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id.bacterial-meningitis.core.v1PRODUCTION
id.bacterial-meningitis.core.v1

Bacterial meningitis (acute, community-acquired)

infectious_diseaseacuteadult
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11/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Adult community-acquired bacterial meningitis. Healthcare-associated covered as phenotype; tuberculous / fungal / viral covered by sibling engines

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Patient inputs (13)

Fever ≥38°C is one of the classic triad components and triggers empiric coverage

Tachycardia component of qSOFA / SIRS

HIV, transplant, steroids, age >50 → add ampicillin for Listeria

Healthcare-associated phenotype → vancomycin + cefepime/meropenem (IDSA/AAN 2017)

Bacterial pattern: PMN-predominant pleocytosis, glucose <40, protein >100

Gram stain narrows empiric → directed therapy

Drives narrowing + duration

50-80% positive in pneumococcal/meningococcal — drawn before antibiotics

Hypotension drives SSC bundle activation (meningitis-with-shock phenotype)

GCS <15 → CT before LP, broader empiric coverage, ICU disposition

Vancomycin AUC + cefepime/meropenem renal dosing

Sepsis bundle if shock pattern

Required before LP if focal deficit, GCS <14, papilledema, immunocompromise, new seizure

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningpetechial_purpuric_rash
    Petechial / purpuric rash (especially trunk/extremities) with fever (NICE 2024 NG240)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningseptic_shock_phenotype
    Hypotension on adequate fluids + lactate >2 + bacterial meningitis suspicion (SSC 2021; Sepsis-3 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningincreased_intracranial_pressure
    Cushing reflex, papilledema, asymmetric pupils, posturing, or imaging signs of raised ICP (IDSA 2004 Tunkel)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningraised_icp_features
    Behaviourally explicit raised-ICP phenotype: bradycardia + hypertension (Cushing reflex) + abnormal / asymmetric pupils + GCS drop ≥2 points OR new posturing OR new seizure with elevated opening pressure (ESCMID 2016; IDSA 2004 Tunkel)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningacute_bacterial_meningitis_with_septic_shock
    Bacterial meningitis + septic shock features (hypotension on adequate fluids + lactate >2 + vasopressor requirement; Sepsis-3 Singer JAMA 2016; SSC 2026) — most commonly Waterhouse-Friderichsen with meningococcus, but pneumococcal sepsis can present similarly
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverealtered_mental_status_or_focal_deficit
    GCS <14, focal neurologic deficit, papilledema, new seizure, or immunocompromise (IDSA 2004 Tunkel)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepost_neurosurgical_or_device
    Recent neurosurgery, ventricular shunt, EVD, or intrathecal pump in situ (IDSA/AAN 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereno_improvement_at_48h
    Persistent fever, AMS, or no clinical improvement at 48 h on empiric therapy (IDSA 2004 Tunkel)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredelayed_lp_or_abx_after_clinical_suspicion
    Empiric dexamethasone + antibiotic NOT administered within 1 h of clinical suspicion of bacterial meningitis OR LP delayed beyond 30 min when not contraindicated (analogous to SSC Hour-1 bundle; Auburtin CCM 2006 PMID 16915106 each-hour-delay mortality in pneumococcal meningitis)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateage_over_50_or_immunocompromise
    Patient >50 years OR immunocompromised OR pregnant OR alcoholic (IDSA 2004 Tunkel)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Empiric adult bacterial meningitis bundle
axis: meningitis_empiric_adult
Selected axis "Empiric adult bacterial meningitis bundle" by default fallback (first axis)
  • dexamethasone
    first line
    corticosteroid
    triggers: suspected_pneumococcal
    0.15 mg/kg q6h × 4d, before/with first abx (de Gans NEJM 2002; Brouwer Cochrane 2010)
    rxcui 3264
  • ceftriaxone
    first line
    3rd_gen_cephalosporin
    triggers: suspected_bacterial_meningitis
    2 g IV q12h — IDSA 2004 / ESCMID 2016 standard for pneumococcus / meningococcus / H. influenzae
    rxcui 2193
  • vancomycin
    first line
    glycopeptide
    triggers: cephalosporin_resistant_pneumococcus_risk
    AUC/MIC targeted; combined with CTX for resistant pneumococci
    rxcui 11124
  • ampicillin
    first line
    aminopenicillin
    triggers: age>50, immunocompromise, pregnancy
    Listeria coverage when risk factors present
    rxcui 733
  • cefepime
    contraindication substitute
    4th_gen_cephalosporin
    triggers: post_neurosurgical, gram_neg_risk
    Healthcare-associated / device-related per IDSA/AAN 2017
    rxcui 20481
  • meropenem
    contraindication substitute
    carbapenem
    triggers: ESBL_risk, beta_lactam_severe_allergy_partial
    Broad-spectrum CNS penetration; alternative for resistant Gram-negatives
    rxcui 29561
  • acyclovir
    add on
    antiviral
    triggers: encephalitic_features, temporal_lobe_findings
    Cover HSV encephalitis until PCR returns negative
    rxcui 281

outpatient playbook — drug actions (6)

