Acute Meningitis

Description

Emergency measures

Medicine treatment 

Referral

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A39.0+(G01*)/G00.0-3/G00.8-9/G01/G02.0-1/G02.8/G03.0/G03.8-9

DESCRIPTION

• Infection of the membranes of the brain
• Clinical signs and symptoms include:
  • Headache
  • Neck stiffness
  • Vomiting
  • Fever
  • Impaired level of consciousness
  • Photophobia
  • Bulging fontanelle in infants

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Note:

- During the early phase of TB meningitis, malaise, low-grade fever, headache and personality change rather than the above-mentioned symptoms may be present

- Duration of treatment for TB meningitis is 9 months

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• Neck stiffness is rare in young children, and especially neonates, and may be absent in adults, especially debilitated patients and the elderly
• Young children with fever, vomiting and convulsions or an impaired level of consciousness must be assumed to have meningitis. Signs may be even more subtle in newborns

EMERGENCY MEASURES

• Stabilise before referral
• Treat for shock, if present
• If patient’s level of consciousness is depressed:
  • Maintain airway
  • Give oxygen
• Ensure hydration
• If convulsing, see: Seizures and status epilepticus.

MEDICINE TREATMENT

• Initiate medicine treatment before transfer

Children

• Ceftriaxone, IM/IV, 100 mg/kg/dose immediately as a single dose before referral. See: dosing table
  • For IM administration, do not inject more than 1 g at one injection site.
  • Maximum pre-referral dose: 2 g IM/IV.
  • If referral is delayed, repeat dose after 12 hours.
  • Maximum daily dose of 4 g, given in divided doses 12 hourly.

LoE:IVb³⁸

CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone, even if jaundiced Avoid giving calcium-containing IV fluids (e.g. Ringer-Lactate) together with ceftriaxone: - If ≤ 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone  administered. - If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given  sequentially provided the giving set is flushed thoroughly with sodium chloride 0.9% before and after. - Preferably administer IV fluids without calcium contents Always include the dose and route of administration of ceftriaxone in the referral letter

• Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See: dosing table

AND/OR

• NSAID, e.g.:
• Ibuprofen, oral, 5–10 mg/kg/dose 8 hourly with or after a meal. See: dosing table

Adults

• Ceftriaxone, IM, 2 g immediately before referral.
  • Do not inject more than 1 g at one injection site.
  • If referral is delayed, repeat dose after 12 hours.

LoE:IVb³⁹

• Paracetamol, oral, 500 mg–1 g, 4–6 hourly as required (to a maximum of 4 g in 24 hours).
  • Maximum dose: 15 mg/kg/dose.

AND/OR

• NSAID, e.g.:
• Ibuprofen, oral, 400 mg then 8 hourly with meals, if needed.

Severe pain:

• Tramadol, oral, 50–100 mg 4–6 hourly.
  • May be increased to a maximum daily dose of 400mg.

During a listeria outbreak, ADD as a pre-referral dose:

A32.1/A32.7-9

Children

• Ampicillin, IM/IV 75 mg/kg/dose immediately before referral.
  • If referral is delayed by 6 hours or more, administer second dose.

Weight  kg	Dose  mg	Injection  500 mg/mL  (500 mg diluted in 0.9 mL water for injection (WFI))	Age  months/ years
>3.5–5.5 kg	300 mg	0.6 mL	>1–3 months
>5–7 kg	450 mg	0.9 mL	>3–6 months
>7–9 kg	600 mg	1.2 mL	>6–12 months
>9–11 kg	750 mg	1.5 mL	>12–18 months
>11–17.5 kg	1000 mg	2 mL	>18 months–5 years
>17.5–25 kg	1500 mg	3 mL	>5–7 years
>25–35 kg	2000 mg	4 mL	>7–11 years
>35 kg	3000 mg	6 mL	>11 years

Adults

• Ampicillin, IM/IV, 3 g immediately before referral
  • If referral delayed by 6 hours, administer second dose

Severe penicillin allergy: 
Z88.0

Children

• Cotrimoxazole, oral, immediately before referral. See: dosing table
  • If referral delayed by 12 hours, administer second dose

Adults

• Cotrimoxazole, oral, 80/400 immediately before referral
  • If referral delayed by 12 hours, administer second dose

LoE:IVb⁴⁰

REFERRAL

• All patients with meningitis, or suspected meningitis or suspected listeria meningitis

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4_Version 1.0_26 May 2025

Chapter 15: Central Nervous System Conditions_15.8 Meningitis_15.8.1 Acute Meningitis