Nursing Diagnosis Bacterial Meningitis: A Comprehensive Guide for Healthcare Professionals

Introduction

Meningitis, an inflammation of the protective membranes covering the brain and spinal cord known as the meninges, poses a significant global health challenge. While historical records detail symptoms of meningeal inflammation, it was surgeon John Abercrombie who formally defined ‘meningitis’ in 1828. Despite medical advancements in diagnosis, treatment, and prevention through vaccination, meningitis remains a serious condition. In 2015 alone, there were an estimated 8.7 million cases worldwide, resulting in 379,000 deaths. Bacterial meningitis, in particular, is a life-threatening infection requiring prompt recognition and intervention. This article delves into the nursing diagnoses associated with bacterial meningitis, providing a comprehensive guide for healthcare professionals to understand and manage this critical condition effectively.

Nursing Diagnoses for Bacterial Meningitis

Nurses play a pivotal role in the care of patients with bacterial meningitis. Based on the pathophysiology and clinical manifestations of the disease, several nursing diagnoses are pertinent. These diagnoses guide nursing interventions aimed at addressing the patient’s physiological and psychological needs, ultimately improving patient outcomes. Key nursing diagnoses associated with bacterial meningitis include:

Ineffective Tissue Perfusion (Cerebral) related to cerebral edema as evidenced by hypercapnia. Cerebral edema is a common and dangerous complication of bacterial meningitis, leading to decreased blood flow and oxygen supply to the brain tissue. Hypercapnia, or increased carbon dioxide in the blood, can be an indicator of impaired cerebral perfusion.
Hyperthermia related to infection as evidenced by body temperature above the normal range. Fever is a hallmark symptom of bacterial meningitis as the body mounts an immune response to the infection. Elevated body temperature can increase metabolic demands and exacerbate neurological symptoms.
Acute Pain related to increased intracranial pressure (ICP) as evidenced by headache. The inflammatory process in meningitis and subsequent cerebral edema contribute to increased ICP. Headache, often severe, is a prominent symptom resulting from this pressure.
Disturbed Sensory Perception related to altered sensorium as evidenced by decreased level of consciousness. Bacterial meningitis can directly affect brain function, leading to changes in sensory perception and consciousness. Alterations can range from mild confusion to coma.
Anxiety related to change in health status as evidenced by expressed concerns about hospitalization and illness severity. The sudden onset and severity of bacterial meningitis, coupled with hospitalization, can induce significant anxiety in patients and their families.
Deficient Knowledge related to lack of information exposure as evidenced by requests for information about medications, signs and symptoms, and necessary reporting behaviors. Patients and families often require comprehensive education about meningitis, its treatment, and necessary follow-up care to ensure optimal recovery and prevent recurrence.
Risk for Injury related to altered neurologic regulatory function. Neurological impairments from meningitis, such as seizures, weakness, and altered consciousness, significantly increase the risk of patient injury.
Impaired Physical Mobility related to nuchal rigidity, intravenous infusion, and potential use of restraining devices. Nuchal rigidity (stiff neck), a classic sign of meningitis, along with medical interventions like IV lines and restraints (if necessary for patient safety), can limit physical mobility.
Interrupted Family Processes related to the critical nature of the situation and uncertain prognosis. The acute and severe nature of bacterial meningitis impacts not only the patient but also their family. The uncertainty surrounding the illness and its potential long-term effects can disrupt normal family processes.
Ineffective Airway Clearance related to neuromuscular damage as evidenced by difficulty breathing. In severe cases, meningitis can lead to neuromuscular complications affecting respiratory muscles, potentially resulting in ineffective airway clearance.

Causes of Bacterial Meningitis

Bacterial meningitis is predominantly caused by infectious agents. Before the advent of antibiotics, this condition was almost invariably fatal. Even with modern medical interventions, bacterial meningitis still carries a significant mortality rate, close to 25%. While meningitis can also arise from non-infectious causes like autoimmune disorders, cancer, or drug reactions, bacterial infections remain the most common and critical etiology.

Common bacterial pathogens responsible for meningitis in the United States include:

Streptococcus pneumoniae: The most frequent cause of bacterial meningitis in adults, and a significant cause in children.
Group B Streptococcus: Primarily affects newborns.
Neisseria meningitidis: Known for causing outbreaks, particularly in crowded settings like college dormitories.
Haemophilus influenzae type b (Hib): Incidence has significantly decreased due to widespread Hib vaccination.
Listeria monocytogenes: More common in newborns, older adults, and immunocompromised individuals.

Less common but important bacterial causes to consider, especially in specific patient populations, include Staphylococcus aureus (in post-surgical patients or those with trauma), Mycobacterium tuberculosis (in immunocompromised individuals), Borrelia burgdorferi (in Lyme disease endemic areas), Treponema pallidum (in HIV/AIDS patients), and Escherichia coli (in neonates).

Risk Factors for Bacterial Meningitis

Several factors can increase an individual’s susceptibility to bacterial meningitis:

Chronic medical conditions: Renal failure, diabetes, adrenal insufficiency, and cystic fibrosis can weaken the immune system.
Age extremes: Infants and young children, as well as older adults, have a higher risk.
Lack of vaccination: Incomplete or absent vaccination against Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis increases risk.
Immunocompromised states: HIV/AIDS, congenital immunodeficiencies, transplant recipients, and individuals on immunosuppressive medications are more vulnerable.
Crowded living conditions: Military barracks and college dormitories facilitate the spread of respiratory pathogens.
Geographical exposure: Travel to endemic areas, such as the “meningitis belt” in sub-Saharan Africa or Lyme disease areas in the Northeastern US, can increase exposure.
Alcohol use disorder: Chronic alcohol abuse can impair immune function.
Medical devices: Presence of ventriculoperitoneal shunts or external ventricular drains can introduce infection.
Trauma and surgery: Penetrating head injuries, lumbar punctures, and cranial or spinal surgeries can breach protective barriers.
Other infections: Bacterial endocarditis can lead to secondary meningitis.
Dural defects: Congenital or acquired defects in the dura mater increase susceptibility.
Intravenous drug use: Introduces bacteria directly into the bloodstream.
Sickle cell anemia and Splenectomy: Impaired immune function in these conditions increases infection risk.

The incidence of bacterial meningitis in the United States is approximately 1.38 cases per 100,000 population annually, with a significant case fatality rate. The highest global incidence is observed in the “meningitis belt” of sub-Saharan Africa.

Assessment of Bacterial Meningitis

Clinical presentation of bacterial meningitis can vary based on age and immune status. Classic symptoms include fever, neck stiffness (nuchal rigidity), and photophobia (sensitivity to light). Other common but less specific symptoms are headache, dizziness, confusion, delirium, irritability, nausea, and vomiting. Signs of increased intracranial pressure, such as altered mental status, neurological deficits, and seizures, are ominous and suggest a poorer prognosis.

Risk factors that should heighten suspicion for meningitis include close contact exposures, incomplete vaccinations, immunosuppression, age extremes (under 5 years and over 65 years), and alcohol use disorder. A thorough history should include potential exposures, travel history, animal contact, neurosurgical history, recent head injury, sexual history, and seasonal factors (viral meningitis is more common in warmer months).

Physical examination in adults focuses on identifying focal neurological deficits, meningeal irritation signs (Brudzinski’s and Kernig’s signs), and characteristic skin lesions (petechiae and purpura), especially in meningococcal meningitis. Cranial nerve abnormalities occur in 10%-20% of patients.

In neonates and infants, symptoms can be subtle and non-specific, potentially including fever or hypothermia, poor feeding, altered mental status, irritability, and a bulging fontanelle. A detailed perinatal history and vaccination records are crucial in this age group.

Evaluation and Diagnosis

Diagnosis of bacterial meningitis relies on cerebrospinal fluid (CSF) analysis obtained through a lumbar puncture (LP). CSF is evaluated for white blood cell count, glucose and protein levels, bacterial culture, and sometimes polymerase chain reaction (PCR) tests. Measuring CSF opening pressure during LP can also provide valuable diagnostic information.

Additional CSF tests may be performed based on suspected etiology:

Viral meningitis: Multiplex and specific viral PCRs.
Fungal meningitis: CSF fungal culture and India ink stain for Cryptococcus.
Mycobacterial meningitis: CSF acid-fast bacilli smear and culture.
Syphilis: CSF VDRL test.
Lyme disease: CSF Borrelia burgdorferi antibody test.

Ideally, CSF should be collected before initiating antibiotics. However, in cases of suspected bacterial meningitis with severe illness, antibiotics should be started promptly, even before LP.

Computed Tomography (CT) Scan before Lumbar Puncture:

While historically there was concern that LP could precipitate brain herniation in patients with increased ICP due to bacterial meningitis, current guidelines prioritize rapid antibiotic administration and supportive care. LP may be deferred if there is clinical suspicion of increased ICP or impending herniation.

Signs and symptoms suggesting impending herniation include:

Glasgow Coma Scale (GCS) score less than 11.
Lethargy.
Altered mental status.
New-onset seizures.
Focal neurological deficits.

It’s crucial to recognize that a normal head CT does not rule out increased ICP or impending herniation. Clinical judgment remains paramount; if herniation is suspected, treatment should be initiated without LP, regardless of CT findings.

Blood work in meningitis evaluation should include blood cultures, serum electrolytes (to assess for SIADH), serum glucose, renal and liver function tests, and HIV testing as appropriate.

Alt text: Microscopic view of purulent meningitis, stained with Hematoxylin and Eosin, showing inflammation of the meninges.

Medical Management of Bacterial Meningitis

Prompt antibiotic therapy and supportive care are the cornerstones of bacterial meningitis management. Initial management focuses on stabilizing the patient by:

Maintaining a patent airway and ensuring adequate oxygenation.
Administering intravenous fluids to maintain hydration and blood pressure.
Managing fever with antipyretics.

Empirical antibiotic therapy is initiated based on the patient’s age and risk factors, aiming to cover the most likely bacterial pathogens. Specific antibiotic regimens include:

Empiric Therapy Guidelines:

Neonates (up to 1 month): Ampicillin IV plus cefotaxime (or ceftazidime/cefepime) IV, and acyclovir IV (to cover for herpes simplex virus).
Infants and Children (over 1 month): Ampicillin IV plus ceftriaxone IV.
Adults (18-49 years): Ceftriaxone IV plus vancomycin IV.
Adults (50+ years and immunocompromised): Ceftriaxone IV, vancomycin IV, and ampicillin IV (to cover Listeria).
Meningitis associated with foreign body/trauma: Cefepime, ceftazidime, or meropenem IV plus vancomycin IV.
Penicillin allergy: Moxifloxacin IV plus vancomycin IV.
Fungal (Cryptococcal) meningitis: Amphotericin B IV and flucytosine orally.

Key Antibiotics Used:

Ceftriaxone: A third-generation cephalosporin with excellent coverage against Streptococcus pneumoniae and Neisseria meningitidis and good CNS penetration.
Vancomycin: Effective against gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA) and resistant pneumococci.
Ampicillin: Provides coverage against Listeria monocytogenes.
Cefepime: A fourth-generation cephalosporin with broader gram-negative coverage, including Pseudomonas aeruginosa.
Cefotaxime: A third-generation cephalosporin similar to ceftriaxone, safe for neonates.

Steroid Therapy:

The role of corticosteroids in bacterial meningitis is debated. Some studies suggest a mortality reduction in Streptococcus pneumoniae meningitis with steroid use, but not consistently in other types. In children with Haemophilus influenzae meningitis, steroids may reduce the risk of hearing impairment. Current evidence does not support routine steroid use in all cases of bacterial meningitis.

Management of Increased Intracranial Pressure:

Signs of increased ICP necessitate interventions to maintain cerebral perfusion:

Elevating the head of the bed to 30 degrees.
Mild hyperventilation (in intubated patients).
Osmotic diuretics like mannitol 25% or hypertonic saline 3%.

Chemoprophylaxis:

Chemoprophylaxis is recommended for close contacts of patients with Neisseria meningitidis or Haemophilus influenzae type B meningitis. Close contacts include household members, intimate partners, those sharing utensils, and healthcare providers exposed to respiratory secretions. Chemoprophylaxis options for N. meningitidis include rifampin, ciprofloxacin, or ceftriaxone, and for H. influenzae type B, rifampin.

Nursing Management of Bacterial Meningitis

Nursing care is crucial in managing patients with bacterial meningitis and addresses the previously outlined nursing diagnoses. Key nursing interventions include:

Vital Signs Monitoring: Frequent monitoring and recording of vital signs are essential to detect changes in patient status.
Neurological Assessment: Regular Glasgow Coma Scale (GCS) assessments, particularly motor response, and mental status evaluations are critical. Any deterioration should be promptly reported.
Psychological Support: Provide emotional support to conscious patients and their families, addressing anxiety and fear.
Positioning: Elevate the head of the bed to 30 degrees with a neutral neck position to promote venous drainage and reduce ICP.
Intravenous Access: Ensure patent IV access for fluid and medication administration.
Medication Administration: Administer antibiotics and other prescribed medications (e.g., mannitol, phenytoin) as ordered and monitor for therapeutic effects and side effects.
Oxygen Therapy: Provide supplemental oxygen if oxygen saturation is low.
Seizure Precautions: Implement seizure precautions, including padded side rails, to ensure patient safety.
Pupillary Assessment: Regularly assess pupil size and reactivity to light to monitor for increased ICP.
Hearing Assessment: Assess hearing function, as hearing loss is a potential complication.
Laboratory Monitoring: Monitor relevant lab values, including electrolytes (for SIADH), renal and liver function tests, and CSF results.
Pressure Ulcer Prevention: For bedridden patients, implement pressure ulcer prevention strategies, such as 2-hourly position changes, air mattresses, and thromboembolic deterrent stockings.
Physical and Respiratory Therapy: Provide limb physiotherapy and chest physiotherapy to prevent complications of immobility.
Blood Glucose Monitoring: Check random blood glucose before lumbar puncture when CSF glucose is to be analyzed.
Nutritional Support: Ensure adequate caloric intake through a proper diet or nasogastric tube feeding for unconscious patients, as prescribed.
Fluid Balance Monitoring: Monitor intake and output to manage fluid balance and detect SIADH.
Comfort Measures: Provide comfort measures to alleviate symptoms such as headache and fever.

Alt text: Table depicting expected cerebrospinal fluid (CSF) findings in bacterial, viral, and fungal meningitis, highlighting key differences in WBC count, glucose, and protein levels.

When to Seek Immediate Medical Help

Patients and families should be educated about when to seek immediate medical attention:

Unresponsiveness
High-grade fever
New onset of mental status changes (confusion, lethargy)
Hypotension
Hypoxia
Bradycardia
Seizures
Severe headache

Outcome Identification and Prognosis

Prognosis for bacterial meningitis is significantly improved with prompt treatment. However, patients presenting with altered consciousness have a higher risk of morbidity and mortality. Complications can include seizures, neurological deficits, and long-term disabilities.

Factors associated with poorer outcomes include:

Advanced age
Low Glasgow Coma Scale score on presentation
Low CSF white blood cell count
Tachycardia
Presence of gram-positive cocci in CSF

Serious long-term complications in survivors may include ataxia, hearing loss, cranial nerve palsies, cognitive dysfunction, cortical blindness, hydrocephalus, seizures, and focal paralysis. Mortality rates are highest in infants under 12 months and increase again in older adults. Overall, bacterial meningitis carries a mortality rate of approximately 10%. Streptococcus pneumoniae and Listeria monocytogenes infections are associated with higher mortality. Meningococcal meningitis, if treated early, often has a better prognosis, but delayed presentation with meningococcemia carries a high mortality.

Monitoring and Ongoing Assessment

Continuous monitoring is essential throughout the course of bacterial meningitis treatment:

Regular vital signs assessment.
Frequent Glasgow Coma Scale scoring.
Monitoring medication dosages and timing.
Assessment of dietary intake and nutritional status.

Coordination of Care

Meningitis requires a multidisciplinary approach. Initial presentation is often in the emergency department, emphasizing the need for efficient interprofessional collaboration. Team members typically include:

Triage nurses (for rapid recognition and referral).
Emergency department clinicians.
Neurologists.
Pediatricians (for child patients).
Intensivists (for critically ill patients).
Infectious disease specialists.
Pharmacists (especially infectious disease specialists, for antibiotic selection and dosing).

Prompt antibiotic administration, even before definitive laboratory results, is critical. Pharmacists play a key role in antibiotic selection, considering patient age, local resistance patterns, and optimal CNS penetration.

Health Teaching and Health Promotion

Public education is vital for meningitis prevention. Healthcare professionals (nurses, physicians, pharmacists) should educate patients and parents about vaccine-preventable meningitis (Hib, S. pneumoniae, N. meningitidis, measles, varicella). Vaccination has significantly reduced meningitis incidence. Family members of patients with Neisseria or H. influenzae type B meningitis need education about prophylaxis. All close contacts should be informed about meningitis signs and symptoms and when to seek emergency care.

Additional health teaching includes:

Nutritional guidance: Emphasize a diet rich in antioxidants, omega-3 fatty acids, probiotics, and citrus fruits to support immune function.
Personal hygiene: Reinforce the importance of good hygiene practices.
Injury prevention: Advise against leaving patients with altered consciousness unattended to prevent falls and injuries.
Driving restrictions: Patients should avoid driving if experiencing blurred vision or as advised by their physician.
Nasogastric tube feeding education: For families caring for unconscious patients at home with NG tubes, provide thorough training on feeding techniques.

Risk Management and Prevention

Meningitis remains a high-risk condition. Effective risk management involves:

Early recognition of signs and symptoms by triage nurses and prompt referral.
Streamlined interprofessional care in the emergency department and inpatient settings.
Public health education on vaccination and prevention measures.

Discharge Planning

Discharge planning for patients recovering from bacterial meningitis should include:

Activity and Rest: Advise alternating rest and activity to manage fatigue.
Infection Control: Educate on home infection control measures.
Symptom Recognition: Instruct patients and families to recognize signs and symptoms of infection recurrence and when to seek prompt medical attention.
Healthy Lifestyle: Encourage a healthy diet, avoidance of alcohol and smoking.
Altitude Restrictions: Advise against high-altitude activities during recovery.
Social Support: Encourage patients to stay connected with family members for support.
Medication Adherence: Emphasize the importance of taking all prescribed medications as directed and not discontinuing without medical advice.

Pearls and Key Considerations

Differentiating between bacterial, viral, and fungal meningitis can be challenging initially. CSF analysis may not be immediately conclusive, and cultures take time. Given the potential severity of bacterial meningitis, empiric antibiotic therapy should be initiated promptly in suspected cases, and patients should be hospitalized under droplet precautions.

References

Chalimou I, Krilis A, Anastopoulou GG, Braun H, Vikelis M, Makridou A, Makris N, Argyriou AA. Acute aseptic meningitis during isotretinoin treatment for nodular acne solely presenting with headache: case report and brief review of the literature. Int J Neurosci. 2019 Feb;129(2):204-206. PubMed: 30160569
Ali M, Chang BA, Johnson KW, Morris SK. Incidence and aetiology of bacterial meningitis among children aged 1-59 months in South Asia: systematic review and meta-analysis. Vaccine. 2018 Sep 18;36(39):5846-5857. PubMed: 30145101
Giovane RA, Lavender PD. Central Nervous System Infections. Prim Care. 2018 Sep;45(3):505-518. PubMed: 30115337
Leonard A, Lalk M. Infection and metabolism – Streptococcus pneumoniae metabolism facing the host environment. Cytokine. 2018 Dec;112:75-86. PubMed: 30077545
Kasim N, Bagga B, Diaz-Thomas A. Intracranial pathologies associated with central diabetes insipidus in infants. J Pediatr Endocrinol Metab. 2018 Sep 25;31(9):951-958. PubMed: 30052518
Thigpen MC, Whitney CG, Messonnier NE, Zell ER, Lynfield R, Hadler JL, Harrison LH, Farley MM, Reingold A, Bennett NM, Craig AS, Schaffner W, Thomas A, Lewis MM, Scallan E, Schuchat A., Emerging Infections Programs Network. Bacterial meningitis in the United States, 1998-2007. N Engl J Med. 2011 May 26;364(21):2016-25. PubMed: 21612470
Sadeghi M, Ahmadrajabi R, Dehesh T, Saffari F. Prevalence of meningococcal carriage among male university students living in dormitories in Kerman, southeast of Iran. Pathog Glob Health. 2018 Sep;112(6):329-333. PMC free article: PMC6381525 PubMed: 30156971
Chauhan D, Mokta K, Kanga A, Grover N. Epidemiology, clinical profile and role of rapid tests in the diagnosis of acute bacterial meningitis in children (aged 1-59 months). Neurol India. 2018 Jul-Aug;66(4):1045-1049. PubMed: 30038091
Castelblanco RL, Lee M, Hasbun R. Epidemiology of bacterial meningitis in the USA from 1997 to 2010: a population-based observational study. Lancet Infect Dis. 2014 Sep;14(9):813-9. PubMed: 25104307
Güldemir D, Turan M, Bakkaloğlu Z, Nar Ötgün S, Durmaz R. [Optimization of real-time multiplex polymerase chain reaction for the diagnosis of acute bacterial meningitis and Neisseria meningitidis serogrouping]. Mikrobiyol Bul. 2018 Jul;52(3):221-232. PubMed: 30156509
Hussien MM, Ali-Eldin F, Adel LA. ASSESSMENT OF THE DIAGNOSTIC AND PROGNOSTIC ROLE OF CEREBEROSPINAL FLUID INTERLEUKIN-8 LEVEL IN ADULT PATIENTS WITH MENINGITIS. J Egypt Soc Parasitol. 2016 Aug;46(2):361-366. PubMed: 30152945
El Shorbagy HH, Barseem NF, Abdelghani WE, Suliman HA, Al-Shokary AH, Elsadek AE, Maksoud YHA, Sabri JH. The value of serum procalcitonin in acute meningitis in children. J Clin Neurosci. 2018 Oct;56:28-33. PubMed: 30143413
Reid S, Thompson H, Thakur KT. Nervous System Infections and the Global Traveler. Semin Neurol. 2018 Apr;38(2):247-262. PubMed: 29791951
Liu ZY, Wang GQ, Zhu LP, Lyu XJ, Zhang QQ, Yu YS, Zhou ZH, Liu YB, Cai WP, Li RY, Zhang WH, Zhang FJ, Wu H, Xu YC, Lu HZ, Li TS., Society of Infectious Diseases, Chinese Medical Association. [Expert consensus on the diagnosis and treatment of cryptococcal meningitis]. Zhonghua Nei Ke Za Zhi. 2018 May 01;57(5):317-323. PubMed: 29747285
Dretler AW, Rouphael NG, Stephens DS. Progress toward the global control of Neisseria meningitidis: 21st century vaccines, current guidelines, and challenges for future vaccine development. Hum Vaccin Immunother. 2018 May 04;14(5):1146-1160. PMC free article: PMC6067816 PubMed: 29543582
Brouwer MC, McIntyre P, Prasad K, van de Beek D. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015 Sep 12;2015(9):CD004405. PMC free article: PMC6491272 PubMed: 26362566
Edmond K, Clark A, Korczak VS, Sanderson C, Griffiths UK, Rudan I. Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis. Lancet Infect Dis. 2010 May;10(5):317-28. PubMed: 20417414
Munguambe AM, de Almeida AECC, Nhantumbo AA, Come CE, Zimba TF, Paulo Langa J, de Filippis I, Gudo ES. Characterization of strains of Neisseria meningitidis causing meningococcal meningitis in Mozambique, 2014: Implications for vaccination against meningococcal meningitis. PLoS One. 2018;13(8):e0197390. PMC free article: PMC6082507 PubMed: 30089105