Drug Insight: adjunctive therapies in adults with bacterial meningitis

Persistent dysexecutive syndrome after pneumococcal meningitis complicated by recurrent ischemic strokes: A case report

BACKGROUND

Meningitis is a possible complication of pneumococcal infection concerning acute otitis media and sinusitis. It might compromise cognitive function, both for the infection itself and the vascular events that sometimes follow the acute phase.

CASE SUMMARY

Here we describe the case of a 32-year-old female patient admitted to the emergency room due to extensive pneumococcal meningitis as a consequence of sinus outbreak. She presented with extensive laminar ischemic damage in the acute phase, resulting in severe cognitive and behavioural impairment. Four years of follow-up, through neuropsychological assessments and neuroradiological investigations, demonstrated the presence of subsequent vascular events, 3 months and 2 years after onset.

CONCLUSION

The case is discussed in light of scientific knowledge of the long-term outcomes of this pathology in order to potentially improve diagnosis and promote better outcomes.

Cerebrovascular complications in patients with community-acquired bacterial meningitis: occurrence and associated factors in the COMBAT multicenter prospective cohort

BACKGROUND

Community-acquired bacterial meningitis is a rare but severe central nervous system infection that may be associated with cerebrovascular complications (CVC). Our objective is to assess the prevalence of CVC in patients with community-acquired bacterial meningitis and to determine the first-48 h factors associated with CVC.

METHODS

We analyzed data from the prospective multicenter cohort study (COMBAT) including, between February 2013 and July 2015, adults with community-acquired bacterial meningitis. CVC were defined by the presence of clinical or radiological signs (on cerebral CT or MRI) of focal clinical symptom. Factors associated with CVC were identified by multivariate logistic regression.

RESULTS

CVC occurred in 128 (25.3%) of the 506 patients in the COMBAT cohort (78 (29.4%) of the 265 pneumococcal meningitis, 17 (15.3%) of the 111 meningococcal meningitis, and 29 (24.8%) of the 117 meningitis caused by other bacteria). The proportion of patients receiving adjunctive dexamethasone was not statistically different between patients with and without CVC (p = 0.84). In the multivariate analysis, advanced age (OR = 1.01 [1.00-1.03], p = 0.03), altered mental status at admission (OR = 2.23 [1.21-4.10], p = 0.01) and seizure during the first 48 h from admission (OR = 1.90 [1.01-3.52], p = 0.04) were independently associated with CVC.

CONCLUSIONS

CVC were frequent during community-acquired bacterial meningitis and associated with advanced age, altered mental status and seizures occurring within 48 h from admission but not with adjunctive corticosteroids.

Community-acquired bacterial meningitis

Progress has been made in the prevention and treatment of community-acquired bacterial meningitis during the past three decades but the burden of the disease remains high globally. Conjugate vaccines against the three most common causative pathogens (Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae) have reduced the incidence of disease, but with the replacement by non-vaccine pneumococcal serotypes and the emergence of bacterial strains with reduced susceptibility to antimicrobial treatment, meningitis continues to pose a major health challenge worldwide. In patients presenting with bacterial meningitis, typical clinical characteristics (such as the classic triad of neck stiffness, fever, and an altered mental status) might be absent and cerebrospinal fluid examination for biochemistry, microscopy, culture, and PCR to identify bacterial DNA are essential for the diagnosis. Multiplex PCR point-of-care panels in cerebrospinal fluid show promise in accelerating the diagnosis, but diagnostic accuracy studies to justify routine implementation are scarce and randomised, controlled studies are absent. Early administration of antimicrobial treatment (within 1 hour of presentation) improves outcomes and needs to be adjusted according to local emergence of drug resistance. Adjunctive dexamethasone treatment has proven efficacy beyond the neonatal age but only in patients from high-income countries. Further progress can be expected from implementing preventive measures, especially the development of new vaccines, implementation of hospital protocols aimed at early treatment, and new treatments targeting checkpoints of the inflammatory cascade.

Update on community-acquired bacterial meningitis: guidance and challenges

BACKGROUND

The existing heterogeneity in diagnostic work-up and treatment strategies in bacterial meningitis was the incentive to develop a European evidence-based guideline, which was published in 2016 by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group on Infections of the Brain (ESGIB).

AIMS

To summarize salient features of the guideline, identify recent developments and challenges currently faced.

SOURCES

The ESCMID guideline, ongoing trial registries.

