World Health Organization · 1st edition, 2026 · 34 pages
Step-by-step clinical and public health guidance for recognising, diagnosing and treating bacterial meningitis during outbreaks and routine settings.
- Issuer
- World Health Organization
- Edition
- 1st edition, 2026
- Audience
- Medical doctors, nurses and other frontline clinicians in primary, secondary and tertiary facilities; particularly relevant for meningitis belt and humanitarian settings
- Evidence
- Based on WHO Guidelines on meningitis diagnosis, treatment and care (2025); expert consensus for operational guidance
- Reviewed
- 15 Oct 2026 · GMJ
What this guideline says
GMJ summary
This comprehensive toolkit translates WHO’s 2025 meningitis guidelines into practical job aids for frontline clinicians managing bacterial meningitis, particularly during outbreaks in high-risk settings including the African meningitis belt and humanitarian emergencies. It covers the full clinical pathway from initial presentation through diagnosis, antibiotic therapy, adjunctive treatment, supportive care and post-exposure prophylaxis for children over 1 month, adolescents and adults.
The core message emphasises rapid treatment initiation: start intravenous empiric antibiotics within 1 hour of admission and do not delay for diagnostic procedures. Outside epidemics, the recommended empiric regimen is IV ceftriaxone or cefotaxime (2 g every 12 hours in adults; 50 mg/kg every 12 hours in children), adding ampicillin for those over 60 years, pregnant or immunocompromised (Listeria risk), and vancomycin in settings with documented pneumococcal resistance. During confirmed meningococcal epidemics, ceftriaxone monotherapy for 5 days is appropriate; during pneumococcal epidemics, continue for 10 days.
The toolkit provides detailed algorithms for lumbar puncture decision-making (absolute contraindications: ongoing haemodynamic/respiratory compromise, severe bleeding disorder, skin infection at puncture site; relative contraindications: GCS <10, focal signs, papilloedema, new seizures in adults), CSF interpretation, antibiotic selection based on isolated pathogens, and adjunctive dexamethasone use (10 mg every 6 hours in adults; 0.15 mg/kg every 6 hours in children for up to 4 days, except during meningococcal outbreaks or when cerebral malaria or cryptococcal meningitis cannot be excluded).
Key points
For clinicians — doses and thresholds as stated in the guideline
- Start IV empiric antibiotics within 1 hour of admission; never delay treatment for lumbar puncture or imaging
- Empiric regimen outside epidemics: ceftriaxone 2 g IV every 12 hours (adults) or 50 mg/kg every 12 hours (children); add ampicillin if age >60 years, pregnant or immunocompromised
- Do not perform lumbar puncture if ongoing haemodynamic/respiratory compromise, severe bleeding disorder, or skin infection at puncture site; defer if GCS <10, focal signs, papilloedema or new seizures (adults)
- During confirmed meningococcal disease epidemics: ceftriaxone monotherapy for 5 days; consider single-dose outpatient protocols with 24- and 48-hour review if resources limited
- Adjunctive dexamethasone 10 mg IV every 6 hours (adults) or 0.15 mg/kg every 6 hours (children) with first antibiotic dose, continuing up to 4 days—but not during meningococcal outbreaks or if cerebral malaria/cryptococcal meningitis possible
- CSF findings suggestive of bacterial meningitis: cloudy/turbid appearance, WBC >100–10 000/mm³ with neutrophil predominance, CSF:blood glucose ratio <0.4, total protein >45 mg/dL
- Pre-referral treatment only if transfer delay >30 minutes: single IM/IV ceftriaxone dose 2 g (adults) or 50 mg/kg (children)
- Post-exposure prophylaxis for meningococcal disease close contacts: single-dose ciprofloxacin 500 mg PO (adults) or 20 mg/kg (children, max 500 mg), or ceftriaxone 250 mg IM (adults) or 125 mg IM (children)
Specific antibiotic therapy by confirmed pathogen (during and outside epidemics)
Table extracted from the guideline
| Pathogen | Specific antibiotic therapy (IV) | Total duration |
|---|---|---|
| Streptococcus pneumoniae (penicillin-susceptible) | Penicillin G / Ampicillin / Amoxicillin | 10–14 days |
| Streptococcus pneumoniae (penicillin-resistant) | Ceftriaxone / Cefotaxime | 10–14 days |
| Streptococcus pneumoniae (cephalosporin-resistant) | Vancomycin + Ceftriaxone/Cefotaxime or Vancomycin + Levofloxacin/Moxifloxacin or Vancomycin + Rifampicin or Rifampicin + Ceftriaxone/Cefotaxime | 10–14 days |
| Neisseria meningitidis (penicillin-susceptible) | Penicillin G / Ampicillin / Amoxicillin | 5–7 days |
| Neisseria meningitidis (penicillin-resistant) | Ceftriaxone / Cefotaxime | 5–7 days |
| Listeria monocytogenes | Penicillin G / Ampicillin / Amoxicillin | 21 days |
| Streptococcus agalactiae | Penicillin G / Ampicillin / Amoxicillin | 14–21 days |
| Haemophilus influenzae (beta-lactamase-negative) | Ampicillin / Amoxicillin | 7–10 days |
| Haemophilus influenzae (beta-lactamase-positive) | Ceftriaxone / Cefotaxime | 7–10 days |
Source: World Health Organization, Preparedness and response to bacterial meningitis outbreaks: toolkit for frontline healthcare workers. Reproduced in summary form.
From the guideline
Verbatim
“Start IV empiric antibiotic therapy as soon as possible and within 1 hour of admission to an appropriate health-care facility.”
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 recognise that bacterial meningitis remains a high-case-fatality emergency in our region, where delays in diagnosis and treatment—particularly in rural areas—contribute to preventable deaths and severe neurological sequelae. This toolkit's most critical message for Georgian clinicians is the absolute imperative of starting antibiotics within one hour of presentation, before any diagnostic procedure; we must abandon the outdated practice of waiting for lumbar puncture or transfer before treatment. The detailed algorithms for empiric regimen selection are directly applicable to Georgia, but we urgently need national data on pneumococcal resistance to third-generation cephalosporins to determine whether vancomycin should be added routinely—currently this surveillance gap leaves clinicians uncertain. The pre-referral treatment protocols are particularly relevant for our mountainous regions where transfer times to Tbilisi or regional infectious disease centres often exceed 30 minutes, and we should train rural GPs and ambulance paramedics in single-dose IM ceftriaxone administration to reduce door-to-antibiotic time across the country.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 15 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia and neighbouring South Caucasus countries are not within the African meningitis belt but face sporadic bacterial meningitis cases and potential for localised outbreaks, particularly in congregate settings (military barracks, universities, refugee centres). The toolkit is directly applicable to Georgian emergency departments, infectious disease hospitals and district health facilities. National programmes should assess local pneumococcal resistance patterns to third-generation cephalosporins and penicillins to determine whether routine addition of vancomycin to empiric regimens is warranted; Georgia’s National Centre for Disease Control should establish sentinel AST surveillance if not already in place. The emphasis on rapid antibiotic initiation (door-to-antibiotic time <1 hour) and not delaying treatment for diagnostics aligns with Georgian emergency care protocols. Pre-referral treatment algorithms are particularly relevant for rural Georgia where transfer times to regional infectious disease centres may exceed 30 minutes. Post-exposure prophylaxis protocols for meningococcal disease contacts should be incorporated into communicable disease surveillance and response plans, with clear definitions of 'close contacts' adapted to Georgian household structures and social practices.
Questions this guideline answers
Quick answers
When should I delay lumbar puncture in suspected bacterial meningitis?
Never delay treatment, but defer lumbar puncture if the patient has ongoing haemodynamic or respiratory compromise (until stabilized), severe bleeding disorder, or skin/epidural infection near the puncture site (absolute contraindications). Also defer if GCS <10, focal neurological signs, cranial nerve deficits, papilloedema, new-onset seizures (adults), or severe immunocompromise (relative contraindications); perform cranial imaging first if readily accessible, or reassess when features resolve.
Should I give pre-referral antibiotics before transferring a patient to another hospital?
Only if acute bacterial meningitis is strongly suspected and door-to-door transfer time will exceed 30 minutes. Give a single dose of ceftriaxone 2 g IV/IM (adults) or 50 mg/kg IV/IM (children), adding ampicillin if age >60, pregnant or immunocompromised. Do not give pre-referral antibiotics routinely or if transfer can be completed within 30 minutes.
When should I use adjunctive dexamethasone in bacterial meningitis?
Start dexamethasone 10 mg IV every 6 hours (adults) or 0.15 mg/kg every 6 hours (children) with the first antibiotic dose outside epidemics, continuing up to 4 days. Do not use during meningococcal disease outbreaks, if cerebral malaria is possible (even if test negative, interpret with caution in endemic areas), if cryptococcal meningitis is suspected (HIV, advanced immunocompromise), or in people with advanced HIV disease. Stop if bacterial meningitis is ruled out.
What antibiotic regimen should I use during a confirmed meningococcal disease outbreak?
Use ceftriaxone monotherapy: 2 g IV every 12 hours (adults) or 50 mg/kg IV every 12 hours (children) for a total of 5 days. If inpatient completion is not feasible and the patient is clinically stable, consider once-daily outpatient ceftriaxone (up to 4 g in adults; 100 mg/kg in children). In resource-limited settings where a 5-day course is impractical, single-dose protocols may be used if the person can be reviewed at 24 and 48 hours.
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- Issuer
- World Health Organization
- Type
- Guidance (normative)
- Edition
- 1st edition, 2026
- Status
- Current
- Published
- 2026-04-28
- Languages
- English (original)
- Scope
- Acute community-acquired bacterial meningitis in children >1 month, adolescents and adults; includes considerations for viral, tuberculous and cryptococcal meningitis
- Audience
- Medical doctors, nurses and other frontline clinicians in primary, secondary and tertiary facilities; particularly relevant for meningitis belt and humanitarian settings
- Pages
- 34
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- Based on WHO Guidelines on meningitis diagnosis, treatment and care (2025); expert consensus for operational guidance
- Record history
- Created 15 Oct 2026 · updated 15 Oct 2026 · next check Apr 2027
World Health Organization. Preparedness and response to bacterial meningitis outbreaks: toolkit for frontline healthcare workers. Geneva: World Health Organization; 2026. 34 p. 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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