Transcript 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.