Name
MENINGITIS, ACUTE BACTERIAL
DESCRIPTION
DETAIL
D.D. : A. ACUTE BACTERIAL MENINGITIS - BACTERIAL MENINGITIS LIKE MENINGOCOCCAL, PNEUMOCOCCAL, L.MONOCYTOGENES, STAPHYLOCOCCAL & GRAM NEGATIVE BACILLARY MENINGITIS B. INFECTIOUS CAUSES OF CHR MENINGITIS 1. COMMON BACTERIAL CAUSES - PARTIALLY TREATED SUPPURATIVE MENINIGITIS - PARAMENINGEAL INFECTION - MYCOBACTERIUM TUBERCULOSIS - LYME DISEASE ( BORRELIA BURGDORFERI ) - SYPHILIS ( SEC. & TERTIARY ) 2. UNCOMMON BACTERIAL CAUSES - ACTINOMYCES - NOCARDIA - BRUCELLA - WHIPPLES DISEASE ( TROPHEREMA WHIPPELII ) 3. RARE BACTERIAL CAUSES - LEPTOSPIROSIS - PSEUDOALLESCHERIA BOYDII. Turbid CSF . Neonates . > 10 WBCfs in CSF . CSF: blood glucose ratio < 0.6 . CSF protein >150 mg/dL (> 1500 mg/L) . Infants/children . > 5 WBCfs in CSF . CSF: blood glucose ratio < 0.6 . CSF protein > 50 mg/dL (> 500 mg/L) . Adults . 1000-100,000 WBCfs in CSF . CSF: blood glucose ratio < 0.4 . CSF protein > 45 mg/dL (usually 150-400 mg/dL) . Suspect ruptured brain abscess when WBC count is unusually high (> 100,000) . In all age groups: . CSF opening pressure > 180 mm H2O (1.77 kPa) . CSF Gram stain + in 75% of untreated patients . CSF culture + 70-80% of the time . Blood culture + 40-60% of the time . CSF bacterial antigen test (sensitivity varies) IMAGING • CT scan of head if concern for increased intracranial pressure (ICP) • Chest x-ray may reveal silent area of pneumonitis or abscess • Sinus/skull x-rays may reveal cranial osteomyelitis, paranasal sinusitis or skull fracture • Later in course, head CT scan, if hydrocephalus, brain abscess, subdural effusions or subdural empyema are considered DIAGNOSTIC PROCEDURES Lumbar puncture OTHER TESTS : * BLOOD EXAMI & BLOOD CULTURE TO ISOLATE INFECTIVE ORGANISM * X-RAYS - TO RULE OUT CHEST INFECTION, SINUSITIS & MASTOIDITIS * CSF CULTURE FOR BACTERIAL & FUNGAL GROWTH, GRAM STAINING & VDRL TEST * SERUM LYME ANTIBODY TITER & WESTERN BLOT TEST FOR CONFIRMATION OF LYME DISEASE * ANAEROBIC BLOOD CULTURE * INDIRECT HAEMAGGLUTINATION ASSAY IN CSF & ELISA TEST FOR CYSTICERCOSIS * MENINGEAL BIOPSY OR BIOPSY OF ANY UNUSUAL SKIN LESIONS OR ENLARGED LYMPH NODES.
TYPENOTES
RISK FACTORS: Immunocompromised host, Alcoholism, Neurosurgical procedure or head injury, Abdominal surgery for gram-negativeAPPROPRIATE HEALTH CARE Inpatient often in ICU. If diagnosis is suspected, lumbar puncture should be done in offi ce with antimicrobial therapy begun before transfer to hospital. GENERAL MEASURES • Appropriate antibiotic therapy • Vigorous supportive care with constant nursing to ensure prompt recognition of seizures and prevention of aspiration • Therapy for any coexisting conditions • Measures to prevent hypothermia and dehydration ACTIVITY As tolerated in hospital and on discharge DIET Regular as tolerated, except when SIADH complicates course DRUG(S) OF CHOICE . Empiric IV therapy until culture results available (consider local patterns of bacterial sensitivity). See Causes for age definitions and likely organisms. . Treatment duration: . N. meningitides , H. influenzae : 7-10 days . S. pneumoniae : 10-14 days . Group B Streptococcus , E. coli , L. monocytogenes : 14-21 days . Neonates 12-21 days or at least 14 days after a repeat culture is sterile . The following regimens are somewhat simplified but will adequately treat all patients while awaiting culture results. Additional subgroupings may simplify treatment in certain patients. Penicillin allergic patients present a special challenge not covered here. . Corticosteroids. For all ages > 1 month and < 50 years corticosteroids decrease mortality and morbidity. Dexamethasone 0.15 mg/kg q6h, started 15-20 minutes before or with the antibiotic x 4 days. (N Engl J Med 324:1525, 1991) . Antibiotics . Children and adults - (1) Ceftriaxone 100 mg/kg/d q12h (max 2 gm q12h) OR cefotaxine 200 mg/kg/d q4h OR - (2) Ampicillin 400 mg/kg/d q4h (max 2 gm q4h) and vancomycin 10 mg/kg q12h (max 1500 mg q12h) . Neonates - ampicillin 100-400 mg/kg/d q6-12h and tobramycin 7.5 mg/kg/d q6h (2.5 mg/kg q12h for premature or infants < 1 week of age) . Age > 1 month - ampicillin 400 mg/kg/d q4h (max 2 gm q4h) and chloramphenicol 75 mg/kg/d q6h ALTERNATIVE DRUGS • Antipseudomonal penicillins • Aztreonam • Quinolones (e.g., ciprofloxacin) • Meropenem PATIENT MONITORING Brainstem auditory evoked response (BAER) test should be done with infants prior to hospital discharge. Further followup will depend on its results and course of meningitis while in hospital. PREVENTION/AVOIDANCE . Prompt medical treatment for infections . Strict aseptic techniques when treating patients with head wounds or skull fractures . Look for evidence of CSF fi stula in patients with recurrent meningitis POSSIBLE COMPLICATIONS . Seizures (20-30% during course of illness) . Focal neurologic deficit . Cranial nerve palsies (III, VI, VII, VIII) 10-20% of cases, usually disappear within a few weeks . Sensorineural hearing loss (10% in children) . Neurodevelopmental sequelae (subtle learning deficits 30%) . Obstructive hydrocephalus . Subdural effusions EXPECTED COURSE/PROGNOSIS . Overall case fatality 14% . H. influenza 5% . Neisseria meningitidis 10% . Streptococcus pneumoniae 25%
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
VDRL, MONTOUX TEST, URINE ROUTINE, X-RAY CHEST P.A. VIEW( NORMAL ), BLOOD CULTURE, CT SCAN HEAD, COMPLETE BLOOD COUNT, CSF EXAMINATION, PCR, ELISA TEST