Why this topic matters: Meningitis is inflammation of the membranes surrounding the brain and spinal cord. Bacterial meningitis and meningococcal disease can cause death or permanent disability within hours, so antibiotics and sepsis care must not wait for every diagnostic test. Viral, TB, fungal and other causes require different treatment, but the first emergency priorities remain airway, breathing, circulation, neurological assessment, infection control, early senior review and safe investigation.
Learning objectives
- Recognise meningitis and meningococcal sepsis in adults, children, infants and immunocompromised patients.
- Perform triage, ABCDE, sepsis assessment, neurological examination and exposure precautions.
- Describe urgent investigations, lumbar-puncture safety and empiric treatment principles.
- Manage shock, seizures, raised intracranial pressure, airway compromise and complications.
- Plan nursing observation, contact prophylaxis, vaccination education and discharge follow-up.
Definition, causes and transmission
Meningitis may be bacterial, viral, TB, fungal, parasitic, malignant, autoimmune or drug-related. The common bacterial causes vary by age, vaccination status and immune function; pneumococcus, meningococcus and Haemophilus influenzae remain important. Meningococcal disease may present as meningitis, septicemia, or both. Respiratory and throat secretions can transmit meningococcus during close or prolonged contact.
Bacterial meningitis is a medical emergency. Do not use the absence of the full triad of fever, headache and neck stiffness to rule it out: infants, older adults, immunocompromised people and patients with sepsis may present atypically.
Safety point: If bacterial meningitis is strongly suspected, collect blood cultures when this will not delay treatment and give empiric antimicrobials urgently according to local protocol. If lumbar puncture or imaging is delayed, antibiotics must not be postponed.
Clinical features and red flags
| Group | Possible presentation | High-risk features |
|---|---|---|
| Adults/older children | Fever, severe headache, neck stiffness, photophobia, vomiting, confusion or seizures. | Reduced consciousness, purpura, shock, focal deficit, papilloedema or rapidly worsening symptoms. |
| Infants | Poor feeding, irritability, lethargy, vomiting, abnormal cry, temperature instability or bulging fontanelle. | Apnoea, seizures, poor perfusion, hypothermia, tense fontanelle or persistent inconsolability. |
| Meningococcal sepsis | Fever, rigors, myalgia, limb pain, vomiting, diarrhoea, petechiae or purpura. | Rapid rash progression, hypotension, cold extremities, altered mental state or DIC. |
| TB/fungal/HIV-associated | Subacute headache, fever, weight loss, cranial neuropathy, confusion or focal signs. | Raised ICP, hydrocephalus, profound immunosuppression or prolonged symptoms. |
Triage and infection prevention
- Place the patient in a resuscitation-capable area and notify the senior clinician, laboratory and infection-prevention team.
- Use standard precautions and appropriate droplet precautions for suspected meningococcal disease until the recommended period of effective antibiotics has passed.
- Ask about onset, contacts, vaccination, recent antibiotics, travel/outbreak exposure, splenectomy, HIV, TB, immunosuppression, head injury, neurosurgery and CSF leak.
- Do not leave a confused or seizing patient alone; institute falls, aspiration and seizure precautions.
- Pre-alert a referral hospital if intensive care, neurosurgery, paediatrics, infectious disease or isolation capacity is needed.
ABCDE and neurological assessment
| Step | Assessment | Actions |
|---|---|---|
| A – Airway | GCS, secretions, vomiting, gag, seizures and aspiration. | Position, suction, airway adjuncts and expert airway support if protection is lost. |
| B – Breathing | Rate, effort, SpO₂, cyanosis, aspiration and abnormal pattern. | Oxygen for hypoxaemia/distress; ventilate cautiously with critical-care support. |
| C – Circulation | Pulse, BP, capillary refill, skin, urine output, lactate and rash. | IV/IO access, cultures, cautious fluids, antibiotics and vasopressors for refractory shock. |
| D – Disability | GCS/AVPU, pupils, neck stiffness, focal deficits, seizures and glucose. | Check glucose, treat seizures and escalate possible raised ICP or stroke. |
| E – Exposure | Full skin inspection for petechiae/purpura, fever, trauma, rash and infection source. | Prevent chilling, document rash progression and preserve dignity. |
Immediate management
- Obtain IV/IO access, blood cultures and urgent blood tests while preparing empiric antimicrobial therapy.
- Start antibiotics according to age, immune status, local resistance and Uganda treatment protocol; do not wait for CT or LP if either is delayed.
