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Meningitis > Bacterial Meningitis > Flashcards

Bacterial Meningitis Flashcards

1
Q

Neurological Sequelae can develop even after proper treatment of meningitis. List these:

A

1) Seizures
2) Hearing Loss
3) Learning Disabilities
4) Hydrocephalus

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2
Q

Most common bacteria causing meningitis is:

A

Strep. pneumonia

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3
Q

List the layers of the skull:

A

Dura mater, arachnoid, subarachnoid space, pia mater

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4
Q

The three pathways bacteria can spread to cause meningitis:

A

1) Hematogenous spread (bacteremia, fungemia, parasites invade blood stream)
2) Neuronal pathway spread (never endings in face may transfer bacteria) (olfactory & peripheral nerves)
3) Extension from contiguous and direct inoculation (sinusitis, otitis media, trauma, intracranial manipulation)

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5
Q

What is meningitis?

A

an inflammation of the meninges affecting the subarachnoid space or spinal fluid

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6
Q

What is encephalitis?

A

inflammation of the brain tissue

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7
Q

Acute classification of meningitis occurs within

A

hours to several days

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8
Q

Worst classification of meningitis is…

A

Acute

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9
Q

Chronic Meningitis occurs within

A

weeks to months

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10
Q

Chronic meningitis signs and symptoms in the CSF remain abnormal for how long?

A

at least 4 weeks

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11
Q

Septic meningitis is due to…

A

bacteria in blood

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12
Q

Septic meningitis can cause what?

A

Altered mental status

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13
Q

Aseptic meningitis occurs due to

A

drugs/ chemical irritants, viral infections, spirochetal infections (syphillis & lyme disease)

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14
Q

What drugs can cause aseptic meningitis?

A

1) Bactrim
2) IV Ig
3) NSAIDS (Ibuprofen, Naproxen)
4) Allopurinol (gout)

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15
Q

What are the most likely pathogens associated with bacterial meningitis?

A

1) Streptococcus pneumoniae
2) Neisseria meningitis
3) H. influenza (SERO B TYPE)

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16
Q

Aside from the three most common bacteria, acute bact. meningitis can be caused by what other bacterias?

A

1) listeria monocytogenes
2) staph
3) gram negative bacilli
4) anaerobes
5) mycobacterial infxns
6) spirochetal infxns

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17
Q

Acute meningitis is characterized by…

A

an acute onset of meningeal symptoms and CSF pleocytosis (changes in CNS)

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18
Q

Chronic meningitis is characterized by…

A

signs and symptoms of meningeal irritation and CSF pleocytosis for greater than 4 weeks

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19
Q

Meningitis Risk Factors:

A

1) AGE (50)
2) Cranial or congenital deformities
3) Head trauma
4) Diabetes, hypoparathyroidism, CF, sickle cell, alcoholism, cirrhosis, IVDA, IE
5) Immunosuppression- (HIV- encapsulated Strep. pneumo) (mailgnