An adult with fever, neck stiffness, and photophobia. What is the initial step in management?

• A. Emergent empiric intravenous antibiotics after obtaining blood cultures and performing a lumbar puncture if not contraindicated
• B. CT scan first
• C. Oral antibiotics
• D. Reassurance

Answer: (A)

Suspected bacterial meningitis requires urgent action. The priority is to diagnose quickly and start broad-spectrum therapy without delay, because this condition can progress rapidly and cause major harm.

The initial steps are to obtain blood cultures immediately and perform a lumbar puncture to analyze the CSF if there are no contraindications. After those cultures are drawn and LP is performed (if it’s safe and feasible without delaying treatment), initiate emergent intravenous antibiotics that cover the common pathogens in adults (eg, vancomycin plus a third-generation cephalosporin, with dexamethasone added in appropriate cases). Do not delay antibiotic therapy for imaging.

CT scanning before LP is reserved for patients with signs suggesting mass effect or other contraindications to LP; otherwise, it delays treatment and is not the first step here. Oral antibiotics or reassuring the patient are inappropriate for suspected meningitis.