Recommendations

Key Recommendations

Suspected meningitis

The clinical presentation of viral meningitis is often indistinguishable from that of acute bacterial meningitis. If the patient is very ill, is immunocompromised, or has received prior antibiotics, empiric antibiotic therapy is justified as delay in administration of antibiotics is associated with a poor outcome. If the patient appears well it may be appropriate to observe without antibiotics while the cerebrospinal fluid (CSF) is analyzed.

The choice of empiric antibiotics depends on the patient's age, which determines the most likely organisms. Although adjunctive therapy with dexamethasone, prior to the administration of antibiotics, has not been shown to significantly reduce mortality in people with bacterial meningitis, it has been shown to reduce hearing loss and neurologic sequelae in patients living in high-income countries.[57][58][59]​ Typically, adjuvant dexamethasone is recommended in all previously well and nonimmunosuppressed adults and children over 3 months.[3][60][61]​​​

The use of acyclovir may reduce the severity and duration of symptoms in viral meningitis caused by herpes simplex virus (HSV) or varicella zoster virus.[62] Efficacy has not been established in prospective randomized trials.

Confirmed viral meningitis

Antibiotics may be stopped following confirmation of viral infection.[3] Patients who develop severe illness, or who are at risk for developing severe illness, may require continued hospital admission for monitoring and supportive care, including airway management and oxygen if required, adequate analgesia for headaches, antipyretics if fever is present, antiemetics if vomiting, and intravenous fluids if dehydrated.[3][4]​​ Antiviral medication is recommended if infection with herpes simplex, varicella zoster, or cytomegalovirus (CMV) is confirmed. Patients with confirmed viral meningitis who are afebrile and clinically improving may be appropriate for discharge following specialist review, with outpatient therapy as needed.[3] Most patients with mild viral meningitis get better on their own in 7-10 days.[4]

Acyclovir or valacyclovir is typically given first line for HSV and varicella zoster. Valacyclovir is better absorbed orally but is much more expensive. Foscarnet may be used for severe acyclovir-resistant infections.

For CMV, ganciclovir or valganciclovir is used as first-line agent; second- and third-line agents include foscarnet and cidofovir, respectively.

Recurrent benign lymphocytic meningitis (also known as Mollaret meningitis) is a rare condition thought to be due to viral infection.[3] Herpes simplex type 2 is most commonly implicated. Treatment decisions should always be made by a specialist. Acyclovir and valacyclovir should not routinely be given as prophylaxis.[3] A randomized controlled trial of secondary prophylaxis with valacyclovir in patients with either primary or recurrent HSV-2 meningitis found no effect on the risk of recurrence.[63] The study also found an increased risk of recurrence in the valacyclovir group once treatment was stopped.[63] If a specialist initiates antiviral treatment, this should be stopped after 1 year as Mollaret meningitis tends to resolve.

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