Meningitis.ppt contains information on meningitis

This slide contains information on meningitis management and encharitis

1. Meningitis and Encephalitis:Meningitis and Encephalitis:
Diagnosis and Treatment Update

2. DefinitionsDefinitions
•Meningitis – inflammation of
the meninges
•Encephalitis – infection of the
brain parenchyma
•Meningoencephalitis –
inflammation of brain +
meninges
•Aseptic meningitis –
inflammation of meninges with
sterile CSF

3. Symptoms of meningitisSymptoms of meningitis
•Fever
•Altered consciousness, irritability, photophobia
•Vomiting, poor appetite
•Seizures 20 - 30%
•Bulging fontanel 30%
•Stiff neck or nuchal rigidity
•Meningismus (stiff neck + Brudzinski + Kernig
signs)

4. Clinical signs of meningeal irritationClinical signs of meningeal irritation

5. Diagnosis – lumbar punctureDiagnosis – lumbar puncture
•Contraindications:
Respiratory distress (positioning)
 ICP reported to increase risk of herniation
Cellulitis at area of tap
Bleeding disorder

6. CSF evaluationCSF evaluation
Condition WBC
Protein
(mg/dL)
Glucose
(mmol)
Normal <7, lymphs mainly5-45 >2.5
Bacterial,
acute
100 – 60K PMN’s100-500Low
Bacterial,
part rx’d
1 – 10,000 100+
Low to
normal
TB 10 – 500 100-500<2.5
Fungal 25 – 500 25-500<2.5
Viral <1000 50-100Normal

7. CSF Gram stainCSF Gram stain
Hemophilus influenza
(H flu)
Strep pneumoniae

8. Bacterial meningitisBacterial meningitis
•3 - 8 month olds at highest risk
•66% of cases occur in children <5 years old

9. Bacterial meningitis - OrganismsBacterial meningitis - Organisms
•Neonates
Most caused by Group B Streptococci
E coli, enterococci, Klebsiella, Enterobacter,
Samonella, Serratia, Listeria
•Older infants and children
Neisseria meningitidis, S. pneumoniae,
tuberculosis, H. influenzae

10. Bacterial meningitis – Clinical courseBacterial meningitis – Clinical course
•Fever
•Malaise
•Vomiting
•Alteration in mental status
•Shock
•Disseminated intravascular coagulation (DIC)
•Cerebral edema
Vital signs
Level of mentation

11. Increased intracranial pressure (ICP)Increased intracranial pressure (ICP)
•Papilledema
•Cushing’s triad
Bradycardia
Hypertension
Irregular respiration
•ICP monitor (not
routine)
•Changes in pupils

12.  ICP treatmentICP treatment
•3% NaCl, 5 cc/kg over
~20 minutes
•May utilize osmotherapy
- if serum osms <320
•Mild hyperventilation
PaCO2 <28 may cause
regional ischemia
Typically keep PaCO2
32-38 torr
•Elevate Head Of Bed 30
o

13. Meningitis - Fluid managementMeningitis - Fluid management
•Restore intravascular volume & perfusion
•Monitor serum Na
+
(osmolality, urine Na
+
):
If serum Na
+
<135 mEq/L then fluid restrict
(~2/3x), liberalize as Na
+
improves
If severely hyponatremic, give 3% NaCl
•SIADH
4 - 88% in bacterial meningitis
9 - 64% in viral meningitis
•Diabetes insipidus
•Cerebral salt wasting

14. Meningitis - Treatment durationMeningitis - Treatment duration
•Neonates: 14 – 21 days
•Gram negative meningitis: 21 days
•Pneumococcal, H flu: 10 days
•Meningococcal: 7 days

15. Bacterial Meningitis - TreatmentBacterial Meningitis - Treatment
Neonatal (<3 mo) Neonatal (<3 mo)
•Ampicillin (covers Listeria)
+
•Cefotaxime
High CSF levels
Less toxicity than aminoglycosides
No drug levels to follow
Not excreted in bile  not inhibit bowel flora

16. Meningitis - Acute complicationsMeningitis - Acute complications
•Hydrocephalus
•Subdural effusion or
empyema ~30%
•Stroke
•Abscess
•Dural sinus
thrombophlebitis

17. Bacterial meningitis - OutcomesBacterial meningitis - Outcomes
•Neonates: ~20% mortality
•Older infants and children:
<10% mortality
33% neurologic abnormalities at discharge
11% abnormalities 5 years later
•Sensorineural hearing loss 2 - 29%

18. Bacterial meningitis - childrenBacterial meningitis - children
•Strep pneumoniae
•Neisseria meningitidis
•TB
•Hemophilus influenza

19. Meningococcal meningitisMeningococcal meningitis

20. Meningococcal meningitisMeningococcal meningitis
•Neisseria meningitidis
•~10 - 15% with chronic throat carriage
•Outbreaks in households, high schools, dorms
Accounts for <5% of cases
•Peaks <2 years of age & 15-24 years

22. Meningococcal diseaseMeningococcal disease
•Can cause purulent conjunctivitis, septic
arthritis, sepsis +/- meningitis

23. Meningococcemia - PetechiaeMeningococcemia - Petechiae

24. Meningococcemia - Purpura fulminansMeningococcemia - Purpura fulminans

25. DiagnosisDiagnosis
•Diagnose presence of organism (Gram negative
diplococci) via:
CSF Gram stain, culture
Sputum culture
CSF (not urine) Latex agglutination
Petechial scrapings
Buffy coat Gram stain

26. Meningococcemia - IsolationMeningococcemia - Isolation
•Capable of transmitting organism up to 24
hours after initiation of appropriate therapy
•Droplet precautions x 24 hours, then no
isolation
•Incubation period 1 - 10 days, usually <4 days

27. Meningococcemia - TreatmentMeningococcemia - Treatment
•Antibitotic resistance rare
•Antibitotics:
Penicillin
Cefotaxime or Ceftriaxone
•Patient should get rifampin prior to discharge

28. Meningococcemia - ProphylaxisMeningococcemia - Prophylaxis
•No randomized controlled trials of
effectiveness
•Treat within 24 hours of exposure
•Vaccinate affected population, if outbreak

29. Meningococcemia - ProphylaxisMeningococcemia - Prophylaxis
•Rifampin
Urine, tears, soft contact lenses orange
<1 mo 5 mg/kg PO Q 12 x 2 days
>1 mo 10 mg/kg (max 600 mg) PO Q 12 x 2 days
•Ceftriaxone
12 y 125 mg IM x 1 dose
>12 y 250 mg IM x 1 dose
•Ciprofloxacin
18 y 500 mg PO x 1 dose

30. Meningococcal meningitis - OutcomesMeningococcal meningitis - Outcomes
•Substantial morbidity: 11% - 9% of survivors
have sequelae
Neurologic disability
Limb loss
Hearing loss
•10% case-fatality ratio for meningococcal sepsis
•1% mortality if meningitis alone

31. Pneumococcal meningitisPneumococcal meningitis
•Strep pneumococcus - most common cause of
invasive bacterial infections in children >2
months old
•Incidence of Penicillin-, cefotaxime- &
ceftriaxone-resistant isolates has ’d to ~40%
•Strains resistant to Penicillin, cephalosporins,
and other -lactam antibiotics are often also
resistant to trimethoprim-sulfamethoxazole,
erythromycin, chloramphenicol, tetracycline

32. Pneumococcal meningitis – MgmtPneumococcal meningitis – Mgmt
•VancomycinVancomycin + cefotaxime or ceftriaxone, if > 1
month old
•If hypersensitive (allergic) to -lactam
antibiotics, use vancomycin + rifampin
•Discontinue vancomycin once testing shows
Penicillin-susceptibility
•Consider adding rifampin if susceptible &
condition not improving, or cefotaxime or
ceftriaxone MIC high
•Not vancomycin alone

33. Antibiotic use inAntibiotic use in
Pneumococcal meningitisPneumococcal meningitis
•Penicillin-susceptible organism:
PenG 250,000 - 400,000 U/kg/day  Q 4 - 6 h
•Ceftriaxone 100 mg/kg/day  Q 12 - 24 h
•Cefotaxime 225 - 300 mg/kg/day  Q 8 h
•Chloramphenicol 50 - 100 mg/kg/day  Q 6 h
•Adequate cephalosporin levels in CSF ~2.8
hours after dose administration

34. Other antibiotics inOther antibiotics in
pneumococcal meningitis (resistant)pneumococcal meningitis (resistant)
•Rifampin
20 mg/kg/day  Q 12
Not a solo agent
Slowly bactericidal
•Meropenem
Carbapenem
120 mg/kg/day  Q 8 h
 seizure incidence, 
not generally used in
meningitis
Resistance reported

35. Infection control precautionsInfection control precautions
•CDC recommends Standard Precautions
•Airborne, Droplet, Contact are NOT
recommended
•Nasopharyngeal cultures of family members
and contacts is NOT recommended
•No isolation of contacts
•No chemoprophylaxis for contacts

36. Dexamethasone use in meningitisDexamethasone use in meningitis
•Consider if H flu & S pneumo meningitis & > 6
wks old 0.6 mg/kg/day  Q 6h x 2d
 local synthesis of TNF-, IL-1, PAF &
prostaglandins resulting in  BBB permeability,
 meningeal irritation
•Debatable wheter it  incidence of hearing loss
•If used, needs to be given shortly before or at the
time of antibiotic administration
•May adversely affect the penetration of
antibiotics into CSF

37. TB meningitisTB meningitis
•Children 6 months – 6 years
•Local microscopic granulomas on meninges
•Meningitis may present weeks to months after
primary pulmonary process
•CSF:
Profoundly low glucose
High protein
Acid-fast bacteria (AFB stain)
PCR
•Steroids + antimicrobials

38. Viral meningitisViral meningitis
•Seasonal : Summers
•Severe headache
•Vomiting
•Fever
•Stiff neck
•CSF - pleocytosis (monos), NL protein, NL
glucose

39. Etiology viral meningitisEtiology viral meningitis
•Enteroviruses
predominate
Spring, summer
Oral-fecal route
± initial GI
symptoms
Meningitic
symptoms appear 7-
10 days after
exposure
•Less common:
Mumps
HIV
Lymphocytic
choriomeningitis
HSV-2

40. Other causes of aseptic meningitisOther causes of aseptic meningitis
•Leptospira
Young adults
Late summer, fall
Conjunctivitis, splenomegaly, jaundice, rash
Exposure to animal urine
•Lyme Disease (Borrelia burgdorferi)
Spring-late fall
Rash, cranial nerve involvement

41. Viral meningitis - TreatmentViral meningitis - Treatment
•Supportive
•No antibiotics
•Analgesia
•Fever control
•Often feel better after LP
•No isolation - Standard precautions

42. Viral meningitis - OutcomesViral meningitis - Outcomes
•Adverse outcomes rare
•Infants <1 year have higher incidence of speech
& language delay

43. Meningoencephalitis - etiologyMeningoencephalitis - etiology
•Herpes simplex type 1
•Rabies
•Arthropod-borne
St. Louis encephalitis
La Crosse encephalitis
Eastern equine encephalitis
Western equine encephalitis
West Nile

44. Herpes simplex 1 encephalitisHerpes simplex 1 encephalitis
•Symptoms
Depressed level of consciousness
Blood tinged CSF
Temporal lobe focus on CT scan or EEG
+ PCR
Neonates typically will have cutaneous vessicles
•Treatment - IV acyclovir

45. West Nile VirusWest Nile Virus
•Via bite of infected mosquito
•Incubation period 3 - 14 days
•1 in 150 infected persons get encephalitis
4% of those are <20 years of age
•H/A, fever, neck stiffness, stupor, coma,
convulsions, weakness, & paralysis
•Supportive therapy
•Mortality 9%

46. SummarySummary
•Antibiotics ASAP, even if LP not yet done
•Vanco + cephalosporin until some identification known
CSF, Latex, exam
•Isolate if bacterial x 24 hours, Universal Precautions
•Monitor for status changes
Pupils, LOC, HR, BP, resp
Seizures
Hemodynamics
DIC, coagulopathy
Fluid, electrolyte issues