Download 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
Bacteria
 Viruses
 Fungi
 Parasites

The most common organisms
involved in meningitis?
Depend on the age and the clinical situations
Neonates to 2 months of
•Viruses
•Herpes Simplex
•Enteroviruses
•Cytomegalovirus (CMV)
•Bacteria
•Group B Streptococcus
•Escherichia Coli
•Listeria monocytogenes
4,7
age ?
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
Antibiotics for infants 0 to 2
months of age?
Third-generation cephalosporins
(cefotaxime or ceftriaxone)
Ampicillin
Should corticosteroid be used in
4
meningitis ?
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

Streptococcus pneumoniae
Neisseria meningitidis
Greater than 3 months to 60 years of age?
Antibiotics for patients greater
than 2 months to 60 years of age?
Third-generation cephalosporins
(cefotaxime or ceftriaxone)
Vancomycin
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

Greater 60 years of age
Streptococcus pneumoniae
Neisseria meningitidis
Listeria monocytogenes
Antibiotics for patients greater
than 60 years of age?
Third-generation cephalosporins
(cefotaxime or ceftriaxone)
Vancomycin
Ampicillin
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
Antibiotics for nosocomial
4,5
meningitis
Ceftazidime or cefepime and Vancomycin
 Imipenem

– Resistant Gram negative rods
– Associated with seizure

Aminoglycoside
– Indicated in patients with poor response to IV
antibiotics
– Intrathecal
Aseptic meningitis8
CSF analysis not consistent with
bacterial infection
Infectious aseptic meningitis9,10?
Viruses
 Bacteria – mycobacterium tuberculosis,

treponema pallidum, borerrelia burgdorferi

Fungi – cryptococcus neoforman, coccidioides
immitis, histoplama capsulatum

Parasites
Non-infectious aseptic
meningitis?

Drugs
–
–
–
–
Penicillin
Trimethoprim/sulfamethoxazole
NSAIDs
Carbamezepine
Granuloma
 Neoplasm
 Idiopathic

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
Clinical presentations in children?
Nonspecific
General toxic appearance
Fever
Decreased PO intake
Decreased alertness
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
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
CSF analysis
Components
Normal
Newborn
Normal
Children
Bacterial
Meningitis
Viral
Meningitis
Herpes
Meningitis
Glucose (mg/dL) 32-121
40-80
<30
>30
>30
Protein (mg/dL)
19-149
20-30
>100
50-100
>75
Leukocytes/L
0-30
0-6
>1,000
100-500
10-1,000
Neutrophils (%)
2-3
0
>50
<40
<50
Erythrocytes/L
0-2
0-2
0-10
0-2
10-500
True CSF WBC = Measured CSF WBC x (1 – CSF RBC  blood RBC)
In bloody tap, if WBC/RBC in CSF < that of blood
Bacterial invasion of CNS
Ventriculitis
Leptomengitis
CSF flow resistance
IL1 & TNF production
Endothelial injury
Increased ICP
Vascular thrombosis
Decreased blood flow
Infarction
Increased blood brain
barrier permeability
Cerebral hypoxia
Cerebral
edema
Glycolysis
Seizure
Abscesses
Increased
CSF lactate
Decreased
CSF glucose
Increased
CSF protein
CSF analysis
Bacterial antigens by
counterimmunoelectrophesis and latex
agglutination – helpful when patients are
already on antibiotics
 Culture
 PCR for viruses and tuberculosis
 VDRL

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
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
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
References
1.
2.
3.
4.
5.
6.
7.
8.
Smith AL. Bacterial Meningitis. Pediatrics in Review 1993;14:1118.
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.