Sterile body fluids

Brett Crawley
29th September, 2015

Bacterial meningitis

Septic arthritis
Bacterial meningitis
What is meningitis?

Clinical presentation and diagnosis

Pathogenic organisms in bacterial meningitis

Meningococci and Mekka

Meningitis
 Encephalitis

HSV
VZV
Enterovirus
Mycoplasma pneumoniae
(Mumps)
(Measles)

Arbovirusses
e.g. Japanese Encephalitis,
West Nile
 Clinical presentation bacterial meningitis

Headache

Fever
95% 45%
2 or more symptoms
Vomiting
“classical trias”

Neurological signs

Van de Beek et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med 2004; 351: 1849-59.
 Meningitis and meningococcal sepsis

Meningococcal disease:

1. Fulminant septic shock

- within hours
- often without meningitis
- mortality 20-50%

2. Meningitis
- 18-36hrs

Van Deuren et al. Clin Microbiol Rev 2000; 13(1): 144-166

 Causative organisms in bacterial meningitis

Top 3 causative organisms:

1. Streptococcus pneumoniae
2. Neisseria meningitidis
3. Haemophilus influenzae

Immune compromised: Listeria monocytogenes

Neonates: Group B streptococci, E.coli

 Neisseria meningitides: serotypes

Gram negative encapsulated diplococci

13 serogroups based on capsular

polysaccharides
6 can cause life threatening sepsis and
meningitis
– A
– B
– C
– W-135
– X
– Y
Stephens DS, Greenwood B, Brandtzaeg P. Epidemic meningitis, meningococcaemie, and Neisseria meningitidis. Lancet 2007; 369: 2
 CSF, laboratory diagnosis

Gram stain: same day

Culture: 1-4 days

PCR: 24h
 CSF, laboratory diagnosis

 Acute bacterial meningitis

 Lumbar puncture to obtain CSF for culture
 Daily 650 ml of CSF produced
 Normal values:
– Protein <0.55 g/l
– Glucose 2.2-5.0 mmol/l (½ to 2/3 blood level)
– Polynuclear WCC 0.0/mm3 (neutrophils)
– Mononuclear WCC <5/mm3 (lympho- and monocytes)
 CSF, laboratory diagnosis

Acute bacteria meningitis

 WBC usually elevated (but can be normal)
– Often predominance of neutrophils
– In ± 10% of cases lymfocytic predominance (esp. listeria)
 In ± 60% of cases glucose verlaagd (in ± 70% of
cases CSF-serum glucose ratio < 0,31)
 CSF protein almost always raised.

 In clinical suspicion: always LP, gram/culture

 CSF, laboratory diagnosis

Acute bacterial meningitis

 Sensitivity gram depends on
– Concentration of bacteria
 103 csf/ml: ± 25%
 153 csf/ml: ± 97%
– Type pathogen
 Pneumococci ± 86%
 H. influenzae
 Meningococci
 gram-negatieve rods
 Listeria ± 30%

– Previous use of antibiotics

 Meningococcal disease epidemiology

Worldwide distribution of major meningococcal serogroups and of serogroup B outbreaks

by serotype (shaded in purple) The meningitis belt (dotted line) of sub-Saharan Africa
and other areas of substantial meningococcal disease in Africa are shown.

Stephens DS, Greenwood B, Brandtzaeg P. Epidemic meningitis, meningococcaemie, and Neisseria meningitidis. Lancet 2007; 369: 2196-210.
 Septic arthritis

 Joint affected by
rheumatoïd disease
 Trauma, diabetes,
 old age, malnutrition

 S. aureus most common

 S. epidermidis in infections
of prosthetic joint devices
 Diagnosis arthritis

 Laboratory diagnosis
 Bacterial vs. reumatoïd
 Viral, M. tuberculosis
 SRE, CRP, PCT, leucocytes
 Synovial fluid essential
 Purulent of cloudy aspect
 (a.s.a.p.) Gram and culture
 (PCR bacterial DNA)
 BSE and leucocytes

 Increased in bacterial, viral and

M. tuberculosis arthritis
 Low specificity or sensitivity
 Blood: leucocyte number not
increased, only in children
 Synovial fluid: leucocytes
>50.000 mm3 (>75% PMN)
 However, also in gout en RA
 Collection of material

 Disinfect with chlorhexidin or

iodine
 Wait for 2-3 minutes
 Puncture with syringe, remove
needle
 In (too) few material aspirate
first some physiological saline in
the syringe
 Microscopy and culture

 Two-in one in laboratory diagnosis

 Bacteria in one third of the gram
stains visible1
 BC vials positive results possible
(culture negative)
 Combine with blood cultures
 Synovial culture in 90% positive
 Gonococci much lower: <50%2
 Blood culture in 10-60% positive

1Mandell, Douglas & Benneth, 5th Edition (2000)

2Shirtliff &Mader, Clin Microbiol Rev 15 527-544 (2002)
 Bacteria in Gram-stain
Gram positive cocci

-- in duplo Pneumococci (S. pneumoniae)

-- in chains Streptococci (alfa or beta hemolytic)

- in clusters Staphylococci (S. aureus, S. epidermidis)

Gram negative cocci

- in diplo Neisseria (gonococci, meningococci)

Moraxella (M. catarrhalis)
Gram positive rods Corynebacterium, Listeria, Clostridia,
Bacillus
Gram negative rods Salmonella, E. coli, Pseudomonas,
Bacteroides
 ASAP Gram stain

 Always in daytime and morning of

weekend/hollidays
 Add telephone number or pager
 Evening and rest of the weekend
only after consultation of medical
microbiologist on call
 Sensitivity and specificity too low
for treatment decision
 Culture more important than Gram
 Empirical therapy essential