal immunization.
  • Young adults - Routine immunization of this population has been the subject of controversy; however, this group is at greatest risk of exposure to epidemic meningococcal disease.
  • Revaccination is not recommended, but some authorities believe a booster may be required for patients at high risk (eg, nephrotic syndromes, renal failure, transplant recipients, splenectomy, HIV with last vaccine >6 y ago).
 


More on Meningitis

Overview: Meningitis
Differential Diagnoses & Workup: Meningitis
Treatment & Medication: Meningitis
Follow-up: Meningitis
Multimedia: Meningitis
References
[ CLOSE WINDOW ]

References

  1. Scheld WM, Koedel U, Nathan B, Pfister HW. Pathophysiology of bacterial meningitis: mechanism(s) of neuronal injury. J Infect Dis. Dec 1 2002;186 Suppl 2:S225-33. [Medline].

  2. van de Beek D, de Gans J, Tunkel AR, Wijdicks EF. Community-acquired bacterial meningitis in adults. N Engl J Med. Jan 5 2006;354(1):44-53. [Medline].

  3. Thigpen, M, Rosenstein, NE, Whitney, CG. Bacterial meningitis in the United States --1998-2003. Presented at the 43rd Annual Meeting of the Infectious Diseases Society of America, San Francisco, CA. October 2005;65.

  4. Seupaul RA. Evidence-based emergency medicine/rational clinical examination abstract. How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis?. Ann Emerg Med. Jul 2007;50(1):85-7. [Medline].

  5. van de Beek D, de Gans J, McIntyre P, Prasad K. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis. Mar 2004;4(3):139-43. [Medline].

  6. Peltola H, Roine I. Improving the outcomes in children with bacterial meningitis. Curr Opin Infect Dis. Apr 14 2009;[Medline].

  7. Report from the Advisory Committee on Immunization Practices (ACIP): decision not to recommend routine vaccination of all children aged 2-10 years with quadrivalent meningococcal conjugate vaccine (MCV4). MMWR Morb Mortal Wkly Rep. May 2 2008;57(17):462-5. [Medline].

  8. Anderson DC, Kozak AJ. Meningitis, encephalitis, and brain abscess. In: Tintinalli JE, ed. Emergency Medicine [book on CD-ROM]. 4th ed. McGraw-Hill; 1977:chap 199.

  9. Ashwal S. Neurologic evaluation of the patient with acute bacterial meningitis. Neurol Clin. Aug 1995;13(3):549-77. [Medline].

  10. Barkin R. Meningitis, bacterial. In: Barkin R, ed. Pediatric Emergency Medicine [book on CD-ROM]. 2nd ed. 1992:chap 52.

  11. Beckham JD, Tyler KL. Initial management of acute bacterial meningitis in adults: summary of IDSA guidelines. Rev Neurol Dis. Spring 2006;3(2):57-60. [Medline].

  12. de Gans J, van de Beek D,. Dexamethasone in adults with bacterial meningitis. N Engl J Med. Nov 14 2002;347(20):1549-56. [Medline].

  13. Fitch MT, van de Beek D. Emergency diagnosis and treatment of adult meningitis. Lancet Infect Dis. Mar 2007;7(3):191-200. [Medline].

  14. Kelley J, ed. Approach to the patient with suspected central nervous system infections. In: Textbook of Internal Medicine [book on CD-ROM]. 3rd ed. Lippincott-Raven; 1996:chap 435.

  15. Kelley J, ed. Meningitis and ventriculitis. In: Textbook of Internal Medicine [book on CD-ROM]. 3rd ed. Lippincott-Raven; 1996:chap 446.

  16. McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA. Sep 17 1997;278(11):925-31. [Medline].

  17. Mellis P. Bacteria, sepsis, and meningitis in children. In: Tintinalli JE, ed. Emergency Medicine [book on CD-ROM]. 4th ed. McGraw-Hill; 1997:chap 109.

  18. Miller LG, Choi C. Meningitis in older patients: how to diagnose and treat a deadly infection. Geriatrics. Aug 1997;52(8):43-4, 47-50, 55. [Medline].

  19. Pfister HW, Scheld WM. Brain injury in bacterial meningitis: therapeutic implications. Curr Opin Neurol. Jun 1997;10(3):254-9. [Medline].

  20. Pomar V, Martinez S, Paredes R, Domingo P. Advances in adjuvant therapy against acute bacterial meningitis. Curr Drug Targets Infect Disord. Dec 2004;4(4):303-9. [Medline].

  21. Powderly WG. Cryptococcal meningitis and AIDS. Clin Infect Dis. Nov 1993;17(5):837-42. [Medline].

  22. Prasad K, Singhal T, Jain N, Gupta PK. Third generation cephalosporins versus conventional antibiotics for treating acute bacterial meningitis. Cochrane Database Syst Rev. 2004;CD001832. [Medline].

  23. Quagliarello VJ, Scheld WM. Treatment of bacterial meningitis. N Engl J Med. Mar 6 1997;336(10):708-16. [Medline].

  24. Rosenstein N, Levine O, Taylor JP, et al. Efficacy of meningococcal vaccine and barriers to vaccination. JAMA. Feb 11 1998;279(6):435-9. [Medline].

  25. Schaad UB, Kaplan SL, McCracken GH. Steroid therapy for bacterial meningitis. Clin Infect Dis. Mar 1995;20(3):685-90. [Medline].

  26. Sinner SW, Tunkel AR. Antimicrobial agents in the treatment of bacterial meningitis. Infect Dis Clin North Am. Sep 2004;18(3):581-602, ix. [Medline].

  27. [Guideline] Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. Nov 1 2004;39(9):1267-84. [Medline].

  28. Walls RM. Adult meningitis, encephalitis, and intracranial abscess. In: Rosen P, ed. Emergency Medicine [book on CD-ROM]. 3rd ed. Mosby; 1992:chap 94.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Marjorie Lazoff, MD, Editor-in-Chief, Medical Computing Review
Marjorie Lazoff, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Informatics Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Mark S Slabinski, MD, FACEP, FAAEM, Vice President, EMP Medical Group
Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Weiss, MD, DTM&H, Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine
Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.