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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Bacterial meningitis

Neurology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Escalate

Suspected bacterial meningitis or meningococcal disease requires immediate hospital transfer, sepsis resuscitation and intravenous antibiotics. Do not wait for rash, neck stiffness, CT, lumbar puncture or a complete classic triad. Airway compromise, shock, falling consciousness, seizures, focal deficit or rapidly evolving purpura demands senior emergency, critical-care and infectious-disease involvement.

Synopsis

Treat suspected bacterial meningitis as a time-critical emergency, obtain microbiology without unsafe delay, add age- and risk-appropriate therapy, and coordinate complications, prophylaxis and follow-up.

  • Fever, headache, neck stiffness and altered consciousness form a high-risk combination, but presentations are incomplete and can evolve over hours; absence of one feature cannot safely exclude meningitis.
  • Non-blanching petechiae or purpura supports meningococcal disease, yet meningococcal meningitis and sepsis often present before a rash appears and the rash can be subtle on darker skin.
  • Take blood cultures and diagnostic blood samples promptly, but administer empirical antibiotics within one hour of hospital arrival and sooner in shock; investigations must not create treatment delay.
  • Lumbar puncture should occur before antibiotics only when it is immediately safe and will not materially delay therapy; CT is not a routine prerequisite.
  • Signs suggesting raised intracranial pressure, focal neurological findings, uncontrolled seizures, severe coagulopathy, cardiorespiratory instability or local spinal infection make immediate lumbar puncture unsafe.
  • For most adults, NICE recommends intravenous ceftriaxone while the organism is unknown; use cefotaxime if ceftriaxone is contraindicated and follow local antimicrobial dosing and allergy pathways.
  • Add intravenous amoxicillin when Listeria monocytogenes is a meaningful risk, including older age, pregnancy or immunocompromise, as defined by current guidance and local microbiology advice.
  • Give intravenous dexamethasone with or before the first antibiotic where possible in strongly suspected bacterial meningitis, but never delay antimicrobial treatment to obtain or administer it.
  • Cerebrospinal fluid usually shows neutrophils, high protein and low glucose relative to blood, but prior antibiotics, early disease and immunosuppression can alter the pattern; PCR and culture remain important.
  • In England, report every suspected acute meningitis case urgently to the local UKHSA health-protection team by telephone within 24 hours and through the online notification service within 3 days; do not wait for laboratory confirmation. For suspected meningococcal disease, the team also directs contact prophylaxis and vaccination. Use the equivalent statutory route in devolved nations.

Key red flags

Neurological severity

Reduced Glasgow Coma Scale, focal deficit, cranial-nerve palsy, repeated seizure or papilloedema suggests complication and influences airway, imaging and lumbar-puncture decisions.

Investigation priorities

01
Blood culturesFirst step

Identify the organism when cerebrospinal-fluid culture may later be sterilised.

Management branches

First hourResuscitate and treat before certainty

Bacterial meningitis or meningococcal disease is clinically suspected.

  1. Use an ABCDE approach, obtain intravenous access, treat hypoxia, shock, hypoglycaemia and seizures, and involve senior emergency, medical and critical-care clinicians early.
  2. Collect blood cultures and time-critical samples immediately if feasible, then give empirical intravenous antibiotics within the emergency standard without waiting for CT or lumbar puncture.
  3. Administer dexamethasone with or just before antibiotics where indicated, record exact times, isolate according to the infection-control policy and notify microbiology.
Lumbar punctureObtain cerebrospinal fluid without creating harm

The patient is sufficiently stable and the result will refine diagnosis.

  1. Check for focal deficit, abnormal pupils, significant consciousness impairment, ongoing seizure, cardiorespiratory instability, coagulopathy, thrombocytopenia and local infection.
  2. If no contraindication and no treatment delay will occur, measure opening pressure and send adequate paired samples for cells, protein, glucose, Gram stain, culture and PCR.

Key medicines

CeftriaxoneNICE recommends 2 g intravenously twice daily for adults with suspected bacterial meningitis while the organism is unknown; verify the current BNF, allergy status and local protocol.Give promptly after cultures if feasible; assess severe beta-lactam allergy, biliary issues and interactions, and obtain specialist advice for post-neurosurgical infection or resistant organisms.
AmoxicillinFor adult Listeria risk, NICE uses 2 g intravenously every 4 hours as an addition to the cephalosporin; adjust through specialist advice where renal function requires it.Check immediate and delayed penicillin allergy, renal function and sodium load; rash, cytopenia and liver injury require review, and allergy alternatives need microbiology input.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG240 bacterial meningitis recommendationsRecognition, investigations, empirical antibiotics, dexamethasone and follow-up.
  • UKHSA meningococcal disease public-health guidanceNotification, close-contact chemoprophylaxis, vaccination and surveillance.
  • BNF central nervous system infections treatment summaryCurrent UK meningitis antimicrobial regimens and prescribing cautions.
  • NICE NG253 suspected sepsis in people aged 16 or overPhysiological assessment, escalation and time-critical antimicrobial principles.
  • UKHSA notifiable diseases and reportingEngland's suspicion-based statutory notification route and timescales for acute meningitis; follow the equivalent public-health process in each devolved nation.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewUnited Kingdom
If puncture is deferred, document the reason, treat immediately and reassess later because delayed cerebrospinal-fluid analysis may still provide useful molecular or inflammatory evidence.
Jurisdiction