Bacterial meningitis is strongly suspected when fever, headache, neck stiffness and altered level of consciousness or cognition are all present, which NICE guideline NG240, published on 19 March 2024, calls the red flag combination. Intravenous antibiotics go in within 1 hour of arrival in hospital, after blood samples and, where it is safe and will not cause significant delay, a lumbar puncture. At the CT1 anaesthetics interview the marks are for that hour, for the lumbar puncture contraindications, and for knowing where the anaesthetist fits.

Key takeaways

  • The red flag combination for bacterial meningitis is fever, headache, neck stiffness and altered level of consciousness or cognition, including confusion or delirium
  • Meningococcal disease red flags are a non-blanching rash with purpuric lesions larger than 2 mm, a rapidly spreading petechial or purpuric rash, or meningitis signs plus a non-blanching rash
  • Meningococcal disease is not excluded by the absence of a rash, and rashes are harder to see on brown, black or tanned skin
  • Intravenous antibiotics within 1 hour of arrival in hospital, with a senior clinical decision maker doing the initial assessment
  • Dexamethasone is given to people over 3 months with strongly suspected or confirmed bacterial meningitis, with or before the first antibiotic dose if possible, but never delaying antibiotics
  • Do not routinely image before lumbar puncture; image and defer the tap if there are focal signs, abnormal pupils, a Glasgow Coma Scale score of 9 or less, or a rapid fall in consciousness

How do you recognise bacterial meningitis?

You recognise bacterial meningitis from the red flag combination: fever, headache, neck stiffness and altered level of consciousness or cognition, including confusion or delirium. NG240 says to strongly suspect it when all four are present.

However, the guideline is equally clear that it can still be strongly suspected on clinical assessment in someone without all four, and that the more symptoms and signs a person has, the more likely the diagnosis.

Two groups are missed. In older adults fever and neck stiffness are less common and the presentation may be delirium, and in young adults altered behaviour is wrongly blamed on alcohol or substance misuse.

What makes it meningococcal disease rather than meningitis?

Meningococcal disease is strongly suspected on any one of three red flag symptoms in NG240, and the rash is what distinguishes it. The recommendations on meningitis cover meningococcal meningitis without sepsis; meningococcal disease covers sepsis with or without meningitis.

  • A haemorrhagic, non-blanching rash with lesions larger than 2 mm, which is purpura
  • A rapidly progressive or spreading non-blanching petechial or purpuric rash
  • Any symptoms or signs of bacterial meningitis combined with a non-blanching petechial or purpuric rash
  • Do not rule out meningococcal disease just because the person does not have a rash
  • Check all over the body including nappy areas, and look for petechiae in the conjunctivae, because rashes are hard to detect on brown, black or tanned skin
  • Warn the patient and family that a rash can change from blanching to non-blanching

NG240 also lists risk factors worth saying: missed meningococcal vaccinations, reduced or absent spleen function, complement deficiency or inhibition, being a student in shared accommodation, family history, recent contact or an outbreak, and a previous episode.

What happens in the first hour in hospital?

In the first hour of suspected meningitis a senior clinical decision maker assesses the patient and makes sure antibiotics start within that hour, with blood tests and a lumbar puncture first where it is safe and will not cause significant delay.

  • Blood tests: blood culture, white cell count including neutrophils, C-reactive protein or procalcitonin, glucose, whole-blood PCR including meningococcal and pneumococcal, and an HIV test in adults
  • A bacterial throat swab for meningococcal culture, preferably before antibiotics, with the request form stating that it is specifically for meningococcal culture
  • A blood glucose immediately before the lumbar puncture, so the cerebrospinal fluid to blood glucose ratio can be worked out
  • Cerebrospinal fluid for cell count and type, total protein, glucose, gram stain, culture and sensitivities and PCR, with the remainder stored
  • Cell counts, protein and glucose available within 4 hours of the lumbar puncture
  • Do not rule out bacterial meningitis on a normal C-reactive protein, procalcitonin or white cell count

Before hospital, the rule is different. Do not delay transfer to give antibiotics, but give intravenous or intramuscular ceftriaxone or benzylpenicillin for strongly suspected meningococcal disease unless doing so delays the transfer.

Which antibiotic, and when does dexamethasone go in?

For suspected bacterial meningitis with no identified organism, NG240 gives ceftriaxone at the highest doses recommended by the British National Formulary, or cefotaxime if ceftriaxone is contraindicated. Suspected or confirmed meningococcal disease gets intravenous ceftriaxone.

Add intravenous amoxicillin to the cephalosporin for people with risk factors for Listeria monocytogenes, and do not give aciclovir routinely unless herpes simplex encephalitis is strongly suspected. Get infection specialist advice for every case.

Dexamethasone goes to people over 3 months with strongly suspected or confirmed bacterial meningitis, with or before the first antibiotic dose if possible. Antibiotics are never delayed for it, and a delay beyond 12 hours needs specialist advice.

When is it unsafe to do the lumbar puncture?

The lumbar puncture is unsafe in suspected meningitis when there are signs of raised intracranial pressure or of a space-occupying lesion, and NG240 lists those precisely rather than leaving them to judgement.

  • New focal neurological features, including seizures or posturing
  • Abnormal pupillary reactions
  • A Glasgow Coma Scale score of 9 or less, or a progressive and sustained or rapid fall in level of consciousness
  • Risk factors for an evolving space-occupying lesion
  • Extensive or rapidly spreading purpura, or infection at the lumbar puncture site
  • An unprotected airway, respiratory compromise, shock, uncontrolled seizures or a bleeding risk, each of which must be treated and stabilised first

The sequencing is the marked part. NG240 says not to image routinely before a lumbar puncture, and when imaging is needed, to take bloods, give antibiotics and stabilise the patient before the scan.

What is the anaesthetist's part in this?

The anaesthetist's part in suspected meningitis is written into the guideline without being named. Four of the conditions that must be treated and stabilised before a lumbar puncture are airway, breathing and circulation problems.

A patient with a Glasgow Coma Scale score of 9 or less needs imaging rather than a tap, and a falling score needs an airway plan. NICE NG232 puts the airway threshold at 8 or less.

Meningococcal septic shock is the other route in. NG240 asks for urgent critical care advice where raised intracranial pressure raises concern about herniation, and considers low-dose replacement corticosteroids for shock unresponsive to high-dose vasoactive agents.

What about fluids and intracranial pressure?

In confirmed bacterial meningitis, NG240 says not to routinely restrict fluid intake below routine maintenance needs, and to give maintenance fluids orally or by enteral tube where they are tolerated.

Glycerol is not to be used, and other osmotic agents such as mannitol or hypertonic sodium chloride are not to be used routinely. They are considered only as a temporary measure where herniation is a concern.

Invasive intracranial pressure monitoring is not used routinely either. Specialist advice is sought where there are features of raised intracranial pressure or hydrocephalus, which is a decision, not a default.

Who do you call, and when?

In a meningitis scenario you call a senior clinical decision maker at the door, because NG240 makes that person responsible for the initial assessment and for ensuring antibiotics start within 1 hour of arrival.

Infection specialist advice is asked for in all cases of bacterial meningitis, and particularly for recent travel outside the UK with antimicrobial resistance risk, or colonisation with cephalosporin-resistant coliforms.

Critical care is called for the shocked or obtunded patient, and for anyone whose lumbar puncture has been deferred because they are too unstable to have one. Say what you are asking for, not just who you are calling.

What do the assessors score besides the guideline?

Beyond the guideline, the assessors in a meningitis scenario score communication with a frightened patient and family. NG240 devotes a whole section to discussing the reasons for the suspicion, the uncertainty, and when more will be known.

Public health is part of the answer too. Contact tracing and prophylaxis follow a confirmed case, and mentioning it shows you see past the patient in front of you.

Reflective practice is a named domain, so a real example works: a patient in whom you attributed confusion to something else, and the safety netting or reassessment habit you built afterwards.

Which mistakes cost marks in a meningitis scenario?

The meningitis mistakes at interview are almost all sequencing errors, and NG240 was rewritten in 2024 to close them.

  • Waiting for the lumbar puncture before starting antibiotics, when the hour is the limit and the tap is deferred if it would cause significant delay
  • Requesting a CT routinely before every lumbar puncture, when the guideline says not to image routinely and gives specific triggers
  • Ruling out meningococcal disease because there is no rash
  • Ruling out meningitis on a normal C-reactive protein or white cell count
  • Delaying antibiotics to give dexamethasone, when the guideline says never to wait for it
  • Forgetting the bedside glucose before the tap, which is what makes the cerebrospinal fluid glucose interpretable

How this comes up at the CT1 anaesthetics interview

Meningitis reaches the clinical judgement station as a young adult in the emergency department with fever, headache and confusion, or as a call to assess an airway before a lumbar puncture. The station is 15 minutes after five minutes of reading, marked out of 50.

Clinical judgement and decision making is scored on the red flags, the hour and the contraindications. Reflective practice is scored on how you talk to the family, and working under pressure on whether you sequence antibiotics, imaging and the tap correctly.

The follow-up usually escalates: the rash spreads, the conscious level drops, or the patient becomes shocked. anaestheticinterview's bank of 340 questions carries AI-marked spoken practice, so that sequence can be said out loud until it is automatic.