CONTENT

Epidemiology, clinical symptoms, diagnostic work-up and therapy strategies of acute bacterial meningitis.

IMPLICATIONS

The incidence of bacterial meningitis has decreased following pneumococcal and meningococcal conjugate vaccine introduction. In the diagnosis of bacterial meningitis the clinical characteristics and laboratory parameters are of limited diagnostic accuracy and therefore cerebrospinal fluid analysis remains the principal contributor to the final diagnosis. The ESCMID guideline advises to start empiric treatment within one hour of arrival in all suspected meningitis cases, and choice of antibiotics needs to be differentiated according to the patient's age, risk factors, and local resistance rates of pneumococci. Dexamethasone is the only proven adjunctive treatment and should be started together with the antibiotics. The follow-up of surviving patients should include evaluation for hearing loss and pneumococcal vaccination to prevent recurrences. Future perspectives include further development and implementation of vaccines, and new treatments aimed at further reducing the inflammatory response. Studies on implementation of the new guideline should determine adherence and evaluate whether improved prognosis can be achieved by following protocolled management strategies.

Community-acquired bacterial meningitis

Meningitis is an inflammation of the meninges and subarachnoid space that can also involve the brain cortex and parenchyma. It can be acquired spontaneously in the community - community-acquired bacterial meningitis - or in the hospital as a complication of invasive procedures or head trauma (nosocomial bacterial meningitis). Despite advances in treatment and vaccinations, community-acquired bacterial meningitis remains one of the most important infectious diseases worldwide. Streptococcus pneumoniae and Neisseria meningitidis are the most common causative bacteria and are associated with high mortality and morbidity; vaccines targeting these organisms, which have designs similar to the successful vaccine that targets Haemophilus influenzae type b meningitis, are now being used in many routine vaccination programmes. Experimental and genetic association studies have increased our knowledge about the pathogenesis of bacterial meningitis. Early antibiotic treatment improves the outcome, but the growing emergence of drug resistance as well as shifts in the distribution of serotypes and groups are fuelling further development of new vaccines and treatment strategies. Corticosteroids were found to be beneficial in high-income countries depending on the bacterial species. Further improvements in the outcome are likely to come from dampening the host inflammatory response and implementing preventive measures, especially the development of new vaccines.

Meta-analysis of studies comparing adjuvant dexamethasone to glycerol to improve clinical outcome of bacterial meningitis

Background:

Neurological complications are a problematic factor in acute bacterial meningitis; hence, its prevention is the key to ensure the success of meningitis treatment. Glycerol and dexamethasone are both applied in this regard. Oral glycerol is an appropriate alternative instead of intravenous dexamethasone because it does not have problems related to intravenous injection, the high cost, and drug complications. The main objective of this study was to compare the efficacy of adjuvant dexamethasone versus glycerol in order to improve the clinical outcome of bacterial meningitis.

Materials and Methods:

We conducted a search on the available resources including PubMed, Ovid, Elsevier, Cochrane, and another search engines such as Google till 2014. All clinical trials that were performed in the field of comparing the effectiveness of the two drugs and met the inclusion criteria were gathered and after extraction the relative risk (RR) values, the pooled RR was calculated. The main outcome was neurological complications. Meta-analysis of the data was performed in Stata version 11.2 using both fixed and random effect models, weighting each study by inverse of variance.

Results:

In 5 comparative studies (1,340 patients), the rate of neurological complications of glycerol compared to that of dexamethasone was 1.02 [95% confidence interval (CI), 0.98 compared to 1.12]. The rate of neurological complications of dexamethasone compared to dexamethasone + glycerol was 1 (95% CI, 0.97 compared to 1.03), dexamethasone compared to placebo was 0.99 (95% CI, 0.97 compared to 1.03), glycerol compared to glycerol + dexamethasone was 0.98 (95% CI, 0.94 compared to 1.02), and glycerol compared to placebo was 0.97 (95% CI, 0.94 compared to 1.01). In these studies, no difference was reported between dexamethasone and glycerol in terms of reducing neurological complications.

Conclusion:

Although there were some weak evidences for the nonstatistical significant effect of glycerol in the prevention of neurologic complication after meningitis, there was no difference between glycerol and dexamethasone.

