Bacterial Meningitis
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Transcript of Bacterial Meningitis
Bacterial Meningitis
Athit Wutthisanwatthana
Acute purulent infection within the subarachnoid space
Etiology
50
25
15
10
Streptococcus pneumoniae
Neisseria meningitidis
Group B streptococci
Listeria monocytogenes
Community-Acquired Bacterial Meningitis
#1 in age > 20 years Predisposing conditions
#1 Streptococcal pneumonia Acute/chronic pneumococcal sinusitis/otitis media Alchoholism Diabetes Complement deficiency Head trauma with basilar skull fracture and CSF
rhinorrhea Mortality ~20%
Streptococcus pneumoniae
Petechial or purpuric lesion is important clue Some is fulminant Initiated by nasopharyngeal colonization
Asymptomatic carrier Invasive meningococcal disease
Neisseria meningitidis
Enteric Gram-Negative Bacilli
Diabetes mellitus Cirrhosis Alcoholism Chronic urinary tract
infection Craniotomy
Group B Streptococcus
Streptococcus agalactiae
Neonates Age > 50 years
Listeria monocytogenes
Acquired by food ingestion
Cause of meningitis in Neonate Pregnant woman Age > 60 year Immunocompromis
ed patient
Haemophilus influenzae
Unvaccinated children and adults
Staphylococcus aureus and Coagulase-Negative
staphylococci
Invasive neurological procedures
Pathophysiology
Clinical Manifestation
Fever Headache Nuchal rigidity Decreased level of consciousness Nausea Vomiting Photophobia Seizures
Clinical Manifestation
Increase intracranial pressure
Deceased level of consciousness Papilledema Dilated poorly reactive pupils Sixth nerve palsies Decerebrate posturing Cushing reflex
Rash of meningococcemia
Diffuse erythematous maculopapular rash Petechiae
Trunk Lower extremities Mucous membranes Conjuctivae Palms Soles
Management
Management Algorithm for Adults with Suspected Bacterial
Meningitis
Indication Antibiotic
Immunocompetent children > 3 and adults < 55
Cefotaxime/ceftriaxone + vancomycin
Adults > 55 and adult of any age with alcholism or other debilitating illness
Cefotaxime/ceftriaxone + vancomycin +Ampicillin
Empical Antibiotic
Antimicrobial agent
Ampicillin 2 g IV q 6 h
Cefotaxime 2 g IV q 6 h
Ceftriaxone 2 g IV q 12 h
Vancomycin 1 g IV q 12 h
Total Daily Dose and Dosing Interval
Contraindication for LP
Absolute Signs of raised intracranial pressure Local skin infection Evidence of obstructive hydrocephalus, cerebral
edema or herniation in CT/MR scan
Relative
Sepsis/hypotension (BP <100/<60 mmHg) Coagulation disorder (DIC, platelet < 50,000,
warfarin) Neurological deficit GCS ≤ 8 Epileptic seizure
Contraindication for LP
Cerebrospinal Fluid Abnormalities in Bacterial
Meningitis
Comparison of CSF of Meningitis
Antibiotic Based on Positive Gram Stain
Duration of Treatment (A-III)
Decrease inflammatory response Dexamethasone therapy for bacterial
meningitis. N Engl J Med 2002 301 cases Unfavorable outcome (15% vs. 25%, p = 0.03) Death (7% vs. 15%, p = 0.04)
Role of Dexamethasone
Benefit in pneumococcal meningitis subgroup
Unfavorable outcome (26% vs. 52%, p = 0.006) Death (14% vs. 34%, p = 0.02)
Most beneficial in patient with moderate-severe disease on the Glasgow Coma Scale
Dexamethasone 0.15 mg/kg q6h for 2-4 days Suspected/proven pneumococcal meningitis
(A-I) First dose administered 10-20 min before
antibiotic
Recommendation by IDSA
Concerns in highly penicillin- / cephalosporin-
resistant strain Dexamethasone diminishes inflammatory
response
Dexamethasone be administered to all (B-III) Addition of rifampin (B-III)
Dexamethasone and Pneumococcal Meningitis
Any patient who has not responded clinically
after 48 h (A-III)
Indications for Repeated Lumbar Puncture