Running head: MENINGITIS

Meningitis
Matthew Studstrup
University of South Florida

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Introduction
Among the many different diseases or conditions a nurse may see, meningitis well
deserves closer examination. This attention is warranted because of the several different possible
causes, the differing treatment depending on the cause, and the need for quick initial treatment
and thoughtful followup. Meningitis is categorized as inflammation of the meninges caused by
an infectious agent. The key to successfully treating this illness is early recognition and
intervention. Patients will need to be placed on antibiotics. After testing to determine what agent
is causing the meningitis, their treatment plans will be modified with different or supplemental
medication. The adjunctive symptoms of meningitis, such as fever, headache, and intracranial
pressure must also be treated and monitored. Both physicians and nurses must work together to
intervene and help the patient to recovery.
Pathophysiology
According to Huether and McCance (2012, p.394-395), inflammation of the
meninges (membranes that cover the brain or spinal cord) is referred to as meningitis, and can be
caused by bacteria, viruses, fungi, parasites or toxins. Clinical manifestations and treatment plans
differ with each infection. Bacterial meningitis is caused primarily by Neisseria meningitides
(meningococcus) and Streptococcus pneumonia (pneumococcus), and infects the pia mater,
arachnoid space, subarachnoid space, and CSF. Meningococcus affects mostly men and boys,
from fall to spring, and causes epidemics in approximately ten year cycles. Pneumococcus
affects young people as well as individuals over 40. Bacterial meningitis can also infect infants
and children, and can be spread by contact in day care centers. Infants are more commonly
infected by Neisseria meningitides, and children older than four are more commonly infected
with Streptococcus pneumonia. Pneumococcus in children can result from neurosurgery, skull

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fracture, or middle ear infection, and causes 60% of all pediatric meningitis infections. An
example of such infection is "T.J.", a 5 year old Japanese-American boy, who had difficulty
recovering from an ear infection and was diagnosed on hospital admission as presenting with
bacterial meningitis caused by Streptococcus pneumonia. T.J.'s condition and its treatment will
be discussed in more detail below.
Aseptic meningitis, which includes viral and non-purulent meningitis, remains in the
meninges and produces a variety of symptoms. This type of meningitis is thought to be caused
primarily by viruses, but also can be caused by bacterial infections that were not adequately
treated and eliminated. Fungal meningitis is relatively uncommon, and develops over days or
weeks in immunocompromised individuals, or individuals with disrupted normal flora.
Usually a septic or respiratory infection is responsible for meningitis, because direct
access routes lead to the subarachnoid space. This infection launches an immune response.
Neutrophils respond, releasing cytotoxic and bacterial toxic agents, which alter the blood brain
barrier (BBB) causing tissue damage to the brain. The CSF thickens (from the neutrophil
inflammatory exudate) causing hydrocephalous, obstruction of the arachnoid villi, and
intracranial pressure. Engorged blood vessels and thrombi disrupt blood flow. Fungal meningitis
causes the formation of granulomata in the meninges and at the base of the brain, as well as
fibrosis of the meninges. These two conditions combined can cause crania nerve dysfunction
due to compression.
The systematic symptoms of meningitis include: fever, tachycardia, chills, and
petechial rashes. Symptoms of meningeal irritation include: severe headache, photophobia,
nuchal rigidity, and positive Kernig and Brudzinski signs. Neurologic symptoms include:

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decreased conscience, cranial nerve palsies, focal neurological deficits, and seizures. Aseptic
meningitis usually has milder symptoms than bacterial meningitis. Fungal meningitis is usually
asymptomatic with the first manifestation being dementia. 1.3 out of 1000 individuals are
infected with meningitis annually, and CSF cultures are required for diagnosis. (Huether &
McCance, 2012).
Medical/Nursing Interventions and Care Guidelines
Typically, if a patient arrives at an Emergency Department with a headache, fever,
altered mental status and nuchal rigidity, meningitis is suspected. Medical professionals will
perform a physical exam, blood cultures, LP (Lumbar puncture- CSF culture), and brain imaging
in order to verify the illness. Hospital guidelines dictate the order in which these steps are
performed. Some hospitals will only do a LP after the CT has been done to rule out brain lesions;
whereas, other hospitals will proceed with the LP without a CT. All facilities agree that
antibiotics need to be prescribed as quickly as possible, and blood cultures can be done
throughout this process. According to a recent research study by S. Shuh reported in The
American Journal of Emergency Medicine (2013), within the sample of admissions the average
time from entry into the ED to diagnostic procedures was as follows: 284 minutes (LP), 156
minutes (radiology), and 136 minutes (antibiotic therapy). Antibiotic therapy is critical for
treatment of bacterial meningitis, and must be administered as quickly as possible (Schuh, 2013).
Bacterial and fungal meningitis is treated with appropriate antibiotics and supportive treatments,
and aseptic meningitis is treated with antiviral drugs and steroids. Vaccines are available to
prevent meningococcal, pneumococcal, and Haemophilus influenza meningitis, especially in
infants and children (Narayanan, 2012, p. 418). Adjunctive therapies that may be used are:
glycerol to decrease intracranial pressure, fluid management to achieve and maintain a

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normovolaemic state, antipyretics to reduce fever, and anticonvulsant therapy to prevent seizures.
Kidney function must be monitored in patients that developed septic shock. Additional CSF
testing should be performed if patient has not responded to antimicrobial therapy after 48 hours
(Von de Beek, 2012).
Discussion of Clinical relevance/application
As previously introduced, our example T.J was being treated for bacterial meningitis,
caused by Streptococcus pneumonia related to his ear infection. He was diagnosed after a
positive bacteria culture from a lumbar puncture. T.J. was prescribed vancomycin because of his
allergy to Penicillin, and also given corticosteroids to reduce swelling, acetaminophen to reduce
fever, and IV fluids for hydration. The nursing staff was continuously monitoring the patient for
the following: vital signs-heart rate and blood pressure will increase from the pain and fever,
neurological status (speech, hearing, and vision) because a change will indicate injury to that part
of the brain, level of conscience because its related to ICP, dehydration (especially if the patient
has been vomiting) by checking skin turgor and for orthostatic hypotension, and over-hydration
from IV fluids because it can cause cerebral edema. The nurse will also want to keep the lights
down because the patient can experience photophobia.
Gaps between Research and Practice
As evidenced by the 2013 study by S. Schuh, reported in The American Journal of
Emergency Medicine, the research wants medical professionals to get the patients on antibiotics
as quickly as possible. However, that is not always the case in the case in the clinical setting. In
some cases patients went over two hours without getting antibiotic treatment (Schuh, 2013). The
treatment that T.J. received was up to date. The patient received exactly what was needed for a

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positive outcome. The treatment that is described in research literature is straight forward, and
commonly followed in hospitals. There is much room for improvement pertaining to the
efficiency of diagnostic procedures. The most important aspect of treatment is antibiotics in
bacterial and fungal meningitis, and antivirals in viral meningitis. The quicker patients can
receive the proper antimicrobial pharmaceuticals, the better the prognosis.
Summary
Meningitis is a complex disease that is somewhat common and usually treatable.
Research shows that starting treatment as soon as possible is optimal for patient prognosis:
however, it often conflicted with clinical practice and reality. Inter-professional practice is the
key ingredient to the patients recovery.

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References
Boss, B. J. & Huether, S. E. (2012). Chapter 15 - Disorders of the Central and Peripheral
Nervous Systems and Neuromuscular Junction. In S. E. Huether & K. L. McCance
(Eds.), Understanding Pathophysiology (377 408). St. Louis, MO: Elsevier
Mosby.
Narayanan, V. (2012). Chapter 16 Alterations of Neurologic Function in Children.
In S. E. Huether & K. L. McCance (Eds.), Understanding Pathophysiology (409 - 425).
St. Louis, MO: Elsevier Mosby.
Schuh, S. (2013). Determinants of timely management of acute bacterial meningitis in the ED.
The American Journal of Emergency Medicine, 31, 1056-1061.
Von de Beek, D. (2012). Advances in treatment of bacterial meningitis. The Lancet, 380, 1693
1702.