Acute fever and headache is a common clinical problem but clinicians need to remain vigilant with a high index of suspicion for acute bacterial meningitis. Even when the diagnosis is suspected clinically, the subsequent investigation and management is controversial. We discuss the diagnosis and management of these patients relevant to the acute medicine physician. The initial assessment should include severity assessment, as appropriate help can then be obtained early. In the absence of signs of raised ICP, shock, or respiratory failure, a diagnostic LP should be performed. If LP has to be deferred, CSF obtained up to 48 hours after antibiotics have been initiated may still lead to a diagnosis by PCR. Where LP is contraindicated, or it is anticipated that there will be a delay of more than 30 minutes, a dose of 2 g of intravenous cefotaxime or ceftriaxone should be given immediately. Brain imaging is not indicated in the majority of patients. Early treatment with appropriate antibiotics, fluid resuscitation, and management of raised intracranial pressure are key to improving patient outcome. Empirical antibiotic regimens should be guided by the age of the patient and risk factors for resistant pathogens. Microbiological advice should be sought early if there is any uncertainty. Adjunctive dexamethasone therapy for suspected bacterial meningitis should be administered either before or at the time of antibiotic administration.
