Meningitis: Difference between revisions
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==Management==
==Management==
===Acute Treatment===
===Antibiotics===
#Abx
*''Give as soon as possible (if LP performed w/in 2hr of abx CSF culture will not be affected)''
##Give as soon as possible (if LP performed w/in 2hr of abx CSF culture will not be affected)  
 
##Guidelines
{{Meningitis Antibiotics}}
###Age 18-50y
 
####[[Ceftriaxone]] 2gm IV q12hr + [[vancomycin]] 15mg/kg q8-12hr
 
#####(vancomycin is for resistant pneumococcus)
 
###Age >50y
===[[EBQ:De_Gans_-_Steroids_for_Bacterial_Meningitis|Steroids]]===
####[[Ceftriaxone]] 2gm IV q12hr + [[vancomycin]] 15mg/kg q8-12hr + ampicillin 2gm IV q4h
#####(Ampicillin is for listeria)
###CSF leak w/ history of closed head trauma
####[[Ceftriaxone]] 2gm IV q12hr + [[vancomycin]] 15mg/kg q8-12hr
###History of recent penetrating head injury, neurosurgery, CSF shunt
####(Ceftazidime 2gm IV q8hr or cefepime or meropenem) + vanco 25 milligrams/kg load
###Meningitis due to sinusitis
####[[Ceftriaxone]] + metronidazole
###Meningitis with severe PCN allergy
####chloramphenicol 1g IV q6h + [[vancomycin]] 15mg/kg q8-12hr
#Dexamethasone  
#Dexamethasone  
##Only give prior to or w/ first dose of abx  
##Only give prior to or w/ first dose of abx  

Revision as of 03:07, 19 June 2014

Background

  • Microbiology
    • Bacterial meningitis:
      • Pneumococcus (60%), meningococcus (15%), GBS (15%), H flu (7%), listeria (2%)
    • Viral meningitis
      • Echo, coxsackie, entero (85%)
      • HSV, CMV
  • Pathophysiology
    • Hematogenous spread via respiratory tract
    • Contiguous spread (otitis media, sinusitis, brain abscess)

Risk Factors

  1. Otitis Media
  2. Sinusitis
  3. Immunosuppression/splenectomy
  4. Alcoholism
  5. Pneumonia
  6. Diabetes Mellitus
  7. CSF leak
  8. Endocarditis
  9. Neurosurgical procedure / head injury
  10. Indwelling neurosurgical device / cochlear implant
  11. Malignancy

Classification

  1. Acute (<24hr)
    1. Usually bacterial in origin (25%)
  2. Subacute (1-7d)
    1. Viral or bacterial
  3. Chronic (>7d)
    1. Viral, TB, syphilis, fungi, carcinomatous

Diagnosis

Clinical Features

  • Almost all patients present w/ at least 2 of the following:
  • Also may have:
    • Photophobia
    • Vomiting
    • Prodromal URI
    • Focal neuro sx (e.g. CN deficit)
    • Seizure (25%)
  • Jolt Test (~100% Sn)
    • Have pt rapidly shake head L and R; if does not bother pt unlikely to have meningitis

Lumbar Puncture Diagnosis

Measure Normal Bacterial Aseptic (Viral) Fungal Tuberculosis Subarachnoid hemorrhage Neoplastic
Appearance Clear Clear, cloudy, or purulent Clear Clear or opaque Clear or opaque Xanthochromia, bloody, or clear Clear or opaque
Opening Pressure (cm H2O) 10-20 >25 Normal or elevated >25 >25 >25 Normal or elevated
WBC Count^ (cells/µL) 0-5^ >100^ 5-1000 <500 50-500 0-5 (see correction section) <500
% PMNs >80-90% 1-50%^^ 1-50% Early PMN then lymph 1-50%
Glucose >60% of serum glucose Low Normal Low Low Normal Normal
Protein^^^ (mg/dL) < 45 Elevated Elevated Elevated Elevated Elevated >200
Gram Stain Neg Pos Neg India ink Tb stain Blood
  • ^Normal or lower WBC results may be found in immunocompromised, early, or partially treated (e.g. with oral antibiotics) bacterial menintigis, and those with tuberculosis meningitis
  • ^^Lymph predominance may be found in patients with early bacterial meningitis or those that have been partially treated (e.g. with oral antibiotics)
  • ^^^For unexplained elevations of protein, consider encephalitis, MS, Guillian Barre

Corrections

  • WBC correction (for bloody tap)
    • Simplified version (if peripheral WBC and RBC counts are within normal limits):
      • Subtract 1 WBC for every 750 RBC in CSF
    • Complex version (WBC and/or RBC not within normal limits):
      • "WBCs added" = WBC(blood) x [RBC(CSF) / RBC(blood)]
      • WBC counted/resulted - "WBCs added" = actual WBC
  • Protein correction (for bloody tap)
    • For each 1000 RBC decrease protein value by 1mg/dl

Differential Diagnosis

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Work-Up

  1. CBC
  2. Chem
  3. Blood cx
  4. ?CT head: See CT Before Lumbar Puncture
  5. CXR (50% of pts w/ pneumoccocal meningitis have e/o pna on CXR)
  6. Lumbar Puncture

Management

Antibiotics

  • Give as soon as possible (if LP performed w/in 2hr of abx CSF culture will not be affected)

Neonates (up to 1 month of age)[1]

MRSA is uncommon in the neonate

  • Ampicillin 75mg/kg IV q6hrs PLUS
  • Cefotaxime 50mg/kg IV q6hrs OR 2.5mg/kg IV q8hrs
    • Per AAP, ceftazidime 50mg/kg IV (q12hr for babies < 8 days of age, q8hr for >7 days old) is a reasonable alternative to cefotaxime, offering virtually the same coverage for enteric bacilli and is FDA approved for all age groups[2]
  • If suspecting S. pneumoniae or MRSA, add standard neonatal dosing
  • Consider acyclovir for HSV

> 1 month old[3]

Alternatives (e.g. penicillin/cephalosporin allergy):

Adult < 50 yr[4]

Adult > 50 yr and Immunocompromised[5]

Post Procedural (or penetrating trauma)[7]

Cryptococcosis Meningitis

Options

  • Amphotericin B 1mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily
  • Amphotericin B 5mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily

Meningitis with severe PCN allergy

Meningitis with VP shunt

Neisseria meningitidis Prophylaxis

  • Ceftriaxone 250mg IM once
  • Ceftriaxone 125mg IM once (if <=15yr)
  • Ciprofloxacin 500mg PO once
  • Rifampin 600 mg PO BID x 2 days
  • Rifampin <1mo: 5mg/kg PO BID x 2 days; >=1mo: 10mg/kg PO BID x 2 days
  • Ampicillin/Sulbactam 400mg ampicillin/kg/day IM/IV divided q6 hours; First Dose: 100mg ampicillin/kg IM/IV x 1 (150mg Unasyn/kg IM/IV x 1); Max: 2000mg ampicillin (3000mg Unasyn) per DOSE
  • Meropenem 2g IV every 8 hours.
  • Nafcillin 100-200mg/kg/day IV divided q4-6h; Max: 12 g/day


Steroids

  1. Dexamethasone
    1. Only give prior to or w/ first dose of abx
    2. 10mg IV q6hr x4d
  2. Mannitol
    1. For marked cerebral edema
  3. Acyclovir
    1. Consider for pts w/ suspected viral meningitis who present w/ neuro deficits
    2. 10mg/kg IV q8hr (Obese patients should be dosed using ideal body weight)

Prophylaxis

  • For meningococcus exposure
    • Indications:
      • Household contacts
      • School or day care contacts in previous 7d
      • Direct exposure to pt's secretions (kissing, shared utensils or toothbrush)
      • Intubation without facemask
    • Meds
      • Rifampin 600mg PO BID x2d OR ceftriaxone 250mg IM x1 OR ciprofloxacin 500mg PO x1

Disposition

  1. Bacterial meningitis
    1. Admit w/ droplet precautions
  2. Viral meningitis
    1. Admit for empiric abx until culture results return OR
    2. Discharge w/ 24hr f/u

See Also

Source

Tintinalli, Lexicomp

  1. ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
  2. ↑ https://www.aappublications.org/content/early/2015/02/25/aapnews.20150225-1
  3. ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
  4. ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
  5. ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
  6. ↑ [Guideline] Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul. 15(7):649-59.
  7. ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
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