Treatment and investigations:

Blood cultures
Lumbar puncture (delay LP in case of severe respiratory/cardiac compromise or significant bleeding risk)*
Dexamethasone 10mg IV
Ceftriaxone or cefotaxime 2g IV immediately following LP* (see also alternative initial antibiotics)
CT scan normally not indicated
Careful fluid resuscitation (avoid fluid overload)

*If LP cannot be done in the first hour, antibiotics must be given immediately after blood cultures have been taken

Alternative initial antibiotics:

Penicillin/cephalosporin anaphylaxis
- Chloramphenicol 25mg/kg IV
Patient 60 years or older (not allergic) OR immunocompromised (including alcohol dependency and diabetes)
- Ceftriaxone or cefotaxime 2g IV plus amoxicillin 2g IV
Penicillin/cephalosporin anaphylaxis and 60 years or older or immunocompromised (including alcohol dependency and diabetes)
- Chloramphenicol 25mg/kg and co-trimoxazole 10-20mg/kg (of the trimethoprim component) in four divided doses
Recent travel/risk of penicillin resistant pneumococci
- Ceftriaxone/cefotaxime 2g IV plus vancomycin 15-20mg/kg IV or rifampicin 600mg PO/IV

Careful monitoring and repeated review is essential

Additional investigations:

Blood:

**unless a clotting defect is suspected, do LP without waiting for results

CSF (if LP performed):

Other: Throat swab - for meningococcal culture

Infection control

Source isolate all patients until meningococcal disease is excluded or ceftriaxone has been given for 24 hours (or a single dose of ciprofloxacin)
Notify microbiology

Public health

Notify all cases to the relevant public health authority for contact tracing, give antimicrobial prophylaxis and vaccination where necessary.