Download MENINGITIS

Meningitis
Notifiable diseases
Universal Precautions
MENINGITIS
CLINICAL PRESENTATION
Special features
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Only 10 to 20 % of patients develop fulminant symptoms over 24 hours.
80 to 90 % develop symptoms over 1 to 7 days.
Up to 40 % of cases may develop generalized seizures.
20 % of patients may develop cranial nerve signs ( III, IV, VI, VII ).
About 50 % of patients with N meningitides may present with a rash that begins as an
erythematous macular rash, and then eventually progresses to petechiae and purpura.
Patients who have had a course of antibiotics, or who are on steroids may have an altered clinical
picture.
Atypical presentations can occur in the elderly lethargy, obtundation, no fever, no neck stiffness,
hypothermia, confusion. 35 % of elderly will have nuchal rigidity without meningitis.
High risk groups
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Elderly
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Asplenia
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Alcoholism
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Cirrhosis
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Malnutrition
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Chronic liver or renal disease Immunoglobulin or
complement deficiency
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HIV
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Diabetes
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Malignancy
Recent head injury
Recent neurosurgery
Cerebro ventricular shunt or CSF leak
Otitis media
Sinusitis
Mastoiditis
Pneumonia
Brain abscess
Differential diagnosis
Infectious causes
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Aseptic meningitis: viral, tuberculous, fungal, parasitic
Encephalitis
Intracranial abscess
Viral illness with a headache
Noninfectious causes
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Systemic diseases like sarcoid, SLE, multiple sclerosis, migraine, Guillain-Barre,
Vaccine reaction : mumps, MMR, polio
Poison : lead, mercury
Trauma : SAH
Drugs : azothioprine, ibuprofen, trimethoprim-sulfamethoxazole
SAH
MANAGEMENT
Isolate patient.
RESUSCITATION
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Triage to monitoring room
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Oxygen
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IV lines – blood for FBC, U&E;s, coagulation, blood cultures, glucose
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Fluid resuscitation
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Monitoring
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Medical emergency call if patient is in shock
Antibiotics should be administered promptly in suspected meningitis
 Immediately if signs of meningitis with rash and fever or if toxic
 Within 30 minutes following a lumbar puncture provided:
- CT not required
- Young previously healthy, and non toxic
- Result of LP available within 30 minutes (if not treat whilst awaiting result)
LUMBAR PUNCTURE
Perform a CT before LP if any of the following is present
 Altered conscious state
 Focal neurological findings
 Papilloedema
 Focal seizures
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Atypical presentation
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Immunosuppression
Elderly present atypically and may have comorbid illness
Alcoholics are at a higher risk of SAH
Contraindications to LP
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Coagulopathy including petechiae
Anatomical anomaly of the back.
See above for indications for a CT prior to LP.
CSF ANALYSIS
Appearance
WBC x 106/L
Predominant cells
Glucose
Protein ( G/L )
normal
clear
<4
> 1/2 blood
glucose
0.2 - 0.4
viral
clear
50 - 1500
MNL
> 1/2
bacterial
turbid
> 1000
PMN
< 1/3
TB
turbid
< 500
MNL
< 1/3
cryptococcal
Clear
< 150
MNL
< 1/3
0.4 to 0.8
0.5 to 2.0
0.5 - 3.0
0.5 -1.0
The normal opening pressure is 5 to 19.5 cm of water.
If the CSF parameters are nondiagnostic or the patient has had oral antibiotics, Latex Agglutination
tests can be done for Hib, Strep pneumoniae, N meningitides, and strep agalactia.
If the CSF is not diagnostic in a non toxic patient, the LP should be repeated at 12 hours even if Abs
have been given, to differentiate between viral and bacterial meningitis. Discus patient with the
medical unit. Admission can be made to AAW.
Note The CSF in viral meningitis may initially show a predominance of neutrophils which in
12 hours will show an appropriate lymphocytic shift.
Likewise, bacterial meningitis may initially have a predominance of CSF lymphocytes, but
this will shift appropriately in 12 hours as well.
Traumatic tap
True CSF WCC =(CSF WCC - Blood WCC) x (CSF RCC - Blood RCC)
CHOICE OF ANTIBIOTICS
Immunocompetent Patient
N. meningitides
Step pneumoniae
Immunocompromised Patient
N meningitides
Strep pneumoniae
Lysteria monocytogenes
Benzylpenicillin 1.2 G 4 hourly
If allergy to penicillin , Ceftriaxone 2 g IV daily
(ID approval required)
Benzylpenicillin 1.2g IV 4 hourly or
Ceftriaxone 2g IV daily if penicillin allergy
Gram positive cocci
Strep pneumonia have increased tolerance to penicillin. Consider ceftriaxone 2.0.G per day.
(Discuss with ID)
Alternatively, vancomycin 4.0 g per day +/- ceftriaxone 2.0 G iv daily.
Notification
Inform Medical Officer of Health immediately for meningococcal meningitis.
They will organise contact tracing and prophylaxis.
If a close contact of the patient is present in the department, advice and offer
prophylaxis with full explanation.
