Medical-legal considerations related to symptom duration and patient outcome after bacterial meningitis

Asplenia and fever

A 45-year-old-man presented with the abrupt onset of a fever over 30 years after surgical splenectomy. He presented with symptoms and findings that seemed consistent with influenza. He rapidly developed fulminant meningitis that resulted in his death.

Emergency department management of meningitis and encephalitis

Bacterial meningitis and viral encephalitis are infectious disease emergencies that can cause significant patient morbidity and mortality. Clinicians use epidemiologic, historical, and physical examination findings to identify patients at risk for these infections, and central nervous system (CNS) imaging and lumbar puncture (LP) may be needed to further evaluate for these diagnoses. The diagnosis of bacterial meningitis can be challenging, as patients often lack some of the characteristic findings of this disease with presentations that overlap with more common disorders seen in the emergency department. This article addresses considerations in clinical evaluation, need for CNS imaging before LP, interpretation of cerebrospinal fluid results, standards for and effects of timely antibiotic administration, and recommendations for specific antimicrobial therapy and corticosteroids.

Antibiotics for Life-Threatening Illness

Infection is a common reason for seeking treatment in the emergency department. Appropriate and timely therapy for these patients is critical. The therapy of most infectious presentations in the emergency department is empiric, with little information published about the infectious etiology and/or pathogen(s). Optimal antibiotic therapy in these patients involves the selection of the appropriate agent(s), the proper dosing regimen, timely administration, and close therapeutic monitoring. To make these decisions, health care providers must be aware of the appropriate diagnostic criteria, likely pathogens for the suspected site of infection, the latest antimicrobial products, and current antimicrobial resistance patterns and trends. Health care providers are also charged with the task of avoiding unnecessary or inappropriate antimicrobial therapy to prevent or slow further bacterial pathogen resistance. Bacterial meningitis, urinary tract infection, and community-acquired pneumonia are the most commonly seen emergency department infectious presentations.

Timing of Administration of Antimicrobial Therapy in Bacterial Meningitis

Bacterial meningitis is an important cause of morbidity and mortality in the United States and throughout the world. The diagnosis of bacterial meningitis is often delayed in patients as a result of numerous factors such as length of illness, use of radiologic imaging studies, and/or prior use of antimicrobial agents. Many textbooks emphasize the need for prompt initiation of antimicrobial therapy in a patient with suspected acute bacterial meningitis to prevent many of the long-term sequelae associated with this disorder. We have reviewed the literature to determine if there is a standard of care for timing of administration of antimicrobial therapy in patients with a diagnosis of acute bacterial meningitis. Although the clinical data are inconclusive, it makes intuitive sense to initiate antimicrobial therapy as soon as possible in any patient with suspected or proven bacterial meningitis before the patient's illness advances to a high level of clinical severity, beyond which antimicrobial therapy is less likely to be of benefit. However, clinical experiences suggest that patient outcome in bacterial meningitis is a result of multiple factors, since some patients treated within a few hours of symptoms develop an adverse outcome whereas others who are symptomatic for days prior to presentation suffer no adverse sequelae.