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Meningitis

Meningitis. Hai Ho, MD Department of Family Practice Riverside County Regional Medical Center. Easy Concept. Treat empirically with medications that kill the organisms involved Therefore, if you know the organisms involved, you could choose the right medications. Organisms involved.

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Meningitis

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  1. Meningitis Hai Ho, MD Department of Family Practice Riverside County Regional Medical Center

  2. Easy Concept Treat empirically with medications that kill the organisms involved Therefore, if you know the organisms involved, you could choose the right medications

  3. Organisms involved • Bacteria • Viruses • Fungi • Parasites

  4. The most common organisms involved in meningitis? Depend on the age and the clinical situations

  5. Neonates to 2 months of age4,7? • Viruses • Herpes Simplex • Enteroviruses • Cytomegalovirus (CMV) • Bacteria • Group B Streptococcus • Escherichia Coli • Listeria monocytogenes

  6. Listeria monocytogenes4,5 • Risk groups • Extreme age • Impaired immunity • Pregnancy • Presentations • Subacute • Ataxia and myoclonic seizure – small abscesses in cerebellum and brainstem • Treatment – aminoglycoside (poor CSF penetration) synergistic with ampicillin

  7. Antibiotics for infants 0 to 2 months of age? Third-generation cephalosporins (cefotaxime or ceftriaxone) Ampicillin

  8. Should corticosteroid be used in meningitis4? • Controversial • Reduce deafness in children with H. influenza • Give before or at the time of initiation of antibiotics x 2 to 4 days • Lack evidences of beneficial effects in adults

  9. Greater than 3 months to 60 years of age? Streptococcus pneumoniae Neisseria meningitidis

  10. Antibiotics for patients greater than 2 months to 60 years of age? Third-generation cephalosporins (cefotaxime or ceftriaxone) Vancomycin

  11. Vancomycin4,5 • Not to use as monotherapy because of its poor CSF penetration • Added to cover resistant pneumococci • If corticosteroid is used, need to add rifampin because corticosteroid decrease CSF penetration of vancomycin

  12. Greater 60 years of age Streptococcus pneumoniae Neisseria meningitidis Listeria monocytogenes

  13. Antibiotics for patients greater than 60 years of age? Third-generation cephalosporins (cefotaxime or ceftriaxone) Vancomycin Ampicillin

  14. Special Cases

  15. Nosocomial meningitis • Most cases from neurosurgical procedures or CSF shunt placement • Common bacteria • Gram negative rods: E. Coli, Klebsiella, pseudomonas, Acinotobacter, Enterobacter, Serratia species • Staphylococci: Staphylococcus aureus, staphylococcus epidermidis

  16. Antibiotics for nosocomial meningitis4,5 • Ceftazidime or cefepime and Vancomycin • Imipenem • Resistant Gram negative rods • Associated with seizure • Aminoglycoside • Indicated in patients with poor response to IV antibiotics • Intrathecal

  17. Aseptic meningitis8 CSF analysis not consistent with bacterial infection

  18. Infectious aseptic meningitis9,10? • Viruses • Bacteria – mycobacterium tuberculosis, treponema pallidum, borerrelia burgdorferi • Fungi – cryptococcus neoforman, coccidioides immitis, histoplamacapsulatum • Parasites

  19. Non-infectious aseptic meningitis? • Drugs • Penicillin • Trimethoprim/sulfamethoxazole • NSAIDs • Carbamezepine • Granuloma • Neoplasm • Idiopathic

  20. Treatment for aseptic meningitis? • Viral causes • Mainly supportive care • Enterovirus • Most common • Diverse group of RNA viruses including coxsackieviruses, echoviruses, and polioviruses • HIV – anti-HIV meds, but most resolve spontaneously • Herpes simplex – acyclovir • CMV – ganciclovir (not approved for CNS) • Syphilis – Penicillin G • Fungi – amphotericin • Tuberculosis – Isoniazid, pyazinamide, rifampin, steptomycicin, ethambutol

  21. Clinical Presentations

  22. Clinical presentations in children? Nonspecific General toxic appearance Fever Decreased PO intake Decreased alertness

  23. Clinical presentations in adults? • Classic triad • Fever, neck stiffness, and altered mental status • Fever is the most sensitive, followed by neck stiffness • Mental status • High sensitivity – normal rules out meningitis in low-risk patients • More common in bacterial than viral meningitis • Kernig and Brudzinski - Low sensitivity but high specificity • Jolt accentuation of headache – negative test excludes meningitis

  24. Diagnostic tests4,5? • Lumbar puncture • Head CT prior to lumbar puncture • Should NOT delay treatment – blood culture and antibiotics • Indicated if patients have altered mental status, focal neurological deficits, and signs of intracranial pressure such as papilledema

  25. CSF analysis True CSF WBC = Measured CSF WBC x (1 – CSF RBC  blood RBC) In bloody tap, if WBC/RBC in CSF < that of blood

  26. Bacterial invasion of CNS Ventriculitis Leptomengitis CSF flow resistance IL1 & TNF production Endothelial injury Increased ICP Vascular thrombosis Increased blood brain barrier permeability Decreased blood flow Cerebral edema Cerebral hypoxia Infarction Glycolysis Seizure Abscesses Increased CSF lactate Decreased CSF glucose Increased CSF protein

  27. CSF analysis • Bacterial antigens by counterimmunoelectrophesis and latex agglutination – helpful when patients are already on antibiotics • Culture • PCR for viruses and tuberculosis • VDRL

  28. Repeat CSF analysis4? • Consider in all infants and children with bacterial meningitis – 24-36 hours after treatment • Adults • Penicillin-resistant pneumococci or Gram negative rod • Poor clinical response

  29. Complications of meningitis? • Seizure • Subdural effusion • 20-30% of infants with meningitis • Commonly with H. influenza type b & pneumococcal meningitis • Drain only with neurological symptoms from mass effect • Subdural empyema – drainage & prolonged antibiotics • Hearing loss • SIADH – very cautious with fluid restriction because cerebral vascular autoregulation is compromised in meningitis • Loss of cognitive functions

  30. Prevention of meningitis4 • Vaccines • H. influenzae in children • Chemoprophylaxis • Rifampin x 4 days • Neisseria meningitidis • Index case to eradicate pharyngeal carriage • Members in same household • Prolonged close contacts • Direct exposure to respiratory secretion (suction, intubation) • Haemophilus influenzae type b • Children <4 years of age with close contact • All household members with children < 4 years of age

  31. References • Smith AL. Bacterial Meningitis. Pediatrics in Review 1993;14:11-18. • Attia J, et al. Does This Adult Patients Have Acute Meningitis? • Uchihara T, Tsukagoshi H. Jolt Accentuation of Headache: the Most Sensitive Sign of CSF Pleocytosis. Headache 1991; 31: 167-171. • Thomas F. Prevention and Treatment of Bacterial Meningitis. www.uptodate.com 2002. • Mathisen GE. Bacterial Meningitis: 11 Questions Physicians Often Ask. Consultant 2001. • Wubbel L, McCracken GH. Management of Bacterial Meningitis: 1998. Pediatrics in Review 1998;19:78-84. • Prober CG. Central Nervous System Infections. In: Behrman ER, ed. Textbook of Pediatrics. Philadelphia: W.B Saunders Company; 2000:751-757. • Ryan ME, Brendlinger J, Scott T, Metrishyn L. Aseptic Meningitis. Cortlandt Forum 2000.

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