Adjuvant treatment with dexamethasone plus anti-C5 antibodies improves outcome of experimental pneumococcal meningitis: a randomized controlled trial

Background

We compared adjunctive treatment with placebo, dexamethasone, anti-C5 antibodies, and the combination of dexamethasone plus anti-C5 antibodies in experimental pneumococcal meningitis.

Methods

In this prospective, investigator-blinded, randomized trial, 96 mice were infected intracisternally with 10⁷ CFU/ml Streptococcus pneumoniae serotype 3, treated with intraperitoneal ceftriaxone at 20 h, and randomly assigned to intraperitoneal adjunctive treatment with placebo (saline), dexamethasone, anti-C5 antibodies, or dexamethasone plus anti-C5 antibodies. The primary outcome was survival during a 72-h observational period that was analyzed with the log-rank test. Secondary outcome was clinical severity, scored on a validated scale using a linear mixed model.

Results

Mortality rates were 16 of 16 mice (100 %) in the placebo group, 12 of 15 mice (80 %) in the dexamethasone group, 25 of 31 mice (80 %) in the anti-C5 antibody group, and 18 of 30 mice (60 %) in the dexamethasone plus anti-C5 antibody group (Fisher’s exact test for overall difference, P = .012). Mortality of mice treated with dexamethasone plus anti-C5 antibodies was lower compared to the anti-C5 antibody-treated mice (log-rank P = .039) and dexamethasone-treated mice (log-rank P = .040). Clinical severity scores for the dexamethasone plus anti-C5 antibody-treated mice increased more slowly (0.199 points/h) as compared to the anti-C5 antibody-treated mice (0.243 points/h, P = .009) and dexamethasone-treated mice (0.249 points/h, P = .012). Modeling of severity data suggested an additive effect of dexamethasone and anti-C5 antibodies.

Conclusion

Adjunctive treatment with dexamethasone plus anti-C5 antibodies improves survival in severe experimental meningitis caused by S. pneumoniae serotype 3, posing an important new treatment strategy for patients with pneumococcal meningitis.

Outcome in patients with bacterial meningitis presenting with a minimal Glasgow Coma Scale score

OBJECTIVE

In bacterial meningitis, a decreased level of consciousness is predictive for unfavorable outcome, but the clinical features and outcome in patients presenting with a minimal score on the Glasgow Coma Scale are unknown.

METHODS

We assessed the incidence, clinical characteristics, and outcome of patients with bacterial meningitis presenting with a minimal score on the Glasgow Coma Scale from a nationwide cohort study of adults with community-acquired bacterial meningitis in the Netherlands from 2006 to 2012.

RESULTS

Thirty of 1,083 patients (3%) presented with a score of 3 on the Glasgow Coma Scale. In 22 of 30 patients (73%), the minimal Glasgow Coma Scale score could be explained by use of sedative medication or complications resulting from meningitis such as seizures, cerebral edema, and hydrocephalus. Systemic (86%) and neurologic (47%) complications occurred frequently, leading to a high proportion of patients with unfavorable outcome (77%). However, 12 of 30 patients (40%) survived and 7 patients (23%) had a good functional outcome, defined as a score of 5 on the Glasgow Outcome Scale. Patients presenting with a minimal Glasgow Coma Scale score on admission and bilaterally absent pupillary light responses, bilaterally absent corneal reflexes, or signs of septic shock on admission all died.

CONCLUSIONS

Patients with community-acquired bacterial meningitis rarely present with a minimal score on the Glasgow Coma Scale, but this condition is associated with high rates of morbidity and mortality. However, 1 out of 5 of these severely ill patients will make a full recovery, stressing the continued need for aggressive supportive care in these patients.

Bacterial meningitis

Bacterial meningitis is a neurologic emergency. Vaccination against common pathogens has decreased the burden of disease. Early diagnosis and rapid initiation of empiric antimicrobial and adjunctive therapy are vital. Therapy should be initiated as soon as blood cultures have been obtained, preceding any imaging studies. Clinical signs suggestive of bacterial meningitis include fever, headache, meningismus, and an altered level of consciousness but signs may be scarce in children, in the elderly, and in meningococcal disease. Host genetic factors are major determinants of susceptibility to meningococcal and pneumococcal disease. Dexamethasone therapy has been implemented as adjunctive treatment of adults with pneumococcal meningitis. Adequate and prompt treatment of bacterial meningitis is critical to outcome. In this chapter we review the epidemiology, pathophysiology, and management of bacterial meningitis.

