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Clinical 2 - Antibiotics > 8 - Meningitis > Flashcards

8 - Meningitis Flashcards

1
Q

What are the risk factors for meningitis ?

A
  • neonates, advanced age, pregnancy (prob a type of immune deficiency)
  • nasopharyngeal colonization with N. meningitides, S. pneumonia, H. influenzae
  • prior URTI, cochlear implants
  • cranial anatomical defects, trauma, fracture, neurosurgery, prosthesis, drains
  • immunocompromised
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2
Q

Describe the pathophysiology of meningitis

A
  • entry of multiplication of bacteria in CSF
  • lysis of bacteria
  • increases coagulation
  • decreases fibrinolysis
  • BBB permeability
  • metabolic disturbances
  • brain damage
  • increased intracranial pressure
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3
Q

What are the most likely pathogens for meningitis ?

A

N. meningitidis
Strep pneumoniae
H. flu
L. monocytogenes (sandwich meat/pregnant ppl)

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4
Q

What are the most likely pathogens according to patient age:

Neonates ?

A

Neonates < 1 month:
S. agalactiae
E. coli

(less commonly - Strep pneumoniae, L monocytogenes)

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5
Q

What are the most likely pathogens according to patient age:

Children

A

N. meningitidis
S. pneumoniae

(H. flu if unvaccinated)

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6
Q

What are the most likely pathogens according to patient age:

Adults

A

N. meningitidis

S. pneumoniae

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7
Q

What are the most likely pathogens according to patient age:

Pregnancy, advanced age > 60, immunocompromised

A

L. monocytogenes

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8
Q

What are the most likely pathogens according to patient age:

Immunocompromised, HCA

A

S. aureus

GNB (gram negative bacilli)

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9
Q

N. meningitides more common in _______

A

children

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10
Q

S. pneumoniae is more common in ________

A

elderly

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11
Q

nuchal

A

pertaining to the spinal cord

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12
Q

What are the 3 most common clinical signs of meningitis?

A

1) Fever > 40 in 90% of ppl
2) Nuchal rigidity or neck stiffness (80%)
3) CNS (80%) such as headache, photophobia, confusion, seizures, coma

  • 95% of cases with >2
  • 50% of cases with all 3
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13
Q

What are some non-specific symptoms of meningitis?

A
  • fever
  • seizures
  • respiratory distress
  • septic shock in neonates
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14
Q

What sign is HIGHLY suggestive of meningococcal infection?

A

RASH

-petechial or purpural rash present in >50% of meningococcal infections

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15
Q

What are the complications that can arise from meningitis? (3)

A

1) Herniation - diffuse swelling, hydrocephalus
2) Infarcts - inflammatory occlusion of basal arteries
3) Seizures - cortical inflammation

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16
Q

see page 8 for mortalities

A

okay

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17
Q

A 21 yr old female gets meningitis - what are the most likely pathogens based on her age ?

A
  • N. Meningitidis

- Strep pneumo

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18
Q

List 3 antimicrobial fundamentals in treating meningitis?

A

1) Early, prompt initiation
2) CSF penetration (antibiotic size, lipophilicity, ionization, protein binding, barrier inflammation)
3) Rapid sterilization

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19
Q

Delays in administration of antibiotic are associated with ______ from adult acute bacterial meningitis

A

mortality

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20
Q

Why do we depend on inflammation in meningitis ?

A

We need to depend on the inflammation that occurs in these tight junctions that allow the drug to get through the BBB and the BCSFB.

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21
Q

Ceftriaxone is _% free

A

5

*this 5% that is free is therapeutic for meningitis

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22
Q

Which drugs are able to achieve therapeutic CSF concentrations with or without inflammation

A
  • Chloramphenicol
  • Metronidazole
  • Rifampin

“Connie Myers Rules” lol

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23
Q

Which drugs only achieve therapeutic CSF concentrations WITH inflammation?

A
  • Penicillins
  • 3rd GC & Cefuroxime
  • Daptomycin
  • Fluoroquinolones
  • Linezolid
  • Meropenem
  • TMP-SMX
  • Vancomycin
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24
Q

Which drugs will not achieve therapeutic CSF concentrations ?

A
  • Aminoglycosides

- other Cephalosporins

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25
Empirical age based formula for meningitis: | < 1 month
``` Cefotax (covers strep and pneumoniae) + Amp (covers listeria) +/- Gent (this doesn't get into CSF ! sometimes penicillin can be less effective against GAS so Gent is added on) ``` Why not Ceftriax? - cannot be given with calcium - can displace bilirubin
26
Empirical age based formula for meningitis: | 1 month to 17 years
Cefotax / Ceftriax (covers strep and pneumoniae) **Ceftriax can be used here ! + Vanco (covers PRSP) *This is only added on for the initial day or two until you know what the bug is
27
Empirical age based formula for meningitis: | 18 - 50 years
Cefotax / Ceftriax (covers strep and pneumoniae) + Vancomycin (covers PRSP) *This is only added on for the initial day or two until you know what the bug is
28
Empirical age based formula for meningitis: | > 50 years
Cefotax / Ceftriax (covers strep and pneumoniae) + Vancomycin (covers PRSP) *This is only added on for the initial day or two until you know what the bug is + Amp (covers L. monocytogenes)
29
Treatment for: | HCA meningitis
Mero (to cover all the other possible drugs) or Ceftaz + Vanco (covers PRSP) *This is only added on for the initial day or two until you know what the bug is
30
Treatment for: | Immunocompromised
Mero (to cover all the other possible drugs) + Vanco (covers PRSP) *This is only added on for the initial day or two until you know what the bug is + Amp (to cover L. monocytogenes)
31
Meningitis dose: | Cefotaxime
2 g q4h
32
Meningitis dose: | Ceftriaxone
2g q12h
33
Meningitis dose: | Ampicillin
2g q4h
34
Meningitis dose: | Vanco
15-20 mg/kg q8h | troughs 15-20 mg/L
35
Meningitis dose: | Meropenem
2g q8h
36
Meningitis dose: | Ceftazidime
2g q8h
37
Meningitis dose: | Penicillin G
4 MU q4h | Max dose on sheet!
38
Meningitis dose: | Rifampin
600 mg q24h | same as on sheet, don't need to memorize!
39
Meningococcal meningitis: | Peak in ?
late winter and early spring
40
Meningococcal meningitis: | Predominantly Group __
B
41
Meningococcal meningitis: | Peak incidence in who ?
children and young adults | 60% of cases in 2-18 years
42
Meningococcal meningitis: | Colonization in _____% of adolescents and adults
10-20
43
Meningococcal meningitis: | Natural immunity in __% by 2 years of age
80%
44
N. meningitidis: Pen-S 1st line ?
Pen G or Amp
45
N. meningitidis: Pen-S Alternatives ?
Cipro
46
N. meningitidis: Pen-RS 1st line ?
Cefotax / Ceftriax
47
N. meningitidis: Pen-RS Alternatives ?
Chloram
48
N. meningitidis: Duration of treatment ?
5-7 days
49
S. pneumoniae: Pen-S 1st line ?
Pen G or Amp
50
S. pneumoniae: Pen-S Alternatives ?
Levo/Moxi +/- Vanco [Chloram, Linezolid]
51
S. pneumoniae: Pen-R 1st line ?
Cefotax / Ceftriax
52
S. pneumoniae: Pen-R Alternatives ?
Levo/Moxi +/- Vanco [Chloram, Linezolid]
53
S. pneumoniae: 3rd GC, MIC >1 1st line ?
Cefotax / Ceftriax + Vanco
54
S. pneumoniae: 3rd GC, MIC >1 Alternatives ?
Levo/Moxi +/- Vanco [Chloram, Linezolid]
55
S. pneumoniae: 3rd GC, MIC >2 1st line ?
