Bacterial Meningitis: The Daily PANCE Blueprint

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Bacterial Meningitis: The Daily PANCE Blueprint

A 64-year-old man is brought in with 1 day of fever, severe headache, and neck stiffness. He is now confused and lethargic, with a temperature of 39.4°C (102.9°F) and nuchal rigidity. On exam he has a new left pronator drift. Bacterial meningitis is strongly suspected, and a head CT is planned before lumbar puncture because of his altered mental status and focal deficit. After blood cultures are drawn, which of the following is the most appropriate next step?

A. Perform the lumbar puncture before any antibiotics
B. Obtain the head CT and withhold antibiotics until the lumbar puncture is done
C. Administer dexamethasone plus empiric IV antibiotics immediately
D. Order an MRI of the brain before treatment
E. Await blood culture results before starting antibiotics

Answer and topic summary

The answer is C. Administer dexamethasone plus empiric IV antibiotics immediately.

When bacterial meningitis is suspected and neuroimaging is needed before lumbar puncture (altered mental status, focal neurologic deficit, papilledema, immunocompromise, or seizure), you must NOT delay treatment: draw blood cultures, then give dexamethasone with or just before the first dose of empiric IV antibiotics (e.g., vancomycin plus ceftriaxone), and obtain the CT and lumbar puncture afterward. Adjunctive dexamethasone reduces neurologic complications and is most effective when given before or concurrently with antibiotics. Delaying antibiotics for imaging, the lumbar puncture, MRI, or culture results increases morbidity and mortality.

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Covered under ⇒ PANCE Blueprint Neurology ⇒ Infectious Disorders ⇒ Meningitis

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