Advances in treatment of bacterial meningitis

Bacterial meningitis kills or maims about a fifth of people with the disease. Early antibiotic treatment improves outcomes, but the effectiveness of widely available antibiotics is threatened by global emergence of multidrug-resistant bacteria. New antibiotics, such as fluoroquinolones, could have a role in these circumstances, but clinical data to support this notion are scarce. Additionally, whether or not adjunctive anti-inflammatory therapies (eg, dexamethasone) improve outcomes in patients with bacterial meningitis remains controversial; in resource-poor regions, where the disease burden is highest, dexamethasone is ineffective. Other adjunctive therapeutic strategies, such as glycerol, paracetamol, and induction of hypothermia, are being tested further. Therefore, bacterial meningitis is a substantial and evolving therapeutic challenge. We review this challenge, with a focus on strategies to optimise antibiotic efficacy in view of increasingly drug-resistant bacteria, and discuss the role of current and future adjunctive therapies.

Pathogenesis and pathophysiology of pneumococcal meningitis

Pneumococcal meningitis continues to be associated with high rates of mortality and long-term neurological sequelae. The most common route of infection starts by nasopharyngeal colonization by Streptococcus pneumoniae, which must avoid mucosal entrapment and evade the host immune system after local activation. During invasive disease, pneumococcal epithelial adhesion is followed by bloodstream invasion and activation of the complement and coagulation systems. The release of inflammatory mediators facilitates pneumococcal crossing of the blood-brain barrier into the brain, where the bacteria multiply freely and trigger activation of circulating antigen-presenting cells and resident microglial cells. The resulting massive inflammation leads to further neutrophil recruitment and inflammation, resulting in the well-known features of bacterial meningitis, including cerebrospinal fluid pleocytosis, cochlear damage, cerebral edema, hydrocephalus, and cerebrovascular complications. Experimental animal models continue to further our understanding of the pathophysiology of pneumococcal meningitis and provide the platform for the development of new adjuvant treatments and antimicrobial therapy. This review discusses the most recent views on the pathophysiology of pneumococcal meningitis, as well as potential targets for (adjunctive) therapy.

Bacterial meningitis

Bacterial meningitis is a neurological emergency. Empiric antimicrobial and adjunctive therapy should be initiated as soon as a single set of blood cultures has been obtained. Clinical signs suggestive of bacterial meningitis include fever, headache, meningismus, vomiting, photophobia, and an altered level of consciousness. The peripheral white blood cell count with a left shift, an elevated serum procalcitonin and C-reactive protein, and a cerebrospinal fluid pleocytosis with a predominance of polymorphonuclear leukocytes, and a decreased glucose concentration are predictive of bacterial meningitis. Patients with documented bacterial meningitis and those in whom the diagnosis is a strong possibility should be admitted to the intensive care unit. Timely recognition of bacterial meningitis and initiation of therapy are critical to outcome.

Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis

The epidemiology of bacterial meningitis has changed as a result of the widespread use of conjugate vaccines and preventive antimicrobial treatment of pregnant women. Given the significant morbidity and mortality associated with bacterial meningitis, accurate information is necessary regarding the important etiological agents and populations at risk to ascertain public health measures and ensure appropriate management. In this review, we describe the changing epidemiology of bacterial meningitis in the United States and throughout the world by reviewing the global changes in etiological agents followed by specific microorganism data on the impact of the development and widespread use of conjugate vaccines. We provide recommendations for empirical antimicrobial and adjunctive treatments for clinical subgroups and review available laboratory methods in making the etiological diagnosis of bacterial meningitis. Finally, we summarize risk factors, clinical features, and microbiological diagnostics for the specific bacteria causing this disease.

Adjunctive dexamethasone in bacterial meningitis: a meta-analysis of individual patient data

BACKGROUND

Dexamethasone improves outcome for some patients with bacterial meningitis, but not others. We aimed to identify which patients are most likely to benefit from dexamethasone treatment.

METHODS

We did a meta-analysis of individual patient data from the randomised, double-blind, placebo-controlled trials of dexamethasone for bacterial meningitis in patients of all ages for which raw data were available. The pre-determined outcome measures were death at the time of first follow-up, death or severe neurological sequelae at 1 month follow-up, death or any neurological sequelae at first follow-up, and death or severe bilateral hearing loss at first follow-up. Combined odds ratios (ORs) and tests for heterogeneity were calculated using conventional Mantel-Haenszel statistics. We also did exploratory analysis of hearing loss among survivors and other exploratory subgroup analyses by use of logistic regression.

