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Intravenous fluids, prochlorperazine, and diphenhydramine
1%
1/69
Lumbar puncture
Non-contrast CT scan of the head
52%
36/69
Obtain blood cultures
10%
7/69
Vancomycin and ceftriaxone
32%
22/69
Select Answer to see Preferred Response
This patient with fever, headache, altered mental status, and meningeal signs on exam likely has bacterial meningitis. The most appropriate first step in management for a patient with suspected bacterial meningitis is to obtain blood cultures prior to the administration of antibiotics.Meningococcal meningitis is common in college students and others living in close quarters, such as military recruits. Symptoms include headache, fever, neck stiffness, photophobia, and altered mental status. Petechial rash is present in over half of patients with meningococcal disease. However, a petechial or purpuric rash is not specific to meningococcal disease but rather indicates the systemic activation of the clotting cascade with risk of progression to disseminated intravascular coagulation. Meningitis due to Haemophilus influenzae and pneumococcus species may also present with a petechial rash. Bamberger reviews management of meningitis. Kernig's sign, in which extension of the knee while both the knee and thigh are flexed produces pain, is poorly sensitive but highly specific for bacterial meningitis. The cardinal features of meningitis, fever, neck stiffness, and altered mental status, are present in 99 to 100% of patients with disease.Kimmel reviews prevention of meningococcal meningitis. The FDA recommends that the meningococcal vaccine be given to 11 and 12 year-olds, adolescents entering high school, and college freshmen living in dormitories. Prophylactic rifampin, ciprofloxacin, or ceftriaxone should be given to household and close contacts of affected patients. Illustration A demonstrates a Gram stain of meningococci from a culture of cerebral spinal fluid. Meningococci are Gram negative diplococci.Incorrect Answers:Answer 1: Intravenous fluids, prochlorperazine, and diphenhydramine would be appropriate if migraine headache were suspected as the cause of this patient's symptoms. However, this patient's fever, headache, and meningeal signs on exam make the diagnosis of bacterial meningitis more likely. Susected bacterial meningitis should rapidly be evaluated with blood cultures, a non-contrast CT scan of the head and lumbar puncture. Answer 2: Lumbar puncture will eventually be indicated in this patient. However, the most appropriate first step is to obtain blood cultures immediately prior to starting broad-spectrum antibiotics (e.g. vancomycin and ceftriaxone). This is done first to ensure that blood cultures do not become sterilized by intravenous antibiotics. Answer 3: A non-contrast CT scan of the head should be obtained prior to lumbar puncture to evaluate for a intracranial mass that may cause herniation during lumbar puncture. However, it should not precede or delay blood cultures being obtained or the administration of broad-spectrum antibiotics.Answer 5: Vancomycin and ceftriaxone would be an appropriate antibiotic regimen for this patient with suspected bacterial meningitis. However, blood cultures should be obtained prior to administration of antibiotics.Bullet Summary:The most appropriate first step in management for a patient with suspected bacterial meningitis is to obtain blood cultures prior to the administration of antibiotics.
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