# Suspected Meningitis (Emergency Referral) - Category: infectious - Review status: reviewed (every claim checked against a document named on this page) - Sources: Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, Meningitis and Other CNS Infections: IV 2 g every 12 hours) · Egyptian National Drug Formulary - Antimicrobial 2023 (chloramphenicol monograph, Serious infections including bacterial meningitis) · NICE Guideline NG240: Meningitis (bacterial) and meningococcal disease 2024 - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, Meningitis and Other CNS Infections: IV 2 g every 12 hours) - Egyptian National Drug Formulary - Antimicrobial 2023 (chloramphenicol monograph, Serious infections including bacterial meningitis) ## Treatment metadata - Ceftriaxone — 1000 mg — injection - Chloramphenicol — 1000 mg — injection ## Complete treatment card ```text SUSPECTED MENINGITIS (EMERGENCY REFERRAL) Sources: Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, Meningitis and Other CNS Infections: IV 2 g every 12 hours) · Egyptian National Drug Formulary - Antimicrobial 2023 (chloramphenicol monograph, Serious infections including bacterial meningitis) · NICE Guideline NG240: Meningitis (bacterial) and meningococcal disease 2024 Review status: REVIEWED against the source listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (7) - Most look acutely ill when they arrive; viral or fungal cases seem less toxic even with headache, fever and a stiff neck [fever · headache · neck stiffness] - Presentation runs to a pattern: a creeping course over days of worsening headache and fever before meningeal signs, typical of pneumococcus [fever · headache] - Or classic symptoms building over a day or two, as with Haemophilus influenzae type B, or septic shock and collapse within hours, as with meningococcus [collapse · shock] - Core symptoms are fever, a stiff neck and dislike of light, with headache, dizziness, confusion, delirium, irritability and vomiting alongside [confusion · dizziness · fever · headache · irritability · neck stiffness · photophobia · vomiting] - Red flag: altered consciousness, neurological deficits and seizures mark raised pressure in the skull and a worse outlook [seizures] - Babies show less: fever or a low temperature, feeding poorly, lethargy, sleeping too much, irritability, or a bulging fontanelle [bulging fontanelle · fever · irritability · lethargy · poor feeding] - A telling infant sign is distress on being handled with calm when left alone SIGNS - what you find (6) - Beyond the newborn period, examination hunts focal neurological deficits and meningeal irritation through the Brudzinski and Kernig signs [neck rigidity on testing] - Brudzinski sign: bending the neck makes the hips flex by reflex, though it is not often seen [neck rigidity on testing] - Kernig sign is commoner: with the hip flexed, straightening the knee causes pain or resistance past 135 degrees [neck rigidity on testing] - Neither sign proves the diagnosis nor rules it out, but they justify going further - Examine all the skin: petechiae or purpura suggest meningococcus, but also appear in other severe illness with clotting failure [petechiae · purpura · rash] - A cranial nerve abnormality appears in roughly 10% to 20% of patients [cranial nerve palsy] TESTS (12) - Only cerebrospinal fluid confirms it; the history and examination raise the suspicion - Send the fluid for Gram stain, white cell count, glucose, protein and culture, with PCR or rapid molecular testing where available - Measure the opening pressure at lumbar puncture whenever it can be done - Tests and scans support the diagnosis but must never hold up the first dose of antibiotic - Take the fluid before antibiotics if you can, but in a severely ill patient with suspected bacterial meningitis treat first; PCR still finds the organism afterwards - Scan the head first only for: consciousness below GCS 10, past CNS disease, a seizure in the last week, a focal deficit, papilloedema, severe immunosuppression, or comorbidity over the age of 60 - Without those features, scanning before the tap only delays treatment and costs money without making it safer - A normal scan does not exclude raised pressure or coning: if the signs suggest it, skip the tap and treat regardless of the pictures - Blood tests: cultures, electrolytes because inappropriate ADH secretion is common, glucose, and kidney and liver function - Suspected viral cause: multiplex and targeted PCR for West Nile and other arboviruses, herpes viruses, mumps and measles - Cryptococcal disease: latex agglutination or lateral flow on the fluid is now the reference test, with India ink only if nothing else is available - TB: acid-fast smear plus culture, a PCR such as GeneXpert or Xpert Ultra, and TB LAMP where available; syphilis needs a CSF VDRL IF NOT THIS - what else fits (10) - Encephalitis can imitate it and can be present at the same time, which makes them hard to separate - Severe rheumatological disease with vasculitis can look identical, though such patients are also at risk of real infection - A stroke - Subdural haematoma - Subarachnoid haemorrhage - A primary brain tumour - Secondary deposits in the brain - Brain abscess, which may sit alongside meningitis - Vasculitis - Migraine Score WHO Emergency Triage (sick child) - Is this sick child safe to wait? Source