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Meningitis Notifiable diseases Universal Precautions MENINGITIS CLINICAL PRESENTATION Special features 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 Elderly Asplenia Alcoholism Cirrhosis Malnutrition Chronic liver or renal disease Immunoglobulin or complement deficiency HIV Diabetes Malignancy Recent head injury Recent neurosurgery Cerebro ventricular shunt or CSF leak Otitis media Sinusitis Mastoiditis Pneumonia Brain abscess Differential diagnosis Infectious causes Aseptic meningitis: viral, tuberculous, fungal, parasitic Encephalitis Intracranial abscess Viral illness with a headache Noninfectious causes 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 Triage to monitoring room Oxygen IV lines – blood for FBC, U&E;s, coagulation, blood cultures, glucose Fluid resuscitation Monitoring 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 Atypical presentation Immunosuppression Elderly present atypically and may have comorbid illness Alcoholics are at a higher risk of SAH Contraindications to LP 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: Household contacts School or day care contacts in the last 7 days Those directly exposed to patients secretions through kissing, shared utensils, toothbrushes, Those who have performed mouth to mouth resuscitation. Those who have intubated the patient without facemask protection. Usual prophylaxis : Rifampicin 600 mg bid X 2 days. Viral Meningitis In the first 24 hours, neutrophils may predominate. Early ABM may show lymphocytosis in 10 % of cases. 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 15g/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 (15g/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: 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: wash the area immediately if appropriate always report it immediately and follow the hospitals Blood / Body Accidents protocol in Health and Safety Manual