Acute bacterial meningitis and meningococcal sepsis — first-hour management

Diagnosis: strongly suspected meningococcal disease with meningitis — NICE red-flag combination (fever, headache, neck stiffness, altered cognition) plus haemorrhagic non-blanching rash with lesions larger than 2 mm. Absence of a rash would not have excluded the diagnosis.^[2]

The classic triad (fever, neck stiffness, altered mental status) is complete in only 44 per cent (van de Beek) / 39 per cent (Drost); 95 per cent have at least two of four (headache, fever, neck stiffness, AMS).^[1][4]

First-hour priorities (do not delay for imaging/LP):

1. Resuscitate airway, breathing and shock before any LP (NICE). Draw bloods (culture, WCC, CRP or PCT, whole-blood meningococcal/pneumococcal PCR) if that will not delay the drug. Blood cultures were positive in 76 per cent of the Dutch adult cohort.^[2][4]
2. Antibiotics within 1 hour of arrival: ceftriaxone at the highest BNF/BNFC dose. UKHSA/BNFC adult pre-hospital dose for suspected IMD: 2 g IV/IM stat. NICE does not list vancomycin as routine empiric cover.^[2][5]
3. Dexamethasone 10 mg IV with or before the first antibiotic if bacterial meningitis remains in play (de Gans: 10 mg every 6 hours for 4 days). Do not delay antibiotics to wait for the steroid. If delayed less than 12 hours, still give it. Once meningococcal disease is the diagnosis, NICE: do not routinely give corticosteroids; consider low-dose replacement steroids only if meningococcal shock is refractory to high-dose vasoactives.^[2][3]
4. Add IV amoxicillin only if Listeria risk factors are present (not taught here as a numbered age cutoff). Do not routinely add aciclovir unless HSV encephalitis is strongly suspected.^[2]
5. Do not LP through spreading purpura. Bloods, antibiotics and stabilisation before imaging. GCS 13 is not the NICE GCS-9-or-less stop; Hasbun still flags abnormal consciousness as a CT-associated feature (NPV 97 per cent when no Hasbun features).^[2][6]

Sourced CSF (Dutch adult proven bacterial meningitis medians): WCC 2400/mm3, protein 3.90 g/L, glucose 0.50 mmol/L — not a universal 1000–5000 / ratio-below-0.4 table.^[4]

Public health: notify. UKHSA: ciprofloxacin 500 mg stat (12 years and over) is first-line; rifampicin 600 mg twice daily for 2 days is the alternative; IM ceftriaxone 250 mg (12+) if rifampicin cannot be offered. A cephalosporin-treated index case does not need carriage eradication.^[5]