Empiric therapy until bacterial meningitis excluded
›Initial antimicrobials
›Empiric antibiotics when bacterial meningitis cannot be excluded
›Ceftriaxone IV 2 g every 12 hours
›Indication
›Community-acquired meningitis coverage
›Allergy alternative logic
›If immediate beta-lactam allergy, consult for alternative regimen
›Vancomycin IV weight-based dosing with trough targeting per local protocol
›Indication
›Pneumococcal resistance coverage
›Renal monitoring
›Creatinine daily while on therapy
›Ampicillin IV 2 g every 4 hours
›If age 50 years or older
›Listeria coverage
›If immunocompromised
›Listeria coverage
›Dexamethasone for suspected bacterial meningitis
›Dexamethasone IV 10 mg every 6 hours for 4 days
›If started before or with first antibiotic dose
›Benefit greatest for pneumococcal meningitis
›Stop if bacterial meningitis not supported
›Viral meningitis confirmed
Antiviral therapy triggers
›Acyclovir decision pathway
›If encephalitis features
›Altered mental status
›Acyclovir IV 10 mg/kg every 8 hours using ideal body weight
›Renal dosing adjustment
›If eGFR reduced, extend interval per protocol
›Hydration strategy
›IV fluids to reduce crystal nephropathy risk
›If suspected HSV meningitis with severe symptoms or immunocompromised
›Acyclovir IV dosing as above
›Transition consideration
›Switch to oral valacyclovir when improving and able to take PO
Supportive care for viral meningitis
›Analgesia and antipyresis
›Acetaminophen PO 1000 mg every 6 hours as needed
›Maximum daily dose per age and liver risk
›Lower maximum with liver disease or heavy alcohol use
›Ibuprofen PO 400 mg every 6 hours as needed
›Renal and GI cautions
›Avoid in significant renal impairment
›Avoid in active GI bleeding
›Antiemetics and hydration
›Ondansetron ODT or PO 4 mg every 8 hours as needed
›QT risk context
›Avoid combining with other strong QT-prolonging agents when possible
›IV crystalloid for dehydration
›Bolus strategy
›10 to 20 mL/kg if significant volume depletion
›Headache refractory options
›Metoclopramide IV 10 mg once
›Dystonia prevention
›Diphenhydramine IV 25 mg if prior dystonia or high risk
›Magnesium sulfate IV 1 to 2 g once
›If migraine-like phenotype prominent
Infection control and public health
›Precaution adjustments
›Stop droplet precautions when bacterial meningitis excluded and no meningococcal concern
›Negative Gram stain and low clinical concern
›Alternative diagnosis established
›Notify public health when indicated
›Suspected meningococcal disease
›Reportable viral etiologies per local rules
De-escalation and stopping therapy
›Narrowing decisions
›If CSF profile and PCR consistent with viral meningitis and cultures negative
›Stop empiric antibiotics when bacterial meningitis reasonably excluded
›Shared decision documentation
›Follow-up plan confirmed
›If HSV and VZV PCR negative and no encephalitis features
›Stop acyclovir
›Clinical reassessment supporting non-HSV course