Viral meningitis
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Treatment algorithm
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
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
possible bacterial meningitis
antibiotic therapy plus supportive care
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.
Antibiotics need to cover group B streptococci, Listeria, and coliforms.
If the infant has been in a hospital nursery before becoming ill, additional Staphylococcus aureus cover should be added (vancomycin if MRSA is prevalent; flucloxacillin or nafcillin if methicillin-sensitive S aureus suspected).
A diagnosis of viral meningitis will allow antibiotics to be stopped.
Local protocols and guidelines should be consulted for selection of empiric antibiotic therapy.
Supportive care may include respiratory support and ensuring adequate hydration.
antibiotic therapy plus supportive care
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.
A diagnosis of viral meningitis will allow antibiotics to be stopped.
Local protocols and guidelines should be consulted for selection of antibiotic therapy.
Supportive care may include securing the patient’s airway, giving oxygen if required, adequate hydration (including intravenous fluids if needed), use of antipyretics for fever, antiemetics if vomiting, and analgesia for headaches.[3]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
dexamethasone
Treatment recommended for SOME patients in selected patient group
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]de Gans J, van der Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002 Nov 14;347(20):1549-56. https://www.nejm.org/doi/10.1056/NEJMoa021334 http://www.ncbi.nlm.nih.gov/pubmed/12432041?tool=bestpractice.com [58]van de Beek D, de Gans J, McIntyre P, et al. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis. 2004 Mar;4(3):139-43. http://www.ncbi.nlm.nih.gov/pubmed/14998499?tool=bestpractice.com [59]Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015 Sep 12;(9):CD004405. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004405.pub5/full http://www.ncbi.nlm.nih.gov/pubmed/26362566?tool=bestpractice.com
Dexamethasone can be stopped if lumbar puncture excludes meningitis or if viral meningitis is suspected.[3]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [57]de Gans J, van der Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002 Nov 14;347(20):1549-56. https://www.nejm.org/doi/10.1056/NEJMoa021334 http://www.ncbi.nlm.nih.gov/pubmed/12432041?tool=bestpractice.com [58]van de Beek D, de Gans J, McIntyre P, et al. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis. 2004 Mar;4(3):139-43. http://www.ncbi.nlm.nih.gov/pubmed/14998499?tool=bestpractice.com [59]Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015 Sep 12;(9):CD004405. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004405.pub5/full http://www.ncbi.nlm.nih.gov/pubmed/26362566?tool=bestpractice.com
Typically, adjuvant dexamethasone is recommended in all previously well and nonimmunosuppressed adults and children over 3 months.[3]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [60]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al; EFNS Task Force. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com [61]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240
Primary options
dexamethasone sodium phosphate: children: consult specialist for guidance on dose; adults: 0.15 mg/kg intravenously every 6 hours for 2-4 days
These drug options and doses relate to a patient with no comorbidities.
Primary options
dexamethasone sodium phosphate: children: consult specialist for guidance on dose; adults: 0.15 mg/kg intravenously every 6 hours for 2-4 days
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
dexamethasone sodium phosphate
antibiotic therapy plus supportive care
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.
Due to lowered immunity in older people, a combination of vancomycin, ceftriaxone, and ampicillin is recommended.
A diagnosis of viral meningitis will allow antibiotics to be stopped.
Local protocols and guidelines should be consulted for selection of antibiotic therapy.
Supportive care may include securing the patient’s airway, giving oxygen if required, adequate hydration (including intravenous fluids if needed), use of antipyretics for fever, antiemetics if vomiting, and analgesia for headaches.[3]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
dexamethasone
Treatment recommended for SOME patients in selected patient group
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]de Gans J, van der Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002 Nov 14;347(20):1549-56. https://www.nejm.org/doi/10.1056/NEJMoa021334 http://www.ncbi.nlm.nih.gov/pubmed/12432041?tool=bestpractice.com [58]van de Beek D, de Gans J, McIntyre P, et al. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis. 2004 Mar;4(3):139-43. http://www.ncbi.nlm.nih.gov/pubmed/14998499?tool=bestpractice.com [59]Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015 Sep 12;(9):CD004405. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004405.pub5/full http://www.ncbi.nlm.nih.gov/pubmed/26362566?tool=bestpractice.com
Dexamethasone can be stopped if lumbar puncture excludes meningitis or if viral meningitis is suspected.[3]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [57]de Gans J, van der Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002 Nov 14;347(20):1549-56. https://www.nejm.org/doi/10.1056/NEJMoa021334 http://www.ncbi.nlm.nih.gov/pubmed/12432041?tool=bestpractice.com [58]van de Beek D, de Gans J, McIntyre P, et al. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis. 2004 Mar;4(3):139-43. http://www.ncbi.nlm.nih.gov/pubmed/14998499?tool=bestpractice.com [59]Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015 Sep 12;(9):CD004405. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004405.pub5/full http://www.ncbi.nlm.nih.gov/pubmed/26362566?tool=bestpractice.com
Typically, adjuvant dexamethasone is recommended in all previously well and nonimmunosuppressed adults and children over 3 months.[3]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [60]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al; EFNS Task Force. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com [61]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240
Primary options
dexamethasone sodium phosphate: 0.15 mg/kg intravenously every 6 hours for 2-4 days
These drug options and doses relate to a patient with no comorbidities.
Primary options
dexamethasone sodium phosphate: 0.15 mg/kg intravenously every 6 hours for 2-4 days
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
dexamethasone sodium phosphate
confirmed viral agent, other than HSV, varicella zoster, or CMV
supportive care
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 for fever, antiemetics if vomiting, and intravenous fluids if dehydrated.[3]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [4]Centers for Disease Control and Prevention. About viral meningitis. Jan 2024 [internet publication]. https://www.cdc.gov/meningitis/about/viral-meningitis.html
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
HSV or varicella zoster confirmed causative agent
antiviral therapy plus supportive care
Reports suggest that acyclovir reduces the severity and duration of symptoms of meningitis due to herpes simplex.[62]Bergstrom T, Alestig K. Treatment of primary and recurrent herpes simplex virus type 2 induced meningitis with acyclovir. Scand J Infect Dis. 1990;22(2):239-40. http://www.ncbi.nlm.nih.gov/pubmed/2162558?tool=bestpractice.com This has not been demonstrated in placebo-controlled prospective trials.
Foscarnet may be used for severe infections due to acyclovir-resistant herpes simplex.
Treatment course: 7-10 days.
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [4]Centers for Disease Control and Prevention. About viral meningitis. Jan 2024 [internet publication]. https://www.cdc.gov/meningitis/about/viral-meningitis.html
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Primary options
acyclovir: children and adults: 10 mg/kg intravenously every 8 hours ; neonates may require higher doses, consult specialist for further guidance on dose
OR
valacyclovir: children: consult specialist for guidance on dose; adults: 1 g orally every 8 hours
Secondary options
foscarnet: children: consult specialist for guidance on dose; adults: 40 mg/kg intravenously every 8 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
acyclovir: children and adults: 10 mg/kg intravenously every 8 hours ; neonates may require higher doses, consult specialist for further guidance on dose
OR
valacyclovir: children: consult specialist for guidance on dose; adults: 1 g orally every 8 hours
Secondary options
foscarnet: children: consult specialist for guidance on dose; adults: 40 mg/kg intravenously every 8 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
acyclovir
OR
valacyclovir
Secondary options
foscarnet
CMV confirmed causative agent
antiviral therapy plus supportive care
For cytomegalovirus (CMV), ganciclovir or valganciclovir is used as first-line agent.
Second- and third-line agents include foscarnet and cidofovir, respectively.
Treatment course: 7-10 days (except cidofovir).
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [4]Centers for Disease Control and Prevention. About viral meningitis. Jan 2024 [internet publication]. https://www.cdc.gov/meningitis/about/viral-meningitis.html
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Primary options
ganciclovir: children: consult specialist for guidance on dose; adults: 5 mg/kg intravenously every 12 hours
OR
valganciclovir: children: consult specialist for guidance on dose; adults: 900 mg orally every 12 hours
Secondary options
foscarnet: children: consult specialist for guidance on dose; adults: 60 mg/kg intravenously every 8 hours
Tertiary options
cidofovir: children: consult specialist for guidance on dose; adults: 5 mg/kg intravenously once weekly
These drug options and doses relate to a patient with no comorbidities.
Primary options
ganciclovir: children: consult specialist for guidance on dose; adults: 5 mg/kg intravenously every 12 hours
OR
valganciclovir: children: consult specialist for guidance on dose; adults: 900 mg orally every 12 hours
Secondary options
foscarnet: children: consult specialist for guidance on dose; adults: 60 mg/kg intravenously every 8 hours
Tertiary options
cidofovir: children: consult specialist for guidance on dose; adults: 5 mg/kg intravenously once weekly
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ganciclovir
OR
valganciclovir
Secondary options
foscarnet
Tertiary options
cidofovir
recurrent viral meningitis
consideration of antiviral therapy
Recurrent benign lymphocytic meningitis (also known as Mollaret meningitis) is a rare condition thought to be due to viral infection.[3]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]Aurelius E, Franzen-Röhl E, Glimåker M, et al. Long-term valacyclovir suppressive treatment after herpes simplex virus type 2 meningitis: a double-blind, randomized controlled trial. Clin Infect Dis. 2012 May;54(9):1304-13. http://www.ncbi.nlm.nih.gov/pubmed/22460966?tool=bestpractice.com The study also found an increased risk of recurrence in the valacyclovir group once treatment was stopped.[63]Aurelius E, Franzen-Röhl E, Glimåker M, et al. Long-term valacyclovir suppressive treatment after herpes simplex virus type 2 meningitis: a double-blind, randomized controlled trial. Clin Infect Dis. 2012 May;54(9):1304-13. http://www.ncbi.nlm.nih.gov/pubmed/22460966?tool=bestpractice.com If a specialist initiates antiviral treatment, this should be stopped after 1 year as Mollaret meningitis tends to resolve.
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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
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