What are the warning signs of bacterial meningitis?

The classic triad is fever, neck stiffness, and altered mental state — but only about 40% of people have all three. About 95% have at least two of four features: fever, neck stiffness, altered mental state, or severe headache. Other warning signs include photophobia, vomiting, seizures, and focal neurological deficits. In meningococcal disease, a non-blanching petechial or purpuric rash often appears on the legs and trunk — press a glass against it to confirm it does not fade. Paediatric signs include a bulging fontanelle, high-pitched cry, irritability, poor feeding, and hypotonia.

Why must antibiotics be given before a lumbar puncture?

Bacterial meningitis progresses rapidly — neurological damage from untreated infection can occur within hours. Waiting for imaging or a lumbar puncture before giving antibiotics introduces a delay that worsens outcomes significantly. The current approach is: take blood cultures quickly if this does not delay the antibiotic by more than a few minutes, then give ceftriaxone immediately. The lumbar puncture can follow safely once the patient is in hospital, after a CT scan has excluded contraindications such as focal neurological signs or elevated intracranial pressure.

Who needs dexamethasone with the antibiotics?

Dexamethasone given immediately before or with the first antibiotic dose reduces neurological complications and hearing loss in adults with pneumococcal meningitis. The landmark De Gans NEJM 2002 trial showed reduced unfavourable outcomes and death when dexamethasone was used. The adult dose is 10 mg IV; paediatric dose is 0.15 mg/kg IV. It is given empirically at first contact and can be stopped once the causative organism is identified if evidence of benefit is less clear for that pathogen (for example, meningococcal disease).

What do household contacts need after a meningococcal case?

Close contacts of someone with confirmed meningococcal disease — household members, intimate partners, and others who have shared saliva within the previous seven days — require chemoprophylaxis within 24 hours to prevent secondary cases. Options are rifampicin 600 mg twice daily for two days, a single 500 mg dose of ciprofloxacin, or a single 250 mg intramuscular dose of ceftriaxone (preferred in pregnancy). The state or territory Public Health Unit coordinates contact tracing and can advise on vaccination for contacts.

What monitoring is needed after recovery from bacterial meningitis?

Audiology review at four to six weeks post-discharge is standard, as around 30% of survivors have some degree of sensorineural hearing loss. A three-month neurological and cognitive review is appropriate. Follow-up blood tests depend on the clinical picture. A Mental Health Care Plan is often valuable — adjustment difficulties, anxiety, depression, and cognitive complaints are common after meningitis. Vaccination gaps identified after recovery should be addressed. If recurrent meningitis occurs, investigations for immune deficiency or an anatomical communication between the subarachnoid space and a sinus or middle ear are warranted.

Bacterial meningitis

Bacterial meningitis: urgent recognition and management in AU general practice

By Dr HB Lo, FACRRM Reviewed 22 August 2026 8 min read

Bacterial meningitis is a medical emergency — bacterial infection of the meninges — carrying 10–30% mortality and permanent sensorineural hearing loss in one in three survivors. Recognise the classic signs (fever, neck stiffness, altered consciousness, non-blanching rash), give intravenous ceftriaxone 2 g plus dexamethasone 10 mg within 30 minutes, and arrange category-1 transfer — do not delay antibiotics for imaging or lumbar puncture. Meningitis is a mandatory notifiable disease; close contacts need antibiotic chemoprophylaxis, and Australia's NIP vaccines (Hib, Prevenar 13, MenACWY, 4CMenB) have substantially reduced incidence.

What bacterial meningitis is

Bacterial meningitis is infection of the meninges — the three protective membranes surrounding the brain and spinal cord. Bacteria reach the subarachnoid space most commonly via the bloodstream from a respiratory source, and set off an intense local inflammatory response that causes cerebral oedema, raised intracranial pressure, and neurological injury. Without treatment, the process progresses to permanent damage or death within hours.

Therapeutic Guidelines and the ESCMID 2016 guideline classify community-acquired bacterial meningitis by organism, age group, and immune status. The most common organisms in Australian adults are Streptococcus pneumoniae (approximately 50%), Neisseria meningitidis (approximately 25%, declining with vaccination), and Listeria monocytogenes (in people over 50, pregnant women, and those who are immunocompromised).

A. Core clinical — the AU general-practice framework

Presentation

The classic triad of fever, neck stiffness, and altered mental state occurs together in only about 40% of people. However, about 95% of people with confirmed bacterial meningitis have at least two of four features: fever, neck stiffness, altered mental state, or severe headache. Other common features include photophobia, vomiting, and seizures. Focal neurological signs occur in around 25% of cases.

Meningococcal rash — a petechial or purpuric non-blanching rash, often appearing first on the lower limbs and trunk — indicates meningococcaemia. The glass test (pressing a glass firmly against the skin to see whether the rash blanches) helps identify non-blanching lesions in good lighting. A petechial rash in the context of fever and systemic illness should be treated as meningococcaemia until proved otherwise.

Paediatric presentation differs importantly from adult presentation: infants may show a bulging fontanelle, high-pitched cry, paradoxical irritability (crying more when handled), poor feeding, hypotonia, and apnoea — without classical neck stiffness.

Kernig and Brudzinski signs (physical signs of meningeal irritation) can be absent, particularly in early disease, in immunocompromised patients, and in the elderly.

Which organisms to think about by age group

Neonates under one month: Group B streptococcus (S. agalactiae), E. coli, Listeria monocytogenes.
Infants and children 1 month to 2 years: S. pneumoniae, N. meningitidis, Haemophilus influenzae type b (now rare with NIP Hib vaccination).
Children 2–18 years: N. meningitidis, S. pneumoniae.
Adults under 50: S. pneumoniae, N. meningitidis.
Adults over 50, immunocompromised, or pregnant: add Listeria monocytogenes.

GP management — the 30-minute window

Step 1 — Recognise and call 000. Fever plus meningism or altered mental state = bacterial meningitis until proved otherwise. Category-1 ambulance. Pre-notify the receiving emergency department.

Step 2 — Give empirical antibiotics and dexamethasone within 30 minutes. Do not delay for imaging or lumbar puncture.

For adults aged 1 month to 50 years, immunocompetent:

Ceftriaxone 2 g IV (or cefotaxime 2 g IV) is the cornerstone.
Add vancomycin if cephalosporin-resistant pneumococcus is possible (recent travel, prior antibiotics, paediatric patient).
Dexamethasone 10 mg IV immediately before or with the first antibiotic dose — De Gans NEJM 2002 showed reduced unfavourable outcomes and death in pneumococcal meningitis.

For adults over 50, immunocompromised, or pregnant:

Add benzylpenicillin 2.4 g IV every four hours or amoxicillin 2 g IV every four hours to cover Listeria.

For neonates:

Ampicillin plus cefotaxime plus gentamicin (covers Group B streptococcus, Listeria, and Gram-negative organisms).

Suspected meningococcal sepsis with rash and hypotension:

Do not wait for a lumbar puncture. Give IV ceftriaxone, IV fluid resuscitation, and category-1 transfer immediately.

Suspected HSV encephalitis (fever plus confusion plus focal features):

Add aciclovir 10 mg/kg IV every eight hours if herpes encephalitis cannot be excluded.

Step 3 — IV access, bloods, and stabilisation. Take blood cultures before antibiotics if this does not cause any delay. Perform FBC, CRP, procalcitonin, electrolytes, glucose, coagulation, and HIV serology. Establish IV access for fluid resuscitation.

Lumbar puncture: who needs CT first?

CT before lumbar puncture is needed in patients who have:

Focal neurological deficit
GCS at or below 12
New-onset seizures
Immunocompromise
Papilloedema
History of central nervous system lesion or surgery

In an alert patient without these features, lumbar puncture can proceed without CT. The key principle from both eTG and IDSA 2017 is that antibiotics are given before lumbar puncture, never after, and the lumbar puncture is never the reason to delay antibiotics.

Bacterial CSF profile: white cell count very high (often above 1,000) with neutrophil predominance; glucose below 40% of serum; protein above 1.0 g/L; lactate above 3.5 mmol/L. Culture yield decreases after antibiotics but PCR (meningococcal, pneumococcal) remains useful.

Public health mandatory notification and contact tracing

All cases of bacterial meningitis from notifiable pathogens must be reported to the state or territory Public Health Unit. Notification timelines:

Meningococcal: immediate (phone notification within 24 hours in all states and territories).
Invasive pneumococcal disease: 24-hour notification in most jurisdictions.
Haemophilus influenzae, Listeria invasive disease: 24-hour notification.

For meningococcal disease, chemoprophylaxis for close contacts must be arranged within 24 hours. Close contacts are household members, intimate partners, and people who have shared saliva in the preceding seven days. Prophylaxis options per eTG: rifampicin 600 mg twice daily for two days; single-dose ciprofloxacin 500 mg; or single-dose ceftriaxone 250 mg IM (preferred in pregnancy). The Public Health Unit coordinates tracing and vaccination advice for contacts.

B. Evidence supporting immediate dexamethasone

The use of dexamethasone before or with the first antibiotic dose is one of the most consistently supported interventions in bacterial meningitis management. De Gans and van de Beek (NEJM 2002) randomised 301 adults with suspected bacterial meningitis to dexamethasone or placebo, finding reduced unfavourable neurological outcomes (15% vs 25%) and reduced mortality (7% vs 15%), particularly in pneumococcal disease.

The mechanism is suppression of the inflammatory cascade in the subarachnoid space — the cytokine storm drives cerebral oedema and vascular injury more than the bacteria directly. Dexamethasone is therefore most effective when given before or simultaneously with antibiotics that trigger bacterial lysis.

Evidence is somewhat less robust in meningococcal and Listeria meningitis, but empirical use before pathogen identification remains standard practice because the benefit in pneumococcal disease is substantial and the risks of dexamethasone in a short 4-day course are low. The ESCMID 2016 guideline recommends continuing dexamethasone until pneumococcal meningitis is confirmed or excluded, then reassessing.

C. Differential diagnosis

Condition	Key discriminating feature
Viral meningitis (enterovirus, HSV-2)	Less severe course; CSF shows lymphocytic predominance with normal glucose; PCR positive
HSV encephalitis	Focal neurology and behavioural change more prominent than meningism; HSV PCR in CSF
Subarachnoid haemorrhage	Thunderclap headache maximal at onset; CT showing blood in basal cisterns; xanthochromia on LP
Cerebral abscess	Focal neurology; ring-enhancing lesion on CT/MRI; no LP until imaging
Sepsis without meningitis	Identifiable source; no meningism; normal CSF
TB meningitis	Subacute onset over days to weeks; basal meningeal enhancement; lymphocytic CSF with very low glucose; high-risk groups (immunocompromise, refugee background, elderly)
Cryptococcal meningitis	Immunocompromised (HIV, post-transplant); India ink positive; cryptococcal antigen
Drug-induced aseptic meningitis	History of NSAIDs, IVIG, or lamotrigine
Autoimmune encephalitis (anti-NMDA receptor, LGI1)	Subacute psychiatric features; seizures; normal or lymphocytic CSF; autoimmune antibodies

D. Australian operations

NIP vaccination schedule

ATAGI’s Australian Immunisation Handbook covers the following meningitis-relevant NIP vaccines:

Hib vaccine (included in DTPa-hepB-IPV-Hib) — 6 weeks, 4 months, 6 months, with 18-month booster. Hib meningitis is now rare in vaccinated cohorts.
Pneumococcal vaccines (Prevenar 13 at 6 weeks, 4 months, with 12-month booster; Prevenar 20 for high-risk adults; PPV23 for people 65 and over plus medical risk groups).
MenACWY (Menactra, Nimenrix, or MenQuadfi) — 12 months and 14–16 years via the school program.
4CMenB (Bexsero) — NIP-funded for Aboriginal and Torres Strait Islander infants and selected high-risk groups; privately available for others at approximately $300 per dose, not on the NIP for the general population.

MBS items

GP attendances: item 23 Level B, item 36 Level C. Post-meningitis complex care: GPCCMP items 965 and 967. MHCP items 2715 and 2717. ATSI health assessment item 715. CT brain item 56001.

PBS

Ceftriaxone, benzylpenicillin, amoxicillin, vancomycin, and aciclovir are hospital-supplied IV formulations. For chemoprophylaxis, rifampicin is Authority Required for meningococcal prophylaxis; ciprofloxacin is on general schedule. Cochlear implants and hearing aids for deafness post-meningitis are accessed via the Hearing Services Program or NDIS.

E. Special populations

Aboriginal and Torres Strait Islander Australians. Rates of invasive bacterial disease including pneumococcal and meningococcal meningitis are higher in Aboriginal and Torres Strait Islander communities. ATAGI recommends expanded pneumococcal vaccination for Aboriginal and Torres Strait Islander infants (including the 6-month Prevenar 13 dose) and a lower threshold for empirical antibiotic treatment. 4CMenB is NIP-funded for Aboriginal and Torres Strait Islander infants. Coordinate via Aboriginal Community Controlled Health Organisations (ACCHOs) for follow-up and vaccination catch-up.

Immunocompromised patients. Those with HIV, post-organ transplant, on biologic therapy, post-splenectomy or with functional asplenia, or on corticosteroids are at significantly higher risk of bacterial meningitis and Listeria in particular. Classic meningism may be absent in these patients. A lower threshold for investigation and empirical treatment is warranted. Add Listeria cover (amoxicillin or benzylpenicillin) regardless of age in immunocompromised patients.

Pregnancy. Pregnancy increases Listeria susceptibility 17-fold compared with the general population. Listeria meningitis in pregnancy carries risk of miscarriage, preterm birth, and foetal infection. Amoxicillin or benzylpenicillin must be added to cover Listeria. Ceftriaxone (250 mg IM) is preferred for chemoprophylaxis in pregnant contacts over rifampicin and ciprofloxacin.

Elderly patients. Classical meningism may be absent or subtle. Listeria becomes more common in people over 50. Confusion, lethargy, and fever may be the only features.

When to escalate

All cases of suspected bacterial meningitis require emergency department transfer by category-1 ambulance. Do not manage bacterial meningitis in the general practice setting beyond the immediate stabilisation period. Escalate immediately for:

Any suspicion of bacterial meningitis — do not wait for results to confirm
Meningococcal sepsis with haemodynamic instability
Paediatric presentations — lower threshold for transfer
Petechial or purpuric rash with fever and systemic illness
Post-meningitis: new neurological symptoms, fever, deteriorating hearing or cognition warrant urgent re-assessment

What this article is and is not

This is general health information drawing on Therapeutic Guidelines, the ATAGI Immunisation Handbook, ESCMID 2016, and IDSA 2017 guidelines. It does not constitute personal medical advice. Treatment decisions — antibiotic choice, dexamethasone dose, investigation sequence, and contact tracing — require input from the treating team and public health authorities.

Consumer resources: Meningitis Centre Australia, HealthDirect — Meningitis, Better Health Channel, ATAGI vaccine information.

For medical emergencies: call 000.

Sources cited

Frequently asked questions

What are the warning signs of bacterial meningitis?

The classic triad is fever, neck stiffness, and altered mental state — but only about 40% of people have all three. About 95% have at least two of four features: fever, neck stiffness, altered mental state, or severe headache. Other warning signs include photophobia, vomiting, seizures, and focal neurological deficits. In meningococcal disease, a non-blanching petechial or purpuric rash often appears on the legs and trunk — press a glass against it to confirm it does not fade. Paediatric signs include a bulging fontanelle, high-pitched cry, irritability, poor feeding, and hypotonia.
Why must antibiotics be given before a lumbar puncture?

Bacterial meningitis progresses rapidly — neurological damage from untreated infection can occur within hours. Waiting for imaging or a lumbar puncture before giving antibiotics introduces a delay that worsens outcomes significantly. The current approach is: take blood cultures quickly if this does not delay the antibiotic by more than a few minutes, then give ceftriaxone immediately. The lumbar puncture can follow safely once the patient is in hospital, after a CT scan has excluded contraindications such as focal neurological signs or elevated intracranial pressure.
Who needs dexamethasone with the antibiotics?

Dexamethasone given immediately before or with the first antibiotic dose reduces neurological complications and hearing loss in adults with pneumococcal meningitis. The landmark De Gans NEJM 2002 trial showed reduced unfavourable outcomes and death when dexamethasone was used. The adult dose is 10 mg IV; paediatric dose is 0.15 mg/kg IV. It is given empirically at first contact and can be stopped once the causative organism is identified if evidence of benefit is less clear for that pathogen (for example, meningococcal disease).
What do household contacts need after a meningococcal case?

Close contacts of someone with confirmed meningococcal disease — household members, intimate partners, and others who have shared saliva within the previous seven days — require chemoprophylaxis within 24 hours to prevent secondary cases. Options are rifampicin 600 mg twice daily for two days, a single 500 mg dose of ciprofloxacin, or a single 250 mg intramuscular dose of ceftriaxone (preferred in pregnancy). The state or territory Public Health Unit coordinates contact tracing and can advise on vaccination for contacts.
What monitoring is needed after recovery from bacterial meningitis?

Audiology review at four to six weeks post-discharge is standard, as around 30% of survivors have some degree of sensorineural hearing loss. A three-month neurological and cognitive review is appropriate. Follow-up blood tests depend on the clinical picture. A Mental Health Care Plan is often valuable — adjustment difficulties, anxiety, depression, and cognitive complaints are common after meningitis. Vaccination gaps identified after recovery should be addressed. If recurrent meningitis occurs, investigations for immune deficiency or an anatomical communication between the subarachnoid space and a sinus or middle ear are warranted.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.

T1 AU primary 8 sources
T2 International primary 2 sources
- ESCMID 2016 Bacterial Meningitis Guidelines
- IDSA 2017 Bacterial Meningitis Guideline
T3 Named-author reconstruction 1 source
- De Gans J et al. Dexamethasone in adults with bacterial meningitis — NEJM 2002