World Health Organization · 1st edition, 2025 · 124 pages
Evidence-based recommendations for clinical management of acute community-acquired meningitis in children, adolescents and adults.
- Issuer
- World Health Organization
- Edition
- 1st edition, 2025
- Audience
- Clinicians in first- and second-level health facilities, policy-makers, programme managers, public health bodies, NGOs
- Evidence
- GRADE-rated recommendations based on systematic reviews; good practice statements based on consensus
- Reviewed
- 15 Oct 2026 · GMJ
What this guideline says
GMJ summary
These comprehensive WHO guidelines provide 20 evidence-based recommendations for diagnosis, treatment and long-term care of acute community-acquired meningitis in children over 1 month, adolescents and adults. Developed as part of the Defeating meningitis by 2030 global roadmap, they cover bacterial and viral meningitis in both epidemic and non-epidemic settings, with special emphasis on resource-limited contexts where the disease burden is highest.
Key diagnostic recommendations include performing lumbar puncture as soon as possible, conducting CSF investigations (Gram stain, cell count, protein, glucose), using PCR-based molecular tests, and performing cranial imaging only in specific at-risk groups (Glasgow Coma Score <10, focal signs, papilloedema, new seizures in adults, severe immunocompromise). For treatment, intravenous ceftriaxone or cefotaxime is recommended as first-line empiric therapy, with ampicillin/amoxicillin added for Listeria risk factors and vancomycin in areas with high pneumococcal resistance. Adjunctive corticosteroids should be given with antibiotics in non-epidemic settings but not during meningococcal epidemics.
The guidelines emphasize early intervention (the “1-hour window” for antibiotics), appropriate antimicrobial stewardship, and systematic follow-up for sequelae including hearing loss, neurological complications and disability. All recommendations follow GRADE methodology and were developed by a multidisciplinary panel including people with lived experience, with careful attention to feasibility in low-resource settings.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Perform lumbar puncture as soon as possible before antibiotics unless contraindicated (Glasgow Coma Score <10, focal signs, papilloedema, new seizures in adults, severe immunocompromise require imaging first)
- Empiric treatment: intravenous ceftriaxone or cefotaxime as first-line; add ampicillin/amoxicillin if age >60 years, pregnant, or immunocompromised (Listeria risk); add vancomycin in areas with high pneumococcal resistance
- Timing: administer antibiotics within 1 hour of admission; pre-hospital parenteral treatment should be considered only if bacterial meningitis strongly suspected and significant transfer delay expected
- CSF investigations: Gram stain, WBC count with differential, protein, glucose (with simultaneous blood glucose for ratio); consider lactate if no prior antibiotics; perform PCR-based molecular tests
- Adjunctive corticosteroids (dexamethasone, hydrocortisone or methylprednisolone): give with first antibiotic dose in non-epidemic settings; do NOT use routinely in meningococcal epidemics; use in pneumococcal epidemics
- Epidemic treatment duration: 5 days parenteral ceftriaxone for suspected meningococcal meningitis; 10 days for suspected pneumococcal meningitis
- Post-exposure prophylaxis: single-dose ceftriaxone (IM/IV) or oral ciprofloxacin for close contacts of meningococcal cases (rifampicin if others unavailable), given as soon as possible
- Follow-up: conduct formal audiological screening before discharge or within 4 weeks; assess for all sequelae; provide rehabilitation as soon as possible for identified complications
Specific antibiotic therapy for common causes of community-acquired acute bacterial meningitis
Table extracted from the guideline
| Pathogen | Susceptibility | Specific therapy | Overall duration |
|---|---|---|---|
| Streptococcus pneumoniae | Penicillin-susceptible | Penicillin G or ampicillin or amoxicillin | 10–14 days |
| Penicillin-resistant | Ceftriaxone or cefotaxime | 10–14 days | |
| Cephalosporin-resistant | Vancomycin + rifampicin, or Vancomycin + ceftriaxone/cefotaxime | 10–14 days | |
| Neisseria meningitidis | Penicillin-susceptible | Penicillin G or ampicillin or amoxicillin | 5–7 days |
| Penicillin-resistant | Ceftriaxone or cefotaxime | 5–7 days | |
| Haemophilus influenzae | Beta-lactamase-negative | Ampicillin or amoxicillin | 7–10 days |
| Beta-lactamase-positive | Ceftriaxone or cefotaxime | 7–10 days | |
| Streptococcus agalactiae | — | Penicillin G or ampicillin or amoxicillin | 14–21 days |
| Listeria monocytogenes | — | Penicillin G or ampicillin or amoxicillin | 21 days |
Source: World Health Organization, Guidelines on meningitis diagnosis, treatment and care. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- Supersedes 2014 WHO recommendations on meningitis outbreak response in sub-Saharan Africa
- Expands scope beyond epidemic settings to include comprehensive guidance for diagnosis, treatment and long-term care in all settings
- Introduces recommendations on cranial imaging criteria, molecular diagnostics, adjunctive corticosteroids by epidemic type, and systematic sequelae management
- Provides specific guidance for epidemic contexts caused by non-serogroup A Neisseria meningitidis and Streptococcus pneumoniae
- Incorporates GRADE methodology for all recommendations with explicit Evidence-to-Decision frameworks
From the guideline
Verbatim