- Give oxygen for hypoxaemia and support ventilation if consciousness or seizures compromise breathing.
- Treat sepsis with cautious isotonic fluid boluses, reassessing lungs, perfusion, BP, urine output and lactate; escalate to vasopressors in critical care when shock persists.
- Control fever and pain, correct hypoglycaemia/electrolyte disturbance and treat seizures promptly.
- Use corticosteroid adjuncts only when indicated by the local meningitis protocol and before/with the first antibiotic dose where appropriate.
- Involve paediatrics, infectious disease, neurology, anaesthesia and critical care early for severe disease.
Investigations and lumbar-puncture safety
| Test | Purpose | Safety point |
|---|---|---|
| Blood cultures | Identify bacterial cause and guide de-escalation. | Collect promptly, but never delay antibiotics in an unstable patient. |
| FBC, CRP/procalcitonin, renal/liver profile, glucose, lactate | Assess inflammation, organ dysfunction, shock and drug safety. | Trend results; normal inflammatory markers do not exclude early disease. |
| Non-contrast CT brain | Assess mass effect, hydrocephalus, oedema or alternative diagnosis before LP when indicated. | CT should not become an automatic reason to delay antibiotics. |
| Lumbar puncture | CSF opening pressure, cells, protein, glucose, Gram stain, culture and PCR. | Do not perform with signs of raised ICP, focal deficit, papilloedema, severe shock, uncontrolled seizures, coagulopathy or unsafe airway without specialist review. |
| Malaria/TB/HIV/fungal testing | Identify local and host-specific causes. | Use epidemiology, immune status and subacute presentation to guide testing. |
Bacterial meningitis pathway
- Recognise suspected disease and start ABCDE/sepsis care.
- Collect blood cultures and give empiric antibiotics urgently according to age and local protocol.
- Assess for shock, respiratory failure, seizure, raised ICP, purpura/DIC and focal neurological deficits.
- Perform LP only when clinically safe and when it will not delay essential treatment; send CSF promptly.
- Adjust antimicrobial therapy when cultures/PCR and specialist advice identify the organism.
- Monitor hearing, cognition, motor function, vision and psychosocial needs because long-term sequelae are common.
Meningococcal sepsis and rash
Meningococcal disease can deteriorate extremely rapidly. A non-blanching petechial or purpuric rash is an important warning sign, but early rash may be absent. Assess for septic shock and disseminated intravascular coagulation (DIC).
- Isolate appropriately, call the sepsis team, establish access and give antibiotics immediately under protocol.
- Mark and photograph/document rash progression according to policy; reassess skin, capillary refill, temperature and perfusion frequently.
- Check FBC/platelets, coagulation, fibrinogen, lactate, renal function and blood gas.
- Manage shock, bleeding, metabolic acidosis, renal injury and limb ischaemia in critical care.
- Notify public health and identify close contacts who may need chemoprophylaxis and vaccination advice.
Raised intracranial pressure and seizures
- Warning signs include falling GCS, repeated vomiting, unequal pupils, new focal signs, abnormal posturing, bradycardia with hypertension, irregular breathing or papilloedema.
- Elevate the head where safe, maintain neutral neck alignment, avoid hypoxia/hypotension/hyperthermia and obtain urgent critical-care/neurosurgical review.
- Treat convulsive seizures immediately according to the seizure pathway; persistent coma may be non-convulsive status.
- Avoid unnecessary LP or excessive fluids when raised ICP is suspected; use imaging and specialist direction.
- Prepare for advanced airway management if protective reflexes fail, with attention to cerebral perfusion.
Viral, TB and fungal meningitis
- Viral meningitis may be self-limiting, but severe illness, encephalitis, immunosuppression or herpes suspicion requires hospital care and targeted antivirals under specialist guidance.
- TB meningitis is often subacute and may cause cranial neuropathies, hydrocephalus and stroke; early TB/HIV evaluation and prolonged treatment are required.
- Fungal meningitis is uncommon but important in advanced HIV or immunosuppression; diagnosis and antifungal therapy require specialist and laboratory support.
- Never label a patient “viral” solely because they are not shocked; early bacterial disease can look mild.
Nursing care and monitoring
- Monitor GCS, pupils, focal power, seizures, temperature, HR, BP, RR, SpO₂, capillary refill and urine output at acuity-appropriate intervals.
- Maintain droplet precautions, hand hygiene, dedicated equipment and safe specimen transport.
- Keep nil by mouth if consciousness or swallow is impaired; provide oral care and aspiration prevention.