``` Cefotax/ Ceftriax + Vanco + Rifampin ```
56
S. pneumoniae: 3rd GC, MIC >2 Alternatives ?
Levo/Moxi +/- Vanco [Chloram, Linezolid]
57
S. pneumoniae: Duration of therapy ?
10-14 days
58
L. monocytogenes: 1st line ?
Pen G + Gent OR Amp + Gent
59
L. monocytogenes: Alternatives ?
TMP-SMX | [Linezolid]
60
L. monocytogenes: Duration of therapy ?
> 21 days
61
H. influenzae: Amp-S 1st line ?
Amp
62
H. influenzae: Amp-S Alternatives ?
Cipro | [Chloram]
63
H. influenzae: Amp-R, non-beta lactamase 1st line ?
Cefotax / Ceftriax (bc they have increased GN coverage to cover H. flu)
64
H. influenzae: Amp-R, non-beta lactamase Alternatives ?
Cipro | [Chloram]
65
H. influenzae: Amp-R, B-lactamase 1st line ?
Mero
66
H. influenzae: Amp-R, B-lactamase Alternatives ?
Cipro | [Chloram]
67
H. influenzae: Duration of therapy ?
7 - 10 days
68
S. agalactiae: 1st line ?
Pen G (+ Gent x 5 days) OR Amp (+ Gent x 5 days)
69
S. agalactiae: Alternatives ?
Vanco | [Chloram]
70
S. agalactiae: Duration of therapy ?
14-21 days
71
Streptococcal meningitis: | Invasive disease in _____
Manitoba
72
Streptococcal meningitis: | Declining incidence as a result of ?
conjugate vaccination
73
Streptococcal meningitis: | Increasing incidence of ?
non-included serotypes
74
What is the role of adjunctive dexamethasone therapy ?
- RR mortality = 0.48 | - Post-hoc analysis showed benefit in pneumococcal disease only
75
Who is adjunctive dexamethasone therapy recommended for?
-immunocompetent adults with suspected or proven pneumococcal meningitis, and infants or children with H. influenzae (or pneumococcal ?) meningitis based on prior data
76
What is the dose for Dexamethasone ?
0.15 mg/kg q6h x 2-4 days initiated 10-20 min before or with 1st antibiotic dose
77
Dexamethasone therapy: | Continue only if ?
GPDC on gram stain or S. pneumonia culture
78
Dexamethasone therapy: | There are concerns regarding reducing antibiotic penetration of which drugs ?
Vancomycin and possibly Rifampin
79
If they already had a dose of antibiotics, do you still give Dex ?
No - it is ineffective now
80
What is the point of giving Dex ?
- steroids decrease inflammation | - reduce amount of hearing issues after meningitis (especially in kids)
81
Meningitis Monitoring: | When should fever resolve ?
within 24-48 hours
82
Meningitis Monitoring: | When should neck stiffness resolve ?
over 48 - 72 hours
83
Meningitis Monitoring: | When should CSF show a culture negative ?
within 24 hours
84
Meningitis Monitoring: | When should glucose be normal ?
3 days
85
Meningitis Monitoring: When should When should protein be normal ?
7 - 10 days
86
Meningitis Monitoring: | When should RASH resolve ?
over 7 days
87
Chemoprophylaxis for who ?
For those whose close contacts have had meningococcal infections within the past 60 days
88
What is the treatment for Chemoprophylaxis for Meningitis ? | just list them
- Cipro - Rifampin - Ceftriaxone
89
Dose of Cipro for Chemoprophylaxis
Adults: 500 mg PO x 1 dose Children: 10 mg/kg PO x 1 dose (max 500 mg)
90
Dose of Rifampin for Chemoprophylaxis
Adults: 600 mg PO q12h x 4 doses Children 3 months - 12 years: 10mg/kg PO q12h x 4 doses
91
Dose of Ceftriaxone for Chemophrophylaxis
Adults: 250 mg IM x 1 dose Children under 12: 125 mg IM x 1 dose

Clinical 2 - Antibiotics (14 decks)

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