Viral meningitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected meningitis, unknown aetiology

1st line – empirical antibiotic therapy + manage in line with local protocols

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1st line –

empirical antibiotic therapy + manage in line with local protocols

Always refer a patient with suspected meningitis to hospital for a thorough assessment.[2][27]

The clinical presentation of viral meningitis is often indistinguishable from that of acute bacterial meningitis.

Start all patients on treatment for bacterial meningitis, including empirical intravenous antibiotics, until the diagnosis of bacterial meningitis is excluded or deemed unlikely. Bacterial meningitis is life-threatening and requires urgent intervention with possible critical care input. See Bacterial meningitis in adults and Bacterial meningitis in children.

Seek advice about initial management of the patient from a senior clinical decision-maker (registrar or consultant) and a microbiologist or infectious diseases consultant.[2]

Respiratory isolate all patients with suspected meningitis until meningococcal meningitis or meningococcal sepsis is excluded (or considered unlikely) or the patient has had 24 hours of antibiotics.[2][38]

Take droplet precautions, including wearing a surgical mask, if likely to be in close contact with respiratory secretions or droplets, until the patient has had 24 hours of antibiotics.[2]

Practical tip

If cerebrospinal fluid (CSF) testing reveals fungal meningitis, follow your local protocols for management recommendations specific to fungal aetiology. See Fungal meningitis.

Empirical antibiotics

Immediately give empirical antibiotics to all patients with suspected meningitis of unconfirmed aetiology.[2][37][38] This is because it is difficult to differentiate viral meningitis from bacterial meningitis on clinical grounds alone.

Choose appropriate empirical antibiotics in consultation with an infectious disease consultant/microbiologist.
Use lumbar puncture to confirm a diagnosis of viral meningitis before stopping antibiotics.[38]

If testing identifies a viral pathogen, stop any empirical antibiotics that have been started.[2]

Supportive care

Give the patient supportive care as needed, including:[2]

Securing the patient’s airway
Giving oxygen if required
Adequate analgesia/antipyretic
Anti-emetics if the patient is vomiting
Fluid management including intravenous fluids if needed.

Corticosteroids

Typically, adjuvant intravenous dexamethasone is recommended in all previously well and non-immunosuppressed adults and children with suspected meningitis.[2][73] Corticosteroids should not be given to patients aged <3 months.[37]

Start dexamethasone shortly before or at the same time as antibiotic therapy.[2] If antibiotics have already been started, dexamethasone may still be given for up to 12 hours after the first dose of antibiotics.[2]

If testing identifies a viral pathogen, stop any corticosteroids that have been started.[2]

ACUTE

confirmed viral meningitis

1st line – supportive care

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1st line –

supportive care

If testing identifies a viral pathogen, give the patient supportive care as needed, including:[2]

Adequate analgesia/antipyretic (e.g., paracetamol, ibuprofen). An opioid (e.g., codeine, morphine) may be required if there is no response to milder analgesics.
Anti-emetics (e.g., ondansetron) if the patient is vomiting.
Fluid management including intravenous fluids if needed.

Stop any empirical antibiotics or corticosteroids that have been started.[2]

Management is usually conservative. No specific treatment has been proven to be beneficial for viral meningitis.[2]

Practical tip

Some clinicians treat meningitis confirmed as being caused by herpes simplex, varicella zoster, or cytomegalovirus with antiviral medication, but there is a lack of evidence for the efficacy of these drugs in this setting and they should not be routinely used unless specifically directed by a specialist. Antiviral drugs pose potential risks from side effects and unnecessarily prolonged hospitalisation.[2][6]

Continue supportive care until the patient is stable. Prioritise the patient’s discharge from hospital if they are well enough.[2]

Primary options

paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)

ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

-- AND / OR --

ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg intravenously every 12 hours

Secondary options

codeine phosphate: 30-60 mg orally every 4 hours when required, maximum 240 mg/day

morphine sulfate: 5-10 mg intravenously every 4 hours initially, adjust dose according to response

-- AND / OR --

ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg intravenously every 12 hours

ONGOING

recurrent viral meningitis

1st line – specialist referral for consideration of antiviral therapy

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1st line –

specialist referral for consideration of antiviral therapy

Refer patients with recurrent episodes of confirmed or probable viral meningitis for assessment by an infection or neurological specialist.[2]

Recurrent benign lymphocytic meningitis (also known as Mollaret's meningitis) is a rare condition thought to be due to viral infection.[2] Herpes simplex virus (HSV)-2 is most commonly implicated. Aciclovir/valaciclovir should not routinely be given as prophylaxis for recurrent herpes meningitis (HSV or varicella zoster virus).[2][74]
- A randomised controlled trial of secondary prophylaxis with valaciclovir in patients with either primary or recurrent HSV-2 meningitis found no effect on the risk of recurrence. The study also found an increased risk of recurrence in the valaciclovir group once treatment was stopped.[74]
If a specialist initiates antiviral treatment, this should be stopped after 1 year as Mollaret's meningitis tends to resolve.

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Viral meningitis

suspected meningitis, unknown aetiology

empirical antibiotic therapy + manage in line with local protocols

Practical tip

Empirical antibiotics

Supportive care

Corticosteroids

confirmed viral meningitis

supportive care

Practical tip

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

recurrent viral meningitis

specialist referral for consideration of antiviral therapy

Viral meningitis

Treatment algorithm

suspected meningitis, unknown aetiology

empirical antibiotic therapy + manage in line with local protocols

Practical tip

Empirical antibiotics

Supportive care

Corticosteroids

confirmed viral meningitis

supportive care

Practical tip

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

recurrent viral meningitis

specialist referral for consideration of antiviral therapy