Bacterial Meningitis

Bacterial meningitis classical occurs very acutely (median duration from symptoms to presentation in one study was 24 hours) and consists of the classic triad of fever, nuchal rigidity, and altered mental status. Headache is also common. Pneumococcus is far and away the most common etiology in our population (see image).

1. What are current IDSA guidelines for treatment of suspected bacterial meningitis? For adults up to age 50, would start with ceftriaxone (covering common etiologies of meningitis, also solid BBB crossing) & vancomycin (covering PCN resistant strep). Over the age of 50, add ampicillin for listeria coverage. Dexamethasone is also currently recommended to be administered 20 minutes prior to antibiotics or coincident with antibiotics (at the latest) for a 4 day duration for all patients with suspected bacterial meningitis, with plans to de-escalate if etiology is not pneumococcus to prevent hearing loss and other permanent neurologic sequelae. Keep in mind these guidelines are >10 years old.

2. What is jolt accentuation (JA)? Jolt accentuation was a bit of a physical exam fad to detect bacterial meningitis. To perform JA, ask the patient to shake there head laterally at a rate of 2-3 Hz. If this makes their headache worse, it has a high sensitivity/specificity for bacterial meningitis (from a study of 30 patients...). This finding has very poor reproducibility in studies of larger size(i.e. was basically found to be no better than the flip of a coin). It has fallen out of use for that reason, but you'll still find some quoting the original study.