“In children and adults with suspected acute meningitis admitted to an appropriate health-care facility, empiric intravenous antimicrobial treatment should be administered as early as possible.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Chair of the Public Health Institute of Georgia and a WHO consultant, I regard these guidelines as essential for Georgia's emergency and infectious disease response infrastructure. The most critical recommendation for our setting is the 1-hour window for empiric antibiotic administration with intravenous ceftriaxone or cefotaxime, which requires robust emergency protocols in both urban and rural facilities where access to tertiary care may be delayed. We must prioritize the guideline's emphasis on systematic audiological screening and rehabilitation follow-up, which aligns with Georgia's universal health coverage commitments but will require strengthening our rehabilitation service networks. The realistic implementation caveat is laboratory capacity: while Tbilisi and regional centres can perform CSF analysis and culture, molecular PCR diagnostics are not yet widely available, and we lack recent surveillance data on pneumococcal resistance patterns to inform decisions on empiric vancomycin use—gaps that our national programme must urgently address through laboratory network strengthening and antimicrobial resistance surveillance as outlined in Georgia's National Action Plan on AMR.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 15 Oct 2026
Applicability
Georgia and the South Caucasus
These guidelines are highly relevant for Georgia and the South Caucasus region, where sporadic bacterial meningitis cases occur and diagnostic and treatment capacity varies across primary, secondary and tertiary facilities. Georgia’s national immunization programme includes vaccines against Haemophilus influenzae type b and Streptococcus pneumoniae, which have reduced but not eliminated bacterial meningitis burden. Implementation will require ensuring availability of recommended antibiotics (ceftriaxone, cefotaxime, ampicillin, vancomycin) at all levels, establishing clear referral pathways for lumbar puncture and CSF analysis where not available at peripheral facilities, strengthening laboratory capacity for culture and PCR diagnostics, and developing systematic follow-up protocols for audiological screening and rehabilitation within the universal health coverage framework. National programmes should assess local antimicrobial resistance patterns for pneumococcus to determine whether empiric vancomycin is warranted, and ensure that the 1-hour treatment window can be operationalized in both urban and rural emergency settings.
Questions this guideline answers
Quick answers
When should I defer lumbar puncture in suspected meningitis?
Defer lumbar puncture if the patient has Glasgow Coma Score below 10, focal neurological signs, cranial nerve deficits, papilloedema, new-onset seizures (in adults), or severe immunocompromise—and perform cranial imaging first where accessible. If imaging not available, defer LP until these features resolve. Always start antibiotics immediately; do not delay treatment for imaging or deferred LP.
What is the first-line empiric antibiotic regimen for suspected bacterial meningitis?
Intravenous ceftriaxone or cefotaxime for all children (>1 month) and adults. Add IV ampicillin or amoxicillin if age >60 years, pregnant, or immunocompromised (Listeria risk). Add IV vancomycin in areas with known high prevalence of penicillin- or cephalosporin-resistant Streptococcus pneumoniae. Administer within 1 hour of admission.
Should I give corticosteroids with antibiotics?
Yes, give IV dexamethasone (or hydrocortisone/methylprednisolone) with the first antibiotic dose in non-epidemic settings when bacterial meningitis is suspected. Discontinue if CSF is not consistent with bacterial meningitis. During meningococcal epidemics, do NOT use corticosteroids routinely. During pneumococcal epidemics, DO give corticosteroids. Maximum duration is 4 days.
Which close contacts need antibiotic prophylaxis after a meningococcal case?
Give single-dose ceftriaxone (IM/IV) or oral ciprofloxacin (rifampicin if others unavailable) to household contacts and those with direct exposure to oral secretions or prolonged close proximity (<1 metre) during the 7 days before symptom onset until 24 hours after antibiotics started. Administer as soon as possible; benefit limited after 14 days.
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- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 1st edition, 2025
- Replaces
- Meningitis outbreak response in sub-Saharan Africa (2014, partial supersession)
- Status
- Current
- Published
- 2025-04-10
- Languages
- English
- Scope
- Acute community-acquired meningitis in children >1 month, adolescents and adults; bacterial and viral causes; epidemic and non-epidemic settings
- Audience
- Clinicians in first- and second-level health facilities, policy-makers, programme managers, public health bodies, NGOs
- Pages
- 124
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-4-010804-2
- Evidence
- GRADE-rated recommendations based on systematic reviews; good practice statements based on consensus
- Next review
- Not specified; evidence update planned as part of monitoring framework
- Record history
- Created 15 Oct 2026 · updated 15 Oct 2026 · next check Apr 2027
WHO guidelines on meningitis diagnosis, treatment and care. Geneva: World Health Organization; 2025. Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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