CCFP priority topic 64 of 105
Meningitis on the CCFP exam
5 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 5 key features for Meningitis. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 5
Think of it
When a fever has no clear cause, think of meningitis, above all in high-risk patients.
CFPC skill Clinical reasoning, selectivityPhase Hypothesis generationSources Canadian Paediatric Society, Public Health Agency of Canada / NACI
On the exam
An 8-month-old with fever, a cold and a bulging eardrum, worse on amoxicillin. Expect a short menu (pick several from a list).
Pick the findings that point to meningitis.
Common mistakes
Stopping at the bulging eardrum, or ordering a chest film for the cold. Neither explains an infant who cries when lifted and settles lying still.
Approach
- A found source does not end the search. Ask if that source explains the whole picture.
- In infants, look for poor feeding, lethargy, vomiting, irritability or a rash. A stiff neck is often missing.
- Crying no one can settle, or lethargy that keeps getting worse, points to the brain or its lining.
- In older children, look for headache, neck pain or stiffness, and a drop in alertness.
- Raise your guard with missed Haemophilus influenzae type b (Hib) vaccines, a weak immune system, no working spleen, sickle cell disease, or HIV.
- Problems with complement (part of the immune system) count too, including drugs that block it, such as eculizumab and ravulizumab.
- So do a crowded home, smoke in the home, recent influenza, and travel to the African meningitis belt or the Hajj.
Key feature 2 of 5
The lumbar puncture
Once you suspect meningitis, get spinal fluid without delay.
CFPC skill SelectivityPhase InvestigationSources Canadian Paediatric Society
On the exam
A febrile infant cries when picked up but is awake, with no focal sign. Expect one best answer.
Pick the next step.
Common mistakes
A head scan, a magnetic resonance scan under sedation, or a brain wave test first. With no seizure or focal sign, each one only delays the puncture.
Approach
- Draw blood cultures before the first antibiotic dose.
- Do the puncture now if the patient is awake, with no focal sign and no new seizure.
- In children, scan first only for papilledema (swollen optic discs), new seizures, a focal deficit, or reduced consciousness.
- Hold the puncture for a bleeding problem, infected skin at the site, signs of brain herniation (brain shifting under pressure), or shock.
- Do not let a scan or a hard puncture hold up intravenous (IV) antibiotics.
- If no one can do the puncture, give antibiotics and transfer to a centre that can.
| Finding | Do first | Puncture |
|---|---|---|
| Awake, no focal sign, no new seizure | Blood cultures | Now. Antibiotics follow without waiting for results. |
| Papilledema, new seizures, a focal deficit, or reduced consciousness | Blood cultures, IV antibiotics, then a head scan | Once the scan shows it is safe |
| Bleeding problem, infected skin at the site, or shock | Blood cultures, IV antibiotics, stabilize | Once it is safe |
Key feature 3 of 5
Fluid after antibiotics
Read spinal fluid results with antibiotics already taken in mind, when you sort viral from bacterial.
CFPC skill Clinical reasoningPhase DiagnosisSources Canadian Paediatric Society
On the exam
Spinal fluid after 3 days of oral amoxicillin: raised white cells and a clear Gram stain. Expect one best answer.
Pick the next step.
Common mistakes
Calling it viral and stopping antibiotics because the Gram stain is clear after days of amoxicillin. If cultures are negative but the findings fit, treat it as bacterial.
Approach
- Ask about any antibiotic in the past days, and why. Oral courses for ear or throat infections are common.
- Send the fluid for cell count, glucose, protein and culture. Add viral studies.
- If cultures are negative and you still suspect bacteria, send a test for bacterial DNA.
- If cultures stay negative but the picture fits, keep ceftriaxone or cefotaxime. A clear stain is no reason to stop.
Key feature 4 of 5
Antibiotics first
Start intravenous antibiotics right away when bacterial meningitis is likely, before tests are back.
CFPC skill Selectivity, clinical reasoningPhase TreatmentSources Canadian Paediatric Society
On the exam
An 8-month-old with likely bacterial meningitis and a normal immune system. Expect one best answer for the first antibiotics.
Pick the first antibiotics, before cultures return.
Common mistakes
Restarting oral amoxicillin, which may not reach the spinal fluid, or giving acyclovir alone. The newborn regimen is wrong too: at 8 months, the germs differ.
Approach
- Give the first IV dose as soon as you suspect bacterial meningitis. Do not wait for a scan, the puncture or results.
- In children over 2 months: ceftriaxone or cefotaxime, plus vancomycin. Doses are in the table below.
- Add ampicillin only for an immunocompromised child, to cover Listeria.
- Under 3 months, think of E. coli and group B streptococcus as well.
