Management of bacterial menigitis in 2016

Bacterial meningitis is a severe infection of the central nervous system with significant impact on survival and functional outcome. Complications are related to the release of bacterial components in the subarachnoid space closed to the brain. Three types of complications are distinguished: septic shock that alters the oxygen delivery, intracranial hypertension (ICH) that may alter the cerebralperfusion pressure and severe metabolic disorders like hyponatremia. The management is based on an early diagnosis allowing initiating antibiotics within the first hour. An associated corticosteroids treatment with dexamethasone improves the prognosis of pneumococcal and Haemophilus meningitis. The identification of septic shock signs should be rapid to initiate fluid bolus and sometimes vasopressors in order to maintain a good organ perfusion. The detection of altered level of consciousness is a crucial indication of ICH. Control of intracranial pressure (ICP) as well as a good hemodynamic is based on a continuous monitoring of ICP and arterial pressure in order to assure an adapted cerebral perfusion pressure. Cerebrospinalfluid (CSF) drainage is one of the most eflicient means to control ICP as resorption of CSF is often altered in bacterial meningitis. Seizures should be avoided, the sedation-pain control optimized and ventilation adapted to assure normal oxygenation and normal CO₂ levels. Hyponatremia is most often related to a salt wasting syndrome linked to aquaporin's deregulation. Its rapid correction is required to avoid worsening of the cerebral oedema.