Approach Considerations
Many patients who have aseptic meningitis can be cared for on an outpatient basis, but those who have profound headache, nausea, vomiting, or CSF pleocytosis with a polymorphonuclear leukocyte predominance should be admitted for observation. Antibiotic coverage for bacterial meningitis may be given, at the discretion of the managing clinician.
No specific treatment exists for most of the viruses that cause meningitis; therefore, management, for the most part, is supportive and includes analgesics, antinausea medications, intravenous fluids, and prevention and treatment of complications.
Headache and fever usually can be treated with judicious doses of acetaminophen. Severe hyperthermia (>40°C) may require vigorous therapy, but mild temperature elevation may serve as a natural defense mechanism, and some authors believe it should be left untreated.
Strict isolation is not necessary. When enteroviral infection is suspected, take precautions in handling stools and wash hands carefully. In patients with meningitis from measles, chickenpox, rubella, or mumps virus infections, the usual precaution of isolation from susceptible individuals should be observed.
For severe cases, meticulous care in an intensive care setting with respiratory and nutritional support is warranted. Remarkable recovery may be achieved in some patients who become comatose. Vigorous support and avoidance of complications are very important in these patients.
Medical Care
Given the potential for serious neurological morbidity and the persistently high mortality rates of bacterial meningitis, rapid institution of antibiotic coverage is essential when the diagnosis of bacterial meningitis is suspected. A third-generation intravenous cephalosporin is the customary choice.
Most studies suggest that rapid sterilization of CSF reduces mortality and long-term sequelae rates. Generally, if imaging studies are indicated before lumbar puncture, blood cultures and empiric antibiotic therapy should be instituted before the imaging studies; these are unlikely to decrease diagnostic sensitivity if CSF is tested for bacterial antigens.
A consensus conference recommended empirical antibiotic therapy for all patients with postoperative meningitis and treatment withdrawal after 48 or 72 hours if CSF culture results are negative. [15] This concept is not universally accepted. Zarrouk et al found that stopping antibiotic treatment after 3 days is effective and safe for patients with postoperative meningitis whose CSF culture results are negative. [16]
Antiviral therapy
Effective antiviral therapy is available against HSV-1, varicella, and cytomegalovirus. In immunosuppressed patients, long-term therapy may be necessary.
Acyclovir is recommended for immunocompetent hosts with HSV-2 meningitis and a primary genital herpes infection. Valacyclovir and foscarnet are alternative antiviral agents.
In patients with Mollaret meningitis, acyclovir (intravenous or oral) or valacyclovir (oral only) are worthy of consideration for both therapy and prophylaxis.
Specific antibacterial therapy
For meningitis from the following pathogens, these specific agents are appropriate:
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Tuberculosis- triple drug therapy with rifampin/isoniazid/pyrazinamide
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Actinomycetes and spirochetes - penicillin and ceftriaxone
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Brucella - doxycycline or rifampin
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Pasteurella tularensis - gentamicin
Antifungal therapy
Antifungal agents of choice include amphotericin B, fluconazole, and flucytosine. For more information, see the Medscape article Meningitis.
Steroids
In general, corticosteroids are avoided in aseptic meningitis because of their inhibitory effects on host immune responses. Occasionally, glucocorticoids, such as dexamethasone, are useful when meningitis is associated with signs of increased intracranial pressure.
Meningitis from Vogt-Koyanagi-Harada syndrome responds to prednisone in moderate to high doses.
Treatment of complications
Seizures sometimes can complicate meningitis; however, prophylactic anticonvulsants are not recommended routinely. If seizures develop, they can be controlled with phenytoin and phenobarbital. If status epilepticus develops, appropriate therapy should be provided to prevent secondary brain injury.
If persistent cognitive problems occur after recovery from acute meningitis, especially residual suboptimal functioning in the workplace or in school, referral for formal neuropsychological testing clarifies the nature of the complaint both to the physician and to the patient and helps separate psychological adjustment factors from organic dysfunction.
Prevention
Hand washing and other general good health measures may reduce the risk of developing an infection that can progress to meningitis.
Many of the causes of meningitis are communicable and, if one case of meningitis is diagnosed within a community, appropriate steps may need to be taken immediately to prevent the further spread of the disease. Since viruses that are passed in the stool cause most cases, people diagnosed with aseptic meningitis should be sure to wash their hands thoroughly after using the toilet. Always wash hands after changing diapers.
Effective vaccines are available for polio, measles, mumps, and rubella. Illnesses related to these viruses have declined dramatically in countries with effective vaccination strategies. Vaccination against Japanese encephalitis has been effective in controlling the infection in Asia. Rabies is the only infection in which the vaccine is given after exposure to the virus.