  1. 1. pneumococcal vaccine (PCV20)
    rxcui 2566308
    PCV20 0.5 mL IM × 1 (or PCV15 then PPSV23 in 1 year if PCV20 unavailable) • IM • one dose (PCV20) per ACIP 2024
    trigger: Pneumococcal aetiology confirmed AND patient not previously vaccinated per current ACIP schedule
    ACIP 2024 simplified PCV20 schedule; meningitis survivors at increased risk of recurrent invasive pneumococcal disease
  2. 2. meningococcal conjugate vaccine (MenACWY)
    0.5 mL IM per product (Menveo / MenQuadfi) • IM • two-dose primary if not previously vaccinated; booster per ACIP
    trigger: Meningococcal aetiology AND prior vaccination incomplete (ACIP)
    Meningitis survivors qualify as high-risk; protect against future serogroup-specific disease
  3. 3. meningococcal B vaccine (MenB-4C or MenB-FHbp)
    0.5 mL IM per product • IM • two-dose Bexsero OR three-dose Trumenba per ACIP
    trigger: Meningococcal serogroup B aetiology OR ongoing risk (functionally asplenic, complement deficiency)
    ACIP — serogroup B not covered by MenACWY; meningitis survivors are at risk for second serogroup
  4. 4. Hib vaccine
    0.5 mL IM • IM • one dose if not previously vaccinated
    trigger: Hib aetiology in incompletely vaccinated adult OR functionally asplenic
    ACIP — adult Hib in functionally asplenic / complement deficient host; uncommon in vaccinated cohorts (Thigpen NEJM 2011)
  5. 5. levetiracetam continuation / taper
    continue 500-1500 mg PO BID; reassess at 3-6 months from seizure-free interval • PO • BID
    trigger: Seizure at presentation during acute meningitis
    Bridge anticonvulsant prophylaxis; taper guided by neurology + EEG; no high-grade evidence for fixed duration
  6. 6. restart pre-admission chronic regimen
    per patient baseline • per agent • per agent
    trigger: Stable post-discharge, no contraindication
    Avoid medication-list drift; reconcile any holds (e.g., antihypertensives held during shock) — restart

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Fever + headache + neck stiffness (classic triad); Altered mental status with fever; Petechial / purpuric rash (meningococcemia).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Bacterial meningitis (acute, community-acquired)** (id.bacterial-meningitis.core.v1).
Phenotype framing: Pneumococcus, meningococcus, Listeria (age >50 / immunocomp), H. influenzae, Gram-negative (post-neurosurg), TB, HSV encephalitis, viral aseptic, parameningeal
Scope: Adult community-acquired bacterial meningitis. Healthcare-associated covered as phenotype; tuberculous / fungal / viral covered by sibling engines

No severity triggers fired against current inputs.

Plan

Regimen axis: **Empiric adult bacterial meningitis bundle**.
1. dexamethasone (corticosteroid, first line) — 0.15 mg/kg q6h × 4d, before/with first abx (de Gans NEJM 2002; Brouwer Cochrane 2010)
2. ceftriaxone (3rd_gen_cephalosporin, first line) — 2 g IV q12h — IDSA 2004 / ESCMID 2016 standard for pneumococcus / meningococcus / H. influenzae
3. vancomycin (glycopeptide, first line) — AUC/MIC targeted; combined with CTX for resistant pneumococci
4. ampicillin (aminopenicillin, first line) — Listeria coverage when risk factors present
5. cefepime (4th_gen_cephalosporin, contraindication substitute) — Healthcare-associated / device-related per IDSA/AAN 2017
6. meropenem (carbapenem, contraindication substitute) — Broad-spectrum CNS penetration; alternative for resistant Gram-negatives
7. acyclovir (antiviral, add on) — Cover HSV encephalitis until PCR returns negative

Setting playbook (outpatient) — Post-meningitis surveillance and recovery — audiology at 4-6 weeks (sensorineural hearing loss ~30% in pneumococcal survivors per de Gans NEJM 2002 / Brouwer Cochrane 2010), cognitive/neurologic screen if any prolonged AMS during the acute course, vaccination catch-up tied to causative organism, antiseizure-medication taper plan if seizure at presentation, close-contact prophylaxis reinforcement for meningococcal, and return-to-school/work guidance (NICE 2024 NG240; IDSA 2004 Tunkel)
8. pneumococcal vaccine (PCV20) PCV20 0.5 mL IM × 1 (or PCV15 then PPSV23 in 1 year if PCV20 unavailable) IM one dose (PCV20) per ACIP 2024 — Pneumococcal aetiology confirmed AND patient not previously vaccinated per current ACIP schedule (ACIP 2024 simplified PCV20 schedule; meningitis survivors at increased risk of recurrent invasive pneumococcal disease)
9. meningococcal conjugate vaccine (MenACWY) 0.5 mL IM per product (Menveo / MenQuadfi) IM two-dose primary if not previously vaccinated; booster per ACIP — Meningococcal aetiology AND prior vaccination incomplete (ACIP) (Meningitis survivors qualify as high-risk; protect against future serogroup-specific disease)
10. meningococcal B vaccine (MenB-4C or MenB-FHbp) 0.5 mL IM per product IM two-dose Bexsero OR three-dose Trumenba per ACIP — Meningococcal serogroup B aetiology OR ongoing risk (functionally asplenic, complement deficiency) (ACIP — serogroup B not covered by MenACWY; meningitis survivors are at risk for second serogroup)
11. Hib vaccine 0.5 mL IM IM one dose if not previously vaccinated — Hib aetiology in incompletely vaccinated adult OR functionally asplenic (ACIP — adult Hib in functionally asplenic / complement deficient host; uncommon in vaccinated cohorts (Thigpen NEJM 2011))
12. levetiracetam continuation / taper continue 500-1500 mg PO BID; reassess at 3-6 months from seizure-free interval PO BID — Seizure at presentation during acute meningitis (Bridge anticonvulsant prophylaxis; taper guided by neurology + EEG; no high-grade evidence for fixed duration)
13. restart pre-admission chronic regimen per patient baseline per agent per agent — Stable post-discharge, no contraindication (Avoid medication-list drift; reconcile any holds (e.g., antihypertensives held during shock) — restart)

Non-pharmacologic actions:
- Audiology referral within 4-6 weeks (NICE 2024 NG240; de Gans NEJM 2002 PMID 12432041)
- Cognitive rehabilitation referral if MoCA <26 at first visit (van de Beek NEJM 2004 PMID 15509818 long-term cognitive sequelae)
- Physical / occupational therapy if functional decline from pre-admission baseline (ESCMID 2016)
- Mental-health screening (PHQ-9, PCL-5) — post-ICU PTSD and depression common after critical illness, including meningitis survivors
- Driving restrictions per local regulations if seizure occurred during admission (NICE 2024 NG240)
- Return-to-school/work guidance — typically full clearance once antibiotics completed, neurology stable, and audiology booked (NICE 2024 NG240)
- Patient and family education on signs of recurrence (fever + new headache + neck stiffness), late-onset hydrocephalus (subacute headache + cognitive decline), and seizure recurrence
- Caregiver support (PICS-Family) if extended ICU stay (SCCM PADIS 2018)

AVOID / contraindication checks:
- Dexamethasone only with or before first antibiotic (de Gans NEJM 2002; IDSA 2004 Tunkel)
- Vancomycin AUC target not trough (IDSA 2020 vancomycin consensus)
- Ampicillin required if listeria risk (IDSA 2004 Tunkel)
- Never delay empiric antibiotics for LP (IDSA 2004 Tunkel; NICE 2024 NG240)

Monitoring

Regimen monitoring:
- neuro check q1-2h first 24h (IDSA 2004 Tunkel)
- vancomycin AUC 24-48h (IDSA 2020 vancomycin consensus)
- repeat LP at 48h only if no improvement or resistant pneumococcus (IDSA 2004 Tunkel)
- audiology pre discharge (NICE 2024 NG240; de Gans NEJM 2002)

Setting (outpatient) monitoring:
- PCP / ID visit within 1-2 weeks of discharge for clinical recheck (IDSA 2004 Tunkel; NICE 2024 NG240)
- Audiology at 4-6 weeks (NICE 2024 NG240)
- Neurology follow-up at 4-6 weeks if any focal deficit / seizure (IDSA 2004 Tunkel)
- Repeat neurocognitive screen at 3 months if initial MoCA abnormal (van de Beek NEJM 2006)
- 30-day readmission monitoring — call patient at day 7 and day 21 to triage symptoms (NICE 2024 NG240)
- Vaccination completion tracking — schedule second-dose meningococcal series and 1-year PPSV23 if PCV15-route used (ACIP)

Follow-up plan: Audiology within 4 weeks (sensorineural hearing loss in pneumococcal); neurology if deficits; close-contact prophylaxis for meningococcal (rifampin / cipro / CTX); vaccinate functionally asplenic / complement-deficient
- Close-out criterion: audiology + public-health notification + vaccination plan complete

Monitoring phase: Neuro checks q1-2h, repeat LP only if no improvement at 48h or resistant pneumococcus, vancomycin AUC, hearing assessment pre-discharge

Disposition

Current setting: outpatient — Post-meningitis surveillance and recovery — audiology at 4-6 weeks (sensorineural hearing loss ~30% in pneumococcal survivors per de Gans NEJM 2002 / Brouwer Cochrane 2010), cognitive/neurologic screen if any prolonged AMS during the acute course, vaccination catch-up tied to causative organism, antiseizure-medication taper plan if seizure at presentation, close-contact prophylaxis reinforcement for meningococcal, and return-to-school/work guidance (NICE 2024 NG240; IDSA 2004 Tunkel)

Disposition criteria:
- Resolution: audiology completed, vaccinations administered, antiseizure plan stable, no late complications at 3 months — discharge from meningitis-specific surveillance back to standard primary care (IDSA 2004 Tunkel; NICE 2024 NG240)

Escalation triggers (move to higher acuity):
- New fever / chills / new headache or neck stiffness → ED for recurrent-meningitis workup (IDSA 2004 Tunkel)
- New focal neurologic deficit / new seizure / worsening cognition → urgent neurology + imaging (IDSA 2004 Tunkel; ESCMID 2016)
- Subacute headache + nausea / vomiting / cognitive decline → suspect late-onset hydrocephalus → urgent imaging + neurosurgery (ESCMID 2016)
- Audiology demonstrates moderate-severe hearing loss → ENT + hearing-aid / cochlear-implant evaluation (de Gans NEJM 2002; NICE 2024 NG240)
- PHQ-9 ≥15 OR suicidal ideation → mental-health urgent referral (routes to psych.depression.core.v1 / psych.suicidality.ed.core.v1)
- Close contact (meningococcal aetiology) develops fever / rash / headache → ED for immediate evaluation (CDC meningococcal guidelines; NICE 2024 NG240)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Petechial / purpuric rash (especially trunk/extremities) with fever (NICE 2024 NG240)
- [LIFE_THREATENING] Hypotension on adequate fluids + lactate >2 + bacterial meningitis suspicion (SSC 2021; Sepsis-3 2016)
- [LIFE_THREATENING] Cushing reflex, papilledema, asymmetric pupils, posturing, or imaging signs of raised ICP (IDSA 2004 Tunkel)

Citations

- IDSA 2004 + IDSA/AAN 2017 (healthcare-associated) + ESCMID 2016 + NICE NG240 (2024) + WHO 2023 + IDSA 2024 community-acquired bacterial meningitis update (referenced; PMID pending verification) [PMID:15494903](https://pubmed.ncbi.nlm.nih.gov/15494903/)
- Cited evidence (PMID 28203777) [PMID:28203777](https://pubmed.ncbi.nlm.nih.gov/28203777/)
- Cited evidence (PMID 12432041) [PMID:12432041](https://pubmed.ncbi.nlm.nih.gov/12432041/)
- Cited evidence (PMID 20824838) [PMID:20824838](https://pubmed.ncbi.nlm.nih.gov/20824838/)
- Cited evidence (PMID 27062097) [PMID:27062097](https://pubmed.ncbi.nlm.nih.gov/27062097/)

Last reconciled with current guidelines: 2026-05-22.
References
  • IDSA 2004 + IDSA/AAN 2017 (healthcare-associated) + ESCMID 2016 + NICE NG240 (2024) + WHO 2023 + IDSA 2024 community-acquired bacterial meningitis update (referenced; PMID pending verification) — PMID:15494903
  • Cited evidence (PMID 28203777) — PMID:28203777
  • Cited evidence (PMID 12432041) — PMID:12432041
  • Cited evidence (PMID 20824838) — PMID:20824838
  • Cited evidence (PMID 27062097) — PMID:27062097