StatPearls "Meningitis" - disease-level clinical article Status traced to the source above 1. CEFTRIAXONE [1st line] Adult 2 g IV. The formulary's meningitis regimen is 2 g every 12 hours; what is given before transfer is the first dose of it. Do not delay the transfer to give it - First dose before transfer; the course is continued in hospital Peds The formulary gives no single pre-hospital dose for a child. Its meningitis regimen is 100 mg/kg/day divided every 12 to 24 hours, maximum 4,000 mg/day; for premature and term neonates, 50 mg/kg/dose IV or IM every 24 hours. A single dose before a long transfer is a prescriber's decision, not a figure that can be cited here. Below 1 month, cefotaxime is preferred over ceftriaxone to avoid displacing bilirubin. AWaRe WATCH group - carries resistance cost. Egyptian EML 2025. Source Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, Meningitis and Other CNS Infections: IV 2 g every 12 hours) Why Third-generation cephalosporin with good central nervous system penetration, covering the meningococcal and pneumococcal pathogens of bacterial meningitis; given pre-hospital only when it will not delay the transfer that is the real priority. Caution The transfer comes first. NG240 says give ceftriaxone or benzylpenicillin as soon as possible outside hospital UNLESS that delays getting the patient there. For strongly suspected bacterial meningitis, as opposed to meningococcal disease with a rash, give it outside hospital only if the delay in transfer is going to be clinically significant. LIFE-THREATENING EMERGENCY: Transfer immediately to hospital emergency department via emergency ambulance. Give pre-hospital antibiotic (ceftriaxone) immediately if meningococcal disease (non- blanching rash) or bacterial meningitis is suspected, unless it delays transfer. Do not delay hospital transfer to perform lumbar puncture or diagnostic investigations in primary care. NG240 names benzylpenicillin alongside ceftriaxone and it is often the one actually to hand outside a hospital. If benzylpenicillin is what is in the bag, it is a legitimate choice under the same recommendation. The 2 g is the formulary's meningitis dose, which it gives as 2 g every 12 hours by the intravenous route. The single-dose, intramuscular pre-hospital framing is practice, not something any document consulted here states - NG240 itself names no doses at all and refers to the BNF, which is not reachable from Egypt. Egypt ZOXIDEL 1 GM PD. FOR I.M. INJ. RAMEDA > DELT... 22.00 EGP CEFTRIAXONE SODIUM 1 GM I.M.VIAL (KAHIRA) KAHIRA 29.00 EGP ZOXIDEL 1 GM PD. FOR I.V. INJ. RAMEDA > DELT... 29.00 EGP WINTRIAXONE 1 GM PD. FOR I.V INJ. SANOFI 48.00 EGP VOTRIAXONE 1 GM I.M VIAL CHEMIPHARM 56.00 EGP OFRAMAX 1 GM I.M. VIAL RAMEDA > SUN ... 71.00 EGP TRIAXONE 1 GM I.M. VIAL TABUK PHARMAC... 106.00 EGP TRIAXONE 1 GM I.V VIAL TABUK PHARMAC... 106.00 EGP 2. CHLORAMPHENICOL [2nd line] Adult IV: 50 to 100 mg/kg/day in divided doses every 6 hours, maximum 4 g daily, with plasma concentration monitoring. The formulary gives no single pre-hospital dose - A hospital regimen; there is no sourced single dose to give before transfer Peds Neonates: 25 mg/kg DAILY, given in 4 equally divided doses every 6 hours - about 6.25 mg/kg per dose, not 25 mg/kg at once. Beyond the neonatal period: 50 mg/kg daily in 4 divided doses, or 50-100 mg/kg daily in 4 divided doses for severe infection, maximum 4,000 mg/day. Adjust to plasma concentrations of 15-25 mcg/mL in children; above 25 mcg/mL is toxic. Source Egyptian National Drug Formulary - Antimicrobial 2023 (chloramphenicol monograph, Serious infections including bacterial meningitis) Why Chloramphenicol IV is the established pre-hospital alternative for patients with a clear history of anaphylaxis to penicillins or cephalosporins. Caution The formulary's 25 mg/kg is a neonatal DAILY total split over four doses, not a single dose, and it gives no 1.2 g single adult dose. Chloramphenicol causes fatal aplastic anaemia and grey syndrome - read the figures against the monograph before prescribing. Intravenous only. The Egyptian formulary states chloramphenicol given intramuscularly does not reach effective concentrations - in the one situation it is listed for, it would be no treatment at all. With no IV access, transfer without it. NG240 is against giving anything outside hospital in this situation: do not give antibiotics outside of hospital if the person has severe allergy to ceftriaxone or benzylpenicillin. Chloramphenicol appears in that guideline only as an in-hospital option on infection-specialist advice. It is listed here because a long transfer from outside Cairo is a different problem from a London ambulance ride - but it is a departure from NG240 and should be a considered one. Reserved for patients with severe anaphylactic allergy to beta-lactam antibiotics. Emergency hospital transfer remains mandatory. The formulary's chloramphenicol dosing is a monitored hospital regimen - divided doses every 6 hours with plasma levels. It is not written for a single dose given before a transfer, and no source reachable gives one. If you give a dose before transferring a doubly-allergic patient, that is your decision and it is outside anything that can be cited here. Egypt CIDOCETINE SUCCINATE 1GM VIAL CID 5.00 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)