Meningitis: How to Answer “Best Next Step” Questions

If, on a  standardized test, you are asked what’s the “best next step” in the management of a patient with suspected meningitis, prioritize thusly:

1. Droplet precautions if Neisseria meningitidis is suspected (this comes first for public health reasons)
2. Administer acyclovir if HSV meningitis is suspected (there’s no reason to delay this)
3. Draw blood cultures (because antibiotics will “spoil” blood culture results)
4. Administer antibiotics (because antibiotics won’t “spoil” lumbar puncture results – it takes several hours for the antibiotics to kill off bacteria in the cerebrospinal fluid)
5. Order a head CT in patients with papilledema, focal neurological deficits, seizures or confusion. “Don’t send patients off to the CT scan to let their brain ‘fry’ from an infection without giving antibiotics [first].” (Fischer, 2013)
6. Finally, perform a lumbar puncture

References

• Fischer, Conrad, MD, Master the Boards: Internal Medicine (2013)
• Sabatine, Marc. S, MD, MPH, Pocket Medicine, 5e (2013)