FINDINGS

Data from 2029 patients from five trials were included in the analysis (833 [41.0%] aged <15 years). HIV infection was confirmed or likely in 580 (28.6%) patients and bacterial meningitis was confirmed in 1639 (80.8%). Dexamethasone was not associated with a significant reduction in death (270 of 1019 [26.5%] on dexamethasone vs 275 of 1010 [27.2%] on placebo; OR 0.97, 95% CI 0.79-1.19), death or severe neurological sequelae or bilateral severe deafness (42.3%vs 44.3%; 0.92, 0.76-1.11), death or any neurological sequelae or any hearing loss (54.2%vs 57.4%; 0.89, 0.74-1.07), or death or severe bilateral hearing loss (36.4%vs 38.9%; 0.89, 0.73-1.69). However, dexamethasone seemed to reduce hearing loss among survivors (24.1%vs 29.5%; 0.77, 0.60-0.99, p=0.04). Dexamethasone had no effect in any of the prespecified subgroups, including specific causative organisms, pre-dexamethasone antibiotic treatment, HIV status, or age. Pooling of the mortality data with those of all other published trials did not significantly change the results.

INTERPRETATION

Adjunctive dexamethasone in the treatment of acute bacterial meningitis does not seem to significantly reduce death or neurological disability. There were no significant treatment effects in any of the prespecified subgroups. The benefit of adjunctive dexamethasone for all or any subgroup of patients with bacterial meningitis thus remains unproven.

FUNDING

Wellcome Trust UK.

Community-acquired bacterial meningitis in alcoholic patients

Background

Alcoholism is associated with susceptibility to infectious disease, particularly bacterial pneumonia. In the present study we described characteristics in alcoholic patients with bacterial meningitis and delineate the differences with findings in non-alcoholic adults with bacterial meningitis.

Methods/Principal Findings

This was a prospective nationwide observational cohort study including patients aged >16 years who had bacterial meningitis confirmed by culture of cerebrospinal fluid (696 episodes of bacterial meningitis occurring in 671 patients). Alcoholism was present in 27 of 686 recorded episodes of bacterial meningitis (4%) and alcoholics were more often male than non-alcoholics (82% vs 48%, P = 0.001). A higher proportion of alcoholics had underlying pneumonia (41% vs 11% P<0.001). Alcoholics were more likely to have meningitis due to infection with Streptococcus pneumoniae (70% vs 50%, P = 0.01) and Listeria monocytogenes (19% vs 4%, P = 0.005), whereas Neisseria meningitidis was more common in non-alcoholic patients (39% vs 4%, P = 0.01). A large proportion of alcoholics developed complications during clinical course (82% vs 62%, as compared with non-alcoholics; P = 0.04), often cardiorespiratory failure (52% vs 28%, as compared with non-alcoholics; P = 0.01). Alcoholic patients were at risk for unfavourable outcome (67% vs 33%, as compared with non-alcoholics; P<0.001).

Conclusions/Significance

Alcoholic patients are at high risk for complications resulting in high morbidity and mortality. They are especially at risk for cardiorespiratory failure due to underlying pneumonia, and therefore, aggressive supportive care may be crucial in the treatment of these patients.

Prostacyclin reduces elevation of intracranial pressure and plasma volume loss in lipopolysaccharide-induced meningitis in the cat

BACKGROUND

Severe meningitis may compromise cerebral perfusion through increases in intracranial pressure (ICP) and through hypovolemia caused by a general inflammation with systemic plasma leakage. From its antiaggregative/antiadhesive and permeability-reducing properties, prostacyclin (PGI2) is a potential adjuvant treatment in meningitis, but previously published data have been ambiguous. The objective of this study was to evaluate the effects of PGI2 on meningitis on ICP, plasma volume, blood pressure, and cerebral oxidative metabolism.

METHODS

Meningitis was induced by intrathecal injection of lipopolysaccharide (LPS, 0.8 x 10 units/kg) in cats. Four hours after the injection, the animals were randomized to intravenous treatment with either low-dose PGI2 (1 ng/kg/min) or the vehicle for 6 hours (n = 7 in each group). No LPS and no PGI2 or vehicle was given to three cats (sham group). Effects of treatment on ICP, mean arterial pressure, plasma volume (I-albumin technique), and brain tissue lactate/pyruvate ratio (microdialysis technique) were evaluated.

