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Bacterial Meningitis—Initial Therapy — UKMLA MCQ

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ModerateInfectious DiseasesBacterial Meningitis—Initial TherapyUKMLAMRCEM SBAMRCP Part 1PARAPSA

A 35-year-old immunocompetent man presents to the emergency department with strongly suspected bacterial meningitis. He is haemodynamically stable with a GCS of 15, no focal neurological deficit, no seizures and no purpuric rash. He has no severe antibiotic allergy or risk factors for Listeria monocytogenes. Lumbar puncture can be performed promptly without clinically significantly delaying treatment. Which is the most appropriate initial antibiotic and investigation strategy?

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Correct answer: B — Take blood cultures, perform lumbar puncture promptly, then start intravenous ceftriaxone within 1 hour of arrival

NICE recommends taking blood cultures and performing lumbar puncture before antibiotics when this is safe and will not cause clinically significant delay. Intravenous antibiotics must nevertheless start within 1 hour of hospital arrival; ceftriaxone is the empirical treatment when the organism is unknown. If lumbar puncture becomes delayed, ceftriaxone should be given first rather than withholding treatment. Routine CT is unnecessary without focal neurology, seizures, abnormal pupils, GCS 9 or less, or deteriorating consciousness. Amoxicillin alone does not provide appropriate empirical coverage; it is added to ceftriaxone when Listeria risk factors are present. Intravenous dexamethasone should be given with or before the first antibiotic dose when possible, but it is adjunctive and must never replace or delay antibiotics.

Reference: National Institute for Health and Care Excellence. NG240: Meningitis (bacterial) and meningococcal disease—recommendations 1.4.1, 1.4.6–1.4.10, 1.6.1–1.6.6 and 1.8.1–1.8.5. Published 2024; updated 2025. https://www.nice.org.uk/guidance/ng240/chapter/recommendations