- No IV line yet? Ceftriaxone can go into the muscle.
- Consider dexamethasone for likely Hib or pneumococcus. Stop it at 48 hours if neither is confirmed.
- Keep treatment IV. Usual length: meningococcus 5 to 7 days, Hib 7 to 10, pneumococcus 10 to 14.
| Drug | IV dose | Use |
|---|---|---|
| Ceftriaxone | 100 mg/kg/day split every 12 hours; max 4 g/day | With vancomycin |
| Cefotaxime | 300 mg/kg/day split every 4 to 6 hours; max 12 g/day | In place of ceftriaxone |
| Vancomycin | 60 mg/kg/day split every 6 hours | With the cephalosporin |
| Ampicillin | 300 mg/kg/day split every 4 to 6 hours; max 12 g/day | Add for an immunocompromised child |
| Dexamethasone | 0.6 mg/kg/day split every 6 hours | Before, with, or within 4 hours of the first antibiotic |
Key feature 5 of 5
Protect the contacts
Work with public health so everyone close to the patient gets preventive treatment.
CFPC skill Clinical reasoning, professionalismPhase TreatmentSources Public Health Agency of Canada / NACI, Canadian Paediatric Society
On the exam
An infant has meningococcal meningitis. The family asks who needs treatment. Expect a short menu (pick several from a list).
Pick the contacts who need prophylaxis.
Common mistakes
Leaving out a contact who had a meningococcal conjugate vaccine. Close contacts get antibiotics whatever their vaccines, and conjugate vaccines do not cover serogroup B (one strain type).
Approach
- Call public health as soon as you suspect it, so contact tracing starts. Ask about child care and school contacts.
- Close contacts: the household, anyone who shares where the patient sleeps, anyone exposed to mouth or nose secretions, and child care children and staff.
- Health workers count only after unprotected airway work, such as intubation or a close throat exam.
- The window runs from 7 days before symptoms began until 24 hours after effective treatment started.
- Give prophylaxis whatever the contact's vaccine history. Vaccine is added based on the serogroup.
- Hib: treat the whole household if it has one of these. An infant under 12 months who has not finished the first vaccine series. A child under 4 not fully vaccinated. An immunocompromised child.
- Ask public health which drug fits each contact, above all a pregnant one.
Flashcards
Answer it first, then check.
KF 1A febrile infant cries when picked up and settles lying still. What do you suspect?
Meningitis, even with a bulging eardrum. An ear infection does not explain pain on handling.
KF 2Awake infant, no seizure, no focal sign. Scan before the lumbar puncture?
No. Scan first only for papilledema, new seizures, a focal deficit or reduced consciousness. Source: Canadian Paediatric Society
KF 2No one can do the lumbar puncture tonight. What now?
Draw blood cultures, give IV antibiotics now, and transfer to a centre that can do it. Source: Canadian Paediatric Society
KF 3After oral amoxicillin, the Gram stain is clear and cultures are negative. Stop antibiotics?
No. If the blood or fluid findings still fit, treat it as bacterial meningitis. Source: Canadian Paediatric Society
KF 4Likely bacterial meningitis at 8 months, normal immune system. Which antibiotics?
IV ceftriaxone or cefotaxime, plus vancomycin. Add ampicillin only if the child is immunocompromised. Source: Canadian Paediatric Society
KF 4When should the first dose of dexamethasone go in?
Before, with, or within 4 hours of the first antibiotic dose. Earlier likely helps more. Source: Canadian Paediatric Society
KF 5A close contact had a meningococcal conjugate vaccine. Skip prophylaxis?
No. Close contacts get prophylaxis whatever their vaccines. Conjugate vaccines do not cover serogroup B. Source: Public Health Agency of Canada / NACI
KF 5How far back do you trace close contacts of meningococcal disease?
To 7 days before symptoms began, through 24 hours after effective treatment started. Source: Public Health Agency of Canada / NACI
FAQ
Which Canadian guideline covers children?
The Canadian Paediatric Society statement on bacterial meningitis. It dates from 2020 and was reaffirmed in 2026. It covers children over 2 months; younger infants follow newborn guidance.
What about adults?
No listed Canadian source covers adults. The scan rules, drug choices and doses on this page come from a children's guideline, so do not carry them to adults.
Why does a child with meningitis need a hearing test?
Meningitis can damage hearing. The Canadian Paediatric Society advises a formal hearing test soon after diagnosis, and always before the child leaves hospital.
The fever came back after dexamethasone stopped. Is that a new problem?
Not always. Fever can rebound when dexamethasone stops. If the child is otherwise getting better, fever alone does not call for more tests.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Position statements and practice pointsCanadian Paediatric Society
- Canadian Immunization GuidePublic Health Agency of Canada / NACI