RESULTS

ICP increased from 10.0 mm Hg +/- 1.3 mm Hg and 10.8 mm Hg +/- 1.7 mm Hg to 19.9 mm Hg +/- 1.7 mm Hg and 19.6 mm Hg +/- 3.3 mm Hg in the PGI2 and the vehicle group, respectively, 4 hours after the LPS injection (not significant). ICP increased further to 21.8 mm Hg +/- 4.5 mm Hg and to 25.8 mm Hg +/- 6.0 mm Hg after treatment for 6 hours with PGI2 or vehicle, respectively (p < 0.05). There was no significant difference in arterial pressure between groups. Plasma volume loss was less in the PGI2 group than in the vehicle group at the end of the experiment and urine production and arterial oxygenation was higher in the PGI2 group. Lactate/pyruvate ratio was within the normal range in all groups.

CONCLUSION

Low-dose PGI2 may be a beneficial adjuvant therapy for meningitis by reducing elevation of ICP and plasma volume loss.

Acute brain injury and therapeutic hypothermia in the PICU: A rehabilitation perspective

Acquired brain injury from traumatic brain injury, cardiac arrest (CA), stroke, and central nervous system infection is a leading cause of morbidity and mortality in the pediatric population and reason for admission to inpatient rehabilitation. Therapeutic hypothermia is the only intervention shown to have efficacy from bench to bedside in improving neurological outcome after birth asphyxia and adult arrhythmia-induced CA, thought to be due to its multiple mechanisms of action. Research to determine if therapeutic hypothermia should be applied to other causes of brain injury and how to best apply it is underway in children and adults. Changes in clinical practice in the hospitalized brain-injured child may have effects on rehabilitation referral practices, goals and strategies of therapies offered, and may increase the degree of complex medical problems seen in children referred to inpatient rehabilitation.

Coagulation, coma, and outcome in bacterial meningitis--an observational study of 38 adult cases

OBJECTIVES

The purpose of this study was to evaluate the epidemiology of intravascular coagulation in bacterial meningitis and to recognise the associations with disease severity and outcome.

METHODS

Thirty-eight consecutively admitted adult patients with microbiologically proven bacterial meningitis were observed prospectively for platelets count (PLT), platelets-decline (dPLT), prothrombin ratio (PTr), INR, and D-dimer levels during the first three days in relation to disease severity (Glasgow Coma Scale--GCS, APACHE-III) and outcome (Glasgow Outcome Scale--GOS).

RESULTS

The prevalence of activated coagulation measured by abnormal laboratory results varied respectively: PTr--30%, INR--36%, PLT--38%, dPLT--50%, and D-dimer--88%. Patients with GCS <9 at admission presented with laboratory results suggesting triggered coagulation: dPLT 48 vs. 15%/day (p=0.0246), INR 1.6 vs. 1.12 (p=0.0014), PTr 76 vs. 93% (p=0.0020). An unfavourable outcome (GOS 1-4) was observed in 42% of patients and was associated with: PLT <170 or >265 G/L (OR--24.4; p=0.0006), PTr <82% (OR--5.00; p=0.0388), INR >1.1 (OR--5.04; 0.0336), and D-dimer >850 ng/ml (OR--24.0; p=0.0033).

CONCLUSIONS

Coagulation was activated in a majority of patients with bacterial meningitis and related to coma and unfavourable outcome.

Emergency diagnosis and treatment of adult meningitis

Despite the existence of antibiotic therapies against acute bacterial meningitis, patients with the disease continue to suffer significant morbidity and mortality in both high and low-income countries. Dilemmas exist for emergency medicine and primary-care providers who need to accurately diagnose patients with bacterial meningitis and then rapidly administer antibiotics and adjunctive therapies for this life-threatening disease. Physical examination may not perform well enough to accurately identify patients with meningitis, and traditionally described lumbar puncture results for viral and bacterial disease cannot always predict bacterial meningitis. Results from recent studies have implications for current treatment guidelines for adults with suspected bacterial meningitis, and it is important that physicians who prescribe the initial doses of antibiotics in an emergency setting are aware of guidelines for antibiotics and adjunctive steroids. We present an overview and discussion of key diagnostic and therapeutic decisions in the emergency evaluation and treatment of adults with suspected bacterial meningitis.