CCS Case: Bacterial Meningitis

Case: Bacterial Meningitis

Clinical Setup

• Presentation: 21-year-old college student with 12 hours of high fever, severe headache, photophobia, neck stiffness, and confusion. Petechial rash on lower extremities.
• Location: Emergency Department.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring.
   • IV access, Normal saline 0.9% IV @ 100 mL/hr.
   • Droplet precautions stat.
2. Focused Exam (Minute 1–2):
   • Focused neuro exam (nuchal rigidity, Kernig/Brudzinski signs, mental status), skin exam (petechiae/purpura).
3. Diagnostics (Minute 2–5):
   • Blood cultures x2 stat, CBC, BMP, PT/INR, PTT.
   • Non-contrast CT head only if papilledema, focal deficit, immunocompromise, or altered consciousness delays LP — do NOT delay antibiotics for imaging.
   • Lumbar puncture stat: opening pressure, CSF cell count, protein, glucose, Gram stain, culture.
4. Therapeutics (Minute 3–8):
   • CRITICAL sequencing: Blood cultures → Dexamethasone IV → Empiric IV antibiotics immediately (e.g., Ceftriaxone + Vancomycin; add Ampicillin if age > 50, neonate, or immunocompromised for Listeria).
   • Never delay antibiotics for LP or CT results.
   • Advance clock 30 min; re-examine neuro status and vitals.
5. Disposition (Minute 8–12):
   • Admit to ICU (altered mental status, possible fulminant course).
   • Tailor antibiotics when Gram stain/cultures return.
6. Final 2 Minutes:
   • Counsel on close-contact prophylaxis (Rifampin or Ciprofloxacin per organism), vaccination (meningococcal, pneumococcal, Hib).
   • Notify public health if Neisseria meningitidis confirmed; schedule neurology/ID follow-up.