- Administer antibiotics on time, check allergies, observe for reactions and document dose/route/time.
- Maintain fluid balance, monitor for pulmonary oedema and assess response to each fluid bolus.
- Observe IV sites, rash, bleeding, pressure areas, hearing/vision changes and medication adverse effects.
- Use SBAR handover with suspected cause, antibiotics, cultures, LP/CT status, neurological trend and escalation plan.
Complications
| Complication | Clues | Response |
|---|---|---|
| Septic shock | Hypotension, cold peripheries, altered state, oliguria or rising lactate. | Sepsis bundle, antibiotics, cautious fluids and early vasopressor/ICU review. |
| Raised ICP/herniation | Falling GCS, pupil change, posturing, vomiting or irregular breathing. | Airway/oxygenation, head positioning, urgent imaging and neurocritical care. |
| Seizures | Convulsions, eye deviation or persistent unexplained unresponsiveness. | Seizure protocol, glucose, airway protection and EEG/specialist review. |
| DIC/purpura fulminans | Rapidly spreading purpura, bleeding, thrombocytopenia or abnormal coagulation. | Critical care, blood-product and source-control guidance. |
| Hearing/neurological disability | Hearing loss, cognitive change, weakness, cranial-nerve deficits. | Early audiology, rehabilitation, neurology and psychosocial support. |
| Hydrocephalus/vasculopathy | Persistent headache, vomiting, reduced consciousness or focal deficit. | Urgent imaging and neurosurgical/neurology referral. |
Prevention and contact management
- Promote routine vaccination, including Hib, pneumococcal and meningococcal vaccines according to Uganda’s schedule and outbreak guidance.
- Notify public health for suspected meningococcal disease or an outbreak; list household, intimate and healthcare contacts.
- Give chemoprophylaxis to eligible close contacts according to the public-health protocol; routine casual contact does not usually require it.
- Use respiratory hygiene, ventilation, hand hygiene and early isolation during outbreaks.
- Provide survivors with follow-up for hearing, cognition, seizures, weakness, mental health and school/work support.
Clinical scenarios
Scenario 1 – Meningococcal sepsis: A young adult has fever, leg pain, confusion, hypotension and a rapidly spreading purpuric rash. Begin ABCDE/sepsis care, droplet precautions, blood cultures if immediately available, urgent antibiotics, cautious fluids and public-health notification.
Scenario 2 – Suspected bacterial meningitis: An adult has fever, severe headache, neck stiffness and photophobia but is currently haemodynamically stable. Start antibiotics promptly, obtain blood cultures, assess LP safety and arrange urgent imaging/specialist review without delaying treatment.
Scenario 3 – Infant: A four-month-old is irritable, feeding poorly, hypothermic and has a tense fontanelle. Treat as a high-risk emergency: ABCDE, glucose, access, antibiotics, sepsis care and paediatric referral.
Common errors to avoid
- Waiting for the classic triad or a rash before treating.
- Delaying antibiotics for CT, LP, transport or laboratory results.
- Performing LP with signs of raised ICP, shock, focal deficit or coagulopathy without specialist assessment.
- Forgetting meningococcal isolation and contact notification.
- Underestimating atypical infant, elderly, HIV-associated or TB presentations.
- Failing to monitor neurological trend, urine output, rash progression and respiratory status.
MENINGITIS emergency check: M – Mask/isolate and monitor; E – Evaluate ABCDE; N – Neurology, neck and rash; I – IV/IO access and glucose; N – Notify seniors/public health; G – Give antibiotics early; I – Investigate safely; T – Treat shock/seizures/ICP; I – Identify contacts; S – Safety-net and support survivors.
Revision questions
- Why must suspected bacterial meningitis be treated before all diagnostic tests are complete?
- List the clinical features of meningococcal sepsis and the appropriate infection precautions.
- When should lumbar puncture be delayed or avoided?
- How would you manage meningitis complicated by seizure and raised ICP?
- What investigations should be taken in a stable adult before or alongside treatment?
- Which contacts may need chemoprophylaxis after meningococcal disease?
- List the long-term complications requiring follow-up.
Key takeaways
- Meningitis and meningococcal sepsis are time-critical emergencies.
- Start ABCDE, isolation, cultures when feasible and empiric antibiotics early.
- Do not let CT or LP delay treatment; assess LP safety carefully.
- Watch continuously for shock, seizures, airway failure and raised ICP.
- Vaccination, contact prophylaxis and survivor follow-up are essential parts of care.