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Bacterial
Viral ( aseptic)
TB
Fungal
Chemical
Parasitic
? Carcinomatous
MENINGITIS
Definition
Bacterial meningitis is an inflammatory response
to bacterial infection of the pia-arachnoid and CSF
of the subarachnoid space
Epidemiology
Incidence is between 3-5 per 100,000
Relative frequency of bacterial species varies with
age.
MENINGITIS
Epidemiology
Neonates (< 1 Month)
Gm (-) bacilli 50-60%
Grp B Strep 20-40%
Listeria sp. 2-10%
H. influenza 0-3%
S. pneumo 0-5%
MENINGITIS
Epidemiology
Children (1 month to 15 years)
H. influenzae
40-60%
N. meningitidis 25-40%
S. pneumo
10-20%
MENINGITIS
Epidemiology
Adults (> 15 years)
S. pneumo
N. Meningitidis
30-50%
10-35%
S. aureus
H. influenzae 1-3%
5-15%
MENINGITIS
Pathogenesis
Majority of cases are hematogenous in
origin
Organisms have virulence factors that allow
bypassing of normal defenses
Proteases
Polysaccharidases
MENINGITIS
Pathology and Pathogenesis
Sequential steps allow the pathogen into the CSF
Nasopharyngeal colonization
Nasopharyngeal epithelial cell invasion
Bloodstream invasion
Bacteremia with intravascular survival
Crossing of the BBB and entry into the CSF
Survival and replication in the subarachnoid space
MENINGITIS
Pathology
Hallmark
Exudate in the subarachnoid space
Accumulation of exudate in the dependent areas of the
brain
Large numbers of PMNs
Within 2-3 days inflammation in the walls of the small
and medium-sized blood vessels
Blockage of normal CSF pathways and blockage of the
normal absorption may lead to obstructive
hydrocephalus
MENINGITIS
Clinical Manifestations
HA
Fever
Meningismus
Cerebral dysfunction
Confusion, delirium, decreased level of consciousness
N/V
Photophobia
MENINGITIS
Clinical Manifestations Nuchal rigidity
Kernigs
Pt supine with flexed knee has increased pain with
passive extension of the same leg
Brudzinskis
Supine pt with neck flexed will raise knees to take
pressure off of the meninges
Present in 50% of acute bacterial meningitis cases
Seizures
MENINGITIS
Clinical Manifestations - Meningococcemia
Prominent rash
Diffuse purpuric lesions principally involving the
extremities
MENINGOCOCCEMIA
MENINGOCOCCAL MENINGITIS
LOOK @ AGE/ARMY
RECRUITS/COLLEGE
STUDENTS/
Rash
MENINGITIS
Diagnosis
Assess for increased ICP
Papilledema
Focal neurologic findings
PAPILLEDEMA
Gram negative:
Diplococci: Meningococcus
Bacilli: E. coli
Coccobacilli: H influenzae
(small, pleomorphic)
Gram Positive:
Diplococci: Pneumococcus
Chains: Strep Group B
Clusters: Staph
Rods & cocobacilli: Listeria
LP-CSF
MENINGITIS
Diagnosis
CSF Findings :
Opening pressure
Appearance
Cell count & differential
Glucose
Protein
Gram stain & culture
MENINGITIS
Diagnosis
Rapid Tests
CIE (Counter immunoelectrophoresis/ latex
agglut.)
PCR
CT/MRI
Little role in DIAGNOSIS of menigitis
Obtain if suspect increased ICP
MENINGITIS
Diagnosis
Additional Tests
CBC w/ diff
Blood cultures
CXR
Electrolytes and renal function
MENINGITIS
Differential Diagnosis
CNS infections (abscess, encephalitis)
Viral/ Tb/ Lyme meningitis
Ricketsial infections
Cerebral vasculitis
Subarachnoid hemorrhage
Neurosyphilis
NMO-SD
MENINGITIS
Treatment
Emergent empirical antimicrobial therapy
Based on age and underlying disease status
Children
Third generation cephalosporin ( alternative -ampicillin and
chloramphenicol)
Young adults
Third generation cephalosporin (Ceftriaxone) + Vancomycin
MENINGITIS
Treatment
Empiric Antibiotic Regimines
Older adults
Ampicillin in combination with third generation
ceph.
Postneurosurgical Pts
Vancomycin plus ceftazidime until cultures are
available
MENINGITIS
Treatment
N. Meningitidis
High dose Pen G
S. pneumoniae
Ceftriaxone
For areas with high level resistance
Vancomycin plus third generation cephalosporin or
rifampin
MENINGITIS
Treatment
Gm (-) Enterics
Third generation cephalosporins
L. monocytogenes
Ampicillin
S. aureus
Vancomycin or Nafcillin
S. epidermidis
Vancomycin
MENINGITIS
Treatment
Duration of Treatment
Dependent on infecting organism
Average of 10-14 days
Gm (-) bacilli for 3 weeks
MENINGITIS
Treatment
Steroids
Shortly before or along with antibiotics. Do not
give steroids after antibiotic treatment.
de Gans J, van de Beek D. Dexamethasone in adults with
bacterial meningitis. N Engl J Med. 2002;347:1549-56.
ADJUNCTIVE DEXAMETHASONE
IN BACTERIAL MENINGITIS
Attenuates subarachnoid space inflammatory response resulting from
antimicrobial-induced lysis
Recommended for infants and children with Haemophilus influenzae
type b meningitis and considered for pneumococcal meningitis in
childhood, if commenced with or before parenteral antimicrobial
therapy
Clinical trials (predominantly in infants and children) have demonstrated
reduction in neurologic and/or audiologic sequelae
Recommended in adults with pneumococcal meningitis
Administer at 0.15 mg/kg every 6 hours for 2-4 days concomitant with or
just before first antimicrobial dose
MENINGITIS
Prognosis
Pneumococcal Meningitis
Associated with the highest mortality rate
20-30%
MENINGITIS
Vaccinations
Asplenic pts should have had a
pneumoccocal vaccine prior to their
splenectomy
Vaccines available for H. influenza
Prophylaxis for N. meningitidis contacts
Rifampin
MENINGITIS
COMMONLY ASKED QUESTIONS
Bacterial infection
Tuberculosis, cryptococcosis, carcinomatous
SAH
Sarcoidosis
Occasional viral
Pressure
<20
In patients with bacterial meningitis
wide range
40% >30, 10% < 14
Usually
Look at the whole pattern!
Protein
> 2.5 suggests bacterial
Cell count
>500 suggests bacterial
>1000 highly suggests bacterial
% polys
>50 suggests bacterial
Not Much
History
Headache: 75-90%
Photophobia: uncommon
Examination
Fever: 95%
Stiff Neck: 85%
Altered mental status: 80%
All three: 40%
Any one of the three: 100%
It is important
But it is not the critical prognostic factor
One factor
33% with adverse outcome
STEROIDS OR NO STEROIDS?
Steroids
(today)
STEROIDS OR NO STEROIDS?
Reduces morbidity and mortality*
Give before or at the same time as the first
dose of antibiotics
Dose studied
Dexamethazone 10 mg Q6H x 4 days
*Only shown for pneumococcal meningitis in adults
and haemophilus meningitis in children
Usually not
A CT scan should never delay therapy (obtain
blood cultures)
Not really
The only bacterial meningitis that is spread
from person to person is meningococcal
The risk is very low
Household contacts have about a 1% risk
Health care workers have not been shown to have a risk
After 24 hours of treatment this is no risk
HSV 1 and 2
Syphilis
Listeria (occasionally)
Tuberculosis
Cryptococcus
Leptospirosis
Cerebral malaria
African tick typhus
Lyme disease
Carcinomatous
Sarcoidosis
Vasculitis
Dural venous sinus
thrombosis
Migraine
Drug
Co-trimoxazole
IVIG
NSAIDS
MENINGITIS
Conclusion
Meningitis is an infectious disease
emergency
Mortality is often high but can be prevented
with appropriate medical therapy
If you consider meningitis in your
differential, you are committed to an LP and
empiric antibiotics