BACTERIAL MENINGITIS presentation slides

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1. BACTERIAL MENINGITIS BY PANYIN ATAKORA 1

2. OUTLINE DEFINITION EPIDEMIOLOGY ETIOLOGY CLINICAL FEATURES TREATMENT PREVENTION REFERENCES 2

3. DEFINITION Bacterial meningitis is an acute purulent infection within the subarachnoid space (SAS ). It is associated with a CNS inflammatory reaction that may result in decreased consciousness, seizures, raised intracranial pressure (ICP), and stroke. The meninges, SAS, and brain parenchyma are all frequently involved in the inflammatory reaction (meningoencephalitis ). 3

4. THE MENINGITIS 4

5. EPIDEMIOLOGY Bacterial meningitis is the most common form of suppurative CNS infection, with an annual incidence in the United States of >2.5 cases/100,000 population . The organisms most often responsible for community-acquired bacterial meningitis are Streptococcus pneumonia (~ 50%), Neisseria meningitidis (~25%), group B streptococci (~ 15%), and Listeria monocytogenes (~10 %). Haemophilus influenzae type b accounts for <10% of cases of bacterial meningitis in most series. N. meningitidis is the causative organism of recurring epidemics of meningitis every 8–12 years. 5

6. EPIDEMIOLOGY & ETIOLOGY AGE/ PEOPLE GROUP PATHOGENS LESS THAN 3 MONTHS Group B Streptococcus Escherichia coli Klebsiella pneumoniae Listeria monocytogenes 3 MONTHS TO LESS THAN 18 YEARS Streptococcus pneumoniae Neisseria meningitidis 18 YEARS TO LESS THAN 60 YEARS S. pneumoniae N. meningitidis 60 YEARS OR OLDER S. pneumoniae Gram-negative bacilli L. monocytogenes IMMUNOCOMPROMISED S. pneumoniae N. meningitidis L. monocytogenes Gram-negative bacilli (including Pseudomonas aeruginosa ) 6

7. EPIDEMIOLOGY & ETIOLOGY PREDISPOSING FACTOR PATHOGEN POSTNEUROSURGICAL INFECTION S. aureus (including MRSA) Coagulase-negative Staphylococcus (including MRSE) Gram-negative bacilli (including P. aeruginosa ) PENETRATING HEAD TRAUMA S. aureus (including MRSA) coagulase-negative Staphylococcus Gram-negative bacilli (including P. aeruginosa ) CSF SHUNT Coagulase-negative Staphylococcus (including MRSE) S. aureus (including MRSA) Gram-negative bacilli (including P. aeruginosa ) 7

8. PATHOPHYSIOLOGY 8

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10. CLINICAL FEATURES Fever Headache Nuchal rigidity Photophobia K ernig’s sign Brudzinski’s sign Altered mental status Stupor Seizures 10 Excessive irritability Crying Vomiting Diarrhea Tachypnea Altered sleep pattern Poor eating

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12. CSF FINDINGS PARAMETER FINDING WBC (× 10*3/mm*3 or × 10*9/L) 1.0–greater than 5.0 WBC differential (% or fraction in brackets, predominant cell type) At least 80% (0.80) PMNs Protein (mg/ dL , mg/L) > 100 (> 1000) Glucose (mg/ dL , mmol /L) 5–40 (0.3–2.2) CSF: serum glucose ratio < 0.4 serum glucose CSF stain Positive Gram stain (60%–90%) Opening pressure > 20 mm Hg 12

13. TREATMENT EMPIRIC THERAPY; PATHOGEN- DIRECTED THERAPY ; ADJUNCTIVE THERAPY; ICP THERAPY 13

14. THE BLOOD BRAIN BARRIER 14

15. ANTIBIOTIC PENETRATION OF BBB Sulfonamides, trimethoprim, chloramphenicol, rifampin, and most antitubercular drugs achieve therapeutic CSF levels even without meningeal inflammation . Most beta-lactams and related antibiotics ( ie , carbapenems and monobactams ), vancomycin, quinolones , acyclovir, linezolid, daptomycin , and colistin achieve therapeutic CSF levels in the presence of meningeal inflammation . Aminoglycosides, first-generation cephalosporins , second- generation cephalosporins (except cefuroxime), clindamycin, and amphotericin do not achieve therapeutic CSF levels, even with inflammation, but clindamycin does achieve therapeutic brain tissue levels . 15

16. EMPIRIC THERAPY INDICATION EMPIRIC THERAPY Preterm infants to infants <1 month Ampicillin + cefotaxime Infants 1–3 months Ampicillin + cefotaxime or ceftriaxone Immunocompetent children >3 months and adults <55 Cefotaxime , ceftriaxone, or cefepime + vancomycin Adults >55 and adults of any age with alcoholism or other debilitating illnesses Ampicillin + cefotaxime , ceftriaxone or cefepime + vancomycin Hospital-acquired meningitis, posttraumatic or Postneurosurgery meningitis, neutropenic patients, or patients with impaired cell-mediated i mmunity Ampicillin + ceftazidime or meropenem + vancomycin 16

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18. INTRAVENTRICULAR INJECTION 18

19. DOSES OF MEDICATIONS 19

20. SAFETY MONITORING DRUG CLASS ADVERSE EFFECTS PENICILLINS Hypersensitivity (rash, anaphylaxis), diarrhea CEPHALOSPORINS Hypersensitivity (rash, anaphylaxis), LFT elevation, cholecystitis , pseudocholelithiasis , pseudomembranous colitis GENTAMICIN Nephrotoxicity, ototoxicity MEROPENEM Rash, hypersensitivity, diarrhea, decreased seizure threshold METRONIDAZOLE Metallic taste, dry mouth, myalgia, nausea and vomiting. VANCOMYCIN Rash, red man syndrome (if infused too quickly) nephrotoxicity, t hrombocytopenia 20

21. ADJUNCTIVE THERAPY IV Dexamethasone 4-10mg x QID for 5-7 days 15- 20minutes before or at time of administration of antibiotic therapy. 21

22. MANAGING INCREASED INTRACRANIAL PRESSURE Elevation of the patient’s head to 30–45° Intubation Hyperventilation (Paco2, 25–30 mmHg) Mannitol 22

23. NON- PHARMACOLOGICAL THERAPY Tepid sponging Keep airway clear NG tube feeding (if applicable) 23

24. PREVENTION OF BACTERIAL MENINGITIS VACCINATION AND ANTIBIOTIC PROPHYLAXIS 24

25. VACCINATION Meningococcal vaccine- N. meningitidis Pneumococcal vaccine- S. pneumoniae Hib vaccine- H. influenzae type B 25

26. ANTIBIOTIC PROPHYLAXIS N. meningitides Rifampin 600 mg orally every 12 hours for 2 days C iprofloxacin 500 mg orally for one dose C eftriaxone 250 mg intramuscularly for one dose. Regimens for children include rifampin 5 mg/kg orally every 12 hours for 2 days (< 1 month of age) rifampin 10 mg/kg orally every 12 hours for 2 days (> 1 month of age) ceftriaxone 125 mg intramuscularly for one dose (< 12 years of age). Hib Rifampin- 600mg/day for 4 days- adults Rifampin 20mg/kg/day (max 600mg/day) for 4 days- children Rifampin prophylaxis is not necessary for individuals who have received the full Hib vaccine series. 26

27. REFERENCES Ministry Of Health (2017). Standard Treatment Guidelines. 7th Edition. Yamens Press Limited, Accra. Pages 494- 498 Jameson J. L. Et Al (2018). Harrison’s Principles Of Internal Medicine. 20th Edition. Mcgraw Hill Education, New York. Pages 998- 1003. Dipiro J. T. Et Al (2020). Pharmacotherapy: A Pathophysiologic Approach. 11th Edition. Mcgraw-hill Education, Usa . Pages 5152- 5198. Chisholm- Burns M. A. Et Al (2019). Pharmacotherapy: Principles And Practice. 5th Edition. Mcgraw - Hill Education, Usa . Pages 1073- 1088. 27

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