Contacts needing prophylaxis are:
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Household contacts
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School or day care contacts in the last 7 days
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Those directly exposed to patients secretions through kissing, shared utensils,
toothbrushes, Those who have performed mouth to mouth resuscitation.
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Those who have intubated the patient without facemask protection.
Usual prophylaxis : Rifampicin 600 mg bid X 2 days.
Viral Meningitis
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In the first 24 hours, neutrophils may predominate.
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Early ABM may show lymphocytosis in 10 % of cases.
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If the diagnosis is uncertain, or the patient is unwell., refer to the medical registrar for admission.
If the patient is well, and the diagnosis certain, and there is access to transport and a telephone, the
patient may be discharged with full explanation and a close follow up.
NOTIFIABLE DISEASES
Purpose
To ensure compliance with the Public Health requirement for the
notification of certain Infectious Diseases
Scope
Patients presenting to the Emergency Department
Policy statement(s)
1. Notifiable Disease
The Health Act 1956 lists certain diseases that are
defined by legislation to be “Notifiable”. When someone
presents with a scheduled disease or a suspected
scheduled disease the Medical Officer of Health must
be notified by the attending Physician. Similarly when
microbiological results indicate a notifiable disease, the
Medical Officer of Health must be notified.
Phone: 262 1855
Inform the patient that you are required to notify the Medical Officer of
Health with relevant personal details.
Following information required:
 Disease – suspected or confirmed
 Name
 Address
 Phone number – home and work
 Inpatient / outpatient
 Occupation
 Place of work / school / pre-school
 Recent overseas travel – if yes – where
 Whether the patient has been informed
 Suspected cause if known
2. Prophylaxis for Contacts of Meningococcal and Haemophilus
influenza Type B disease
There is a public health team consisting of Medical Officers of
Health and Public Health Nurses who are:
 trained and experienced in contact investigations
 available seven days a week to provide Rifampicin prophylaxis
during daylight hours
 geared up to provide written information concerning drug
interactions and side effects, staining of body fluids and contact
lenses, risks of pregnancy and dosage instructions.
 able to provide medication directly into the hands of the contact and
obtain interpreters if needed.
The objective is to provide appropriate prophylaxis within 24 hours of
notification.
Diseases Notifiable in NZ (include suspected cases1)
Notifiable Infections Diseases Under the Health Act 1956
Section A - Infectious Diseases notify MOH and LA
Acute gastroenteritis2
Cholera
Giardiasis
Legionellosis
Meningoencephalitis - 1o amoebic
Shigellosis
Yersiniosis
Campylobacteriosis
Cryptosporidiosis
Hepatitis A (Acute)
Listeriosis
Salmonellosis
Typhoid/paratyphoid fever
Section B - Infectious Diseases notify MOH
Acquired Immunodeficiency Syndrome
Arboviral diseases3
Creutzfeldt Jakob Disease & other spongiform encephalopathies
Haemophilus influenza b
Hepatitis C (Acute)
Hydatid disease
Leptospirosis
Measles
Neisseria meningitidis
Plague
Rabies
Rickettsial diseases
Tetanus
Yellow fever
Tuberculosis
Anthrax
Brucellosis
Diphtheria
Hepatitis B (Acute)
Hepatitis viral
Leprosy
Malaria
Mumps
Pertussis
Poliomyelitis
Rheumatic fever
Rubella
Viral haemorrhagic
fever
Diseases Notifiable to Medical Officer of Health (other than Notifiable Infections Diseases)
Cysticerosis
Taeniasis
Trichinosis
Decompression sickness
Lead absorption equal to or in excess of 15g/dl (0.72 mol/l)4
Poisoning from chemical contamination of the environment
Notifiable Diseases Under Tuberculosis Act 1948 to Medical Officer of
Health
Tuberculosis (all forms)
1. During times of increased incidence practitioners may be requested to
report, with informed consent, to their local Medial Officer of Health cases
of communicable diseases not on this list.
2.
Not every case of acute gastroenteritis is necessarily notifiable – only those where there is a
suspected common source or from a person in a high risk category, (e.g. food handler, child care
worker, etc) or single cases of chemical, bacterial, or toxic food poisoning such as botulism, toxic
shellfish poisoning (any type) and disease caused by verocytotoxic E. coli.
3.
Dengue, acute infective encephalitis/arthropod borne, relapsing fever and Ross River Fever and
related conditions.
Blood lead levels to be reported to the Medical Officer of Health (15g/dl or
0.72 mol/l) are for
environmental exposure. Where occupational exposure is suspected please notify Occupational Safety
and Health Section of the
UNIVERSAL PRECAUTIONS
Emergency Departments are high risk environments for body fluid exposures.
The best defence against such exposures is your own behaviour.
The major principles of universal precautions are:
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regard all patients as potentially infective
always wear gloves when likely to be exposed to body fluids
gowns, goggles / masks are appropriate in many situations
don’t recap needles
always dispose of your own sharps
make sure you have been immunised against hepatitis B and know your antibody status
If you do suffer a body fluid exposure:
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wash the area immediately if appropriate
always report it immediately and follow the hospitals Blood / Body Accidents protocol in Health
and Safety Manual