Neurologic examination should seek out focality that may be present in 25 percent of cases as well as for papilledema. An exam of the skin for purpura, petechiae, maculopapular rash, and signs of microembolization should be sought. It is unnecessary and inexcusable to delay the LP for any other procedure such as an imaging study. In very early bacterial meningitis there may only be a few hundred PMN, and moderately elevated protein, but the glucose will be depressed. With a presumptive diagnosis of bacterial meningitis, awaiting the results of gram stain, ceftriaxone 1 gram IV can be administered for coverage of the most common organisms.
Timely consultation is very important.
Once stabilized, arrangements should be made for transfer of the patient for further definitive care. When the patient has clinical signs of meningitis, but the spinal fluid has fewer than 500 WBC, predominantly lymphocytes, protein below 200, and normal CSF glucose, the gram stain will seldom show any bacteria. This is usually called aseptic meningitis, because of the absence of bacteria. Cultures still need to be taken in the event the patient has compromised reaction or the infection is still early. Antibiotics should usually not be initiated unless there is other evidence to suggest a bacterial infection.