Infectious disease expert weighs in on how physicians can effectively identify meningitis infection for best treatment

A new risk score could help clinicians differentiate viral meningitis from community-acquired bacterial meningitis (CABM), according to a review article by Rodrigo Hasbun, MD, MPH, at UTHealth Houston.

Meningitis caused by viruses is serious but often is less severe than bacterial meningitis, which can be deadly and requires immediate medical attention. In a report published in JAMA, Hasbun assessed current diagnostic and treatment options for CABM with the importance of early detection and administration of antibiotic therapy and steroids playing a critical role in decreasing mortality.    

“The last Infectious Diseases Society of America guidelines were published in 2004. So, we’re 18 years behind that, and there’s been a lot of new studies since then,” said Hasbun, professor of infectious diseases at McGovern Medical School at UTHealth Houston. “I think it is very important to update physicians about what’s new in bacterial meningitis, the progress we’ve made, and what challenges we are still facing.”

Bacterial meningitis is an infection of the membranes (meninges) that protect the spinal cord and brain. When the membranes become infected, they swell and press on the spinal cord or brain. The most common symptoms are headache, fever, stiff neck, altered mental status, and nausea.

While vaccines for bacterial meningitis have been around for decades, not everyone has easy access to them. Bacterial meningitis incidence rates range from 90 per 1 million individuals per year in high-income countries to 800 per 1 million individuals per year in low-income countries. According to Hasbun, in developing countries, CABM has a mortality rate of up to 54%, and up to 24% of those who survive develop chronic neurologic sequelae such as hearing loss or focal neurological deficits. In adults, risk factors for CABM include older age and immunosuppressive conditions.

While bacterial meningitis is still associated with a high degree of neurological morbidity and mortality, researchers have found the only way to decrease mortality in bacterial meningitis, besides antibiotic therapy, is an early adjunctive steroid.

“The idea is that once you give an antibiotic that’s going to kill the bacteria, the antibiotic is going to generate a lot of inflammation,” Hasbun said. “So, we want to give the steroids with the first dose of antibiotics or 15 minutes before the first dose, so while the antibiotic kills the bacteria, the steroid decreases the inflammatory reaction. That is actually what’s causing the brain edema and the neurological morbidity and mortality of the patient. The inflammation is what kills the patient. It is important clinicians are aware that steroids are very important in the treatment of bacterial meningitis with the exception of Listeria monocytogenes.”

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