Meningitis Mangamant

Defintion - Types -risk factors - Diagnsois - treatment & prevention

1. MENINGITIS Dr. Sameh Ahmad Muhamad abdelghany Lecturer Of Clinical Pharmacology Mansura Faculty of medicine

2. 2 CONTENTS 1 4 5 3 2 Diagnosis PREVENTION &TREATMENT INTRODUCTION TYPES RISK FACTORS

3. 3 1 INTRODUCTION

4. 4 What is meningitis? The brain and spinal cord are covered by connective tissue layers collectively called the meninges which form the blood-brain barrier. 1-the pia mater (closest to the CNS) 2-the arachnoid mater 3-the dura mater (farthest from the CNS). The meninges contain cerebrospinal fluid (CSF). Meningitis is an inflammation of the meninges, which, if severe, may become encephalitis, an inflammation of the brain.

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7. 7 What is meningitis? Meningitis can be caused by many different organisms including viruses and bacteria. Meningitis , caused by a bacteria, is life threatening and requires urgent medical attention and treatment with antibiotics. Meningitis caused by a virus is very rarely life threatening but can cause the body to become very weak. When bacteria invade the body they can cause meningitis, septicemia or meningitis and septicemia together

8. 8 2 TYPES

9. 9 MAIN TYPES OF Meninigtis VIRAL FUNGAL BACTERIAL

10. 10 Causes of Meningitis Viral Infections Bacterial Infections Fungal Infections: e.g. Cryptococcus neoformans - Coccidiodes immitus Inflammatory diseases : (SLE) Cancer Trauma to head or spine.

11. 11 I- Viral meningitis Most common cause of meningitis. CAUSES: Enteroviruses - 85%( coxsackievirus A- coxsackievirus B-echoviruses) Mumps Virus- 5-10% Lymphocytic choriomeningitis virus Herpes Simplex Virus (HSV-2) Others

12. 12 Viral meningitis Viruses in the Enterovirus category cause about 10 to 15 million infections per year, but only a small percentage of people who get infected will develop meningitis . Viral meningitis typically goes away without treatment.

13. 13 II- Bacterial meningitis Bacterial meningitis is contagious Fatal if left untreated. Between 5 to 40 percent of children and 20 to 50 percent of adults with this condition die. (even with proper treatment).

14. 14 Bacterial meningitis CAUSES: Pneumococcal , Streptococcus pneumoniae (38 %) Meningococcal, Neisseria meningitidis (14 %) Haemophilus influenzae (4 %) Staphylococcal, Staphylococcus aureus (5 %) Tuberculous, Mycobacterium tuberculosis

15. 15 Common Bacterial Organisms Streptococcus pneumoniae Gram positive diplococci " Pneumococcus" Deafness = 31% Coma and seizures are more common Resistance is becoming a problem

16. 16 Common Bacterial Organisms Neisseria meningitides Usually occurs winter/spring Five main serogroups : A, B, C, Y, and W-135 ( A and C--epidemics; B--individual cases; Y- -pneumonia ) May present with a characteristic immune reaction 10-14 days after infection ( fever, arthritis , pericarditis ).

17. 17 Common Bacterial Organisms Neisseria meningitides 50% die within the first 24 hours Coma and seizures are uncommon Deafness = 10.5% Close contacts are 500-1000x risk

18. 18 Common Bacterial Organisms Haemophilus influenzae Peak incidence: 6-12 months of age: declines after 24 months of age Deafness = 6% Coma/seizures common Close contacts are 200-1000 x risk

19. 19 3 RISK FACTORS

20. 20 Risk Factors Age All ages are at risk for meningitis. However, certain age groups have a higher risk. Children under the age of 5 are at increased risk of viral meningitis. Infants are at higher risk of bacterial meningitis. Compromised Immunity People with an immune deficiency are more vulnerable to infections. Community Living Meningitis is easily spread when people live in close quarters .

21. 21 Risk Factors Pregnancy Pregnant women have an increased risk of listeriosis , which is an infection caused by the Listeria bacteria. Working with Animals Farm workers and others who work with animals have an increased risk of infection with Listeria . Infections Respiratory tract infection ,Otitis media Head trauma

22. 22 4 DIAGNOSIS

23. 23 Viral Meningitis Symptoms Viral meningitis in infants may cause : decreased appetite irritability sleepiness lethargy a fever

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26. 26 Viral Meningitis Symptoms Viral meningitis in adults may cause : headaches a fever stiff neck seizures sensitivity to bright light sleepiness lethargy nausea decreased appetite

27. 27 Kernig’s sign : is assessed with the patient lying supine, with the hip and knee flexed to 90 degrees. In a patient with a positive Kernig's sign, pain limits passive extension of the knee

28. 28 Brudzinski sign : A positive Brudzinski's sign occurs when flexion of the neck causes involuntary flexion of the knee and hip.

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31. 31 Bacterial Meningitis Symptoms symptoms develop suddenly . altered mental status nausea vomiting a sensitivity to light irritability a headache a fever a stiff neck

32. 32 Complications seizures hearing loss brain damage hydrocephalus a subdural effusion

33. 33 Laboratory Studies Lumbar Puncture CSF cell count CSF chemistries CSF gram stain CSF culture

34. 34 Laboratory Studies Abnormal CSF-findings by type of meningitis: Type WBC(mm2) Diff. (%) Protein(mg/dl) Glucose(mg/dl) NML < 10 >50 lymphs < 50 30-70 Bact. 400-100,000 >90 PMN's 80-500 (high) < 35(low) Viral 5-500 >50 lymphs 30-150(high) NML/low Fungal 40-400 >50 lymphs 40-150 (high) NML/low T.B. 100-1,000 >50 lymphs 40-400(high) NML/low

35. 35 Laboratory Studies Blood cultures identify bacteria in the blood: Bacteria can travel from the blood to the brain. N . meningitidis and S. pneumoniae can cause both sepsis and meningitis. A complete blood count with differential is a general index of health. count is usually elevated in meningitis .

36. 36 Radiological Chest X-rays can reveal the presence of pneumonia, tuberculosis, or fungal infections. Meningitis can occur after pneumonia. CT scan of the head may show problems like a brain abscess or sinusitis. Bacteria can spread from the sinuses to the meninges.

37. 37 2 PREVENTION & TREATMENT Treatment of Bacterial Meninigitis

38. 38 Treatment of Bacterial Meninigitis Treatment is determined by the cause of your meningitis . Bacterial meningitis requires immediate hospitalization. Early diagnosis and treatment will prevent brain damage and death. Bacterial meningitis is treated with intravenous antibiotics. Fungal meningitis is treated with antifungal agents. Viral meningitis isn’t treated. It usually resolves on its own. Symptoms should go away within two weeks. There are no serious long-term problems associated with viral meningitis.

39. 39 Treatment Viral Meningitis SUPPORTIVE CARE Antibiotics until bacterial meningitis is ruled out Seizure control Symptom control Acyclovir

40. 40 Antibiotic Therapy Factors Enhancing Antimicrobial Penetration Small MW Unionized at physiologic pH Lipid soluble Large Free Fraction Factors Reduce Antibiotic Activity Low pH of fluid High concentration of protein in fluid High temperature of fluid

41. 41 Antibiotic Therapy Without inflamed meninges Chloramphenicol Rifampin INH Sulfonamides Trimethoprim Triazole antifungals- fluconazole, itraconazole

42. 42 Antibiotic Therapy Needs Inflammation Penicillin,Ampicillin,Carbenicillin Quinolones,Ciprofloxacin Ticarcillin ( clavulanate ), Piperacillin ( tazobactam ) Cefuroxime,Ceftizoxime,Ceftazidime Mezlocillin Imipenem Aztreonam Vancomycin

43. 43 Antibiotic Therapy Questionable concentrations Aminoglycosides: Gentamicin Streptomycin Amikacin Kanamycin Tobramycin Polymyxin

44. 44 Treatment Empiric choice of antibiotic: 0-4 weeks: ampicillin/ cefotaxime or ampicillin/gentamicin 4-12 weeks: ampicillin/ cefotaxime 3mo-4 years: vancomycin/ceftriaxone or cefotaxime

45. 45 Treatment Empiric choice of antibiotic: 5-9 years: vancomycin/ceftriaxone or cefotaxime 9-18 years: vancomycin/ceftriaxone or cefotaxime 18-60 years: vancomycin/ceftriaxone or cefotaxime > 60 years: ampicillin/ceftriaxone or ampicillin/ cefotaxime

46. 46 Treatment Definitive Choice of Antibiotic H. influenzae : ß-lactamase (-) ampicillin ß-lactamase (+) cefotaxime or ceftriaxone N. meningitidis : penicillin G or ampicillin L. monocytogenes : ampicillin

47. 47 Treatment Enterobacteriaceae : cefotaxime P. aeruginosa: ceftazidime /tobramycin S. aureus: MSSA: nafcillin MRSA: vancomycin S. epidermidis: vancomycin/rifampin

48. 48 Treatment Streptococcus pneumoniae Sensitive: Penicillin Intermediate Resistance: Third Generation Cephalosporins Resistant : Vancomycin + Third Generation Cephalosporins

49. 49 Treatment Dexamethasone Blocks TNF alpha and IL-1 release Decreases ICP(intracranial pressure), CNS edema, fever duration, and CSF lactate and protein levels Increased CSF glucose level Decreases neurologic complications (e.g. ataxia,seizures , focal deficit) and hearing loss by approximately 50 % Children with H. influenzae type B

50. 50 Treatment Dexamethasone Indication: > 6 weeks of age, and clinical CSF findings of H. flu meningitis First dose given with/before antibiotics Significant reduction of vancomycin/BBB penetration Somewhat lower CSF concentrations of ceftriaxone

51. 51 Prevention Vaccines N . meningitides covers serotypes A, C, Y, W-135 Type B causes 50% of cases H . influenza all children at 2 months

52. 52 Prevention Vaccines S . pneumoniae Capsular polysaccharide vaccine Heptavalent Conjugate Vaccine

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