Treatment of Viral Meningitis

Immediate Management

Hydration with intravenous crystalloids to maintain euvolemia is recommended for patients with viral meningitis, as per Praxis Medical Insights 1

If herpes simplex virus (HSV) encephalitis cannot be excluded clinically, the American College of Physicians recommends intravenous acyclovir 10 mg/kg three times daily should be started within 6 hours of admission and continued pending CSF PCR results 2
For varicella-zoster virus (VZV) meningitis, intravenous acyclovir 10-15 mg/kg three times daily with renal dose adjustment is recommended by the Infectious Diseases Society of America 2
Treatment with acyclovir for HSV meningitis/encephalitis should continue for 14-21 days if HSV is confirmed, as suggested by the Centers for Disease Control and Prevention 2

Monitor renal function frequently during acyclovir therapy, as crystalluria-induced renal impairment occurs in up to 20% of patients, according to the National Institutes of Health 2
Assess for potential sequelae before discharge, including hearing loss, cognitive deficits, persistent headaches or fatigue, and psychological impacts, as recommended by the Journal of Infection 3

Discontinue empiric antibiotics once bacterial meningitis is definitively excluded by negative CSF Gram stain and culture, or negative bacterial PCR if performed, as per the Clinical Microbiology and Infection guidelines 4

Do not delay acyclovir if HSV cannot be excluded, as waiting for PCR results before starting treatment can worsen outcomes in HSV encephalitis, according to the American Academy of Neurology 2
Do not forget to assess for immunocompromise, as immunocompromised patients may require different management for broader viral pathogens, as suggested by the Infectious Diseases Society of America 2
Do not discharge without counseling, as patients and families should be informed about expected recovery timeline, potential sequelae, and when to seek re-evaluation, as recommended by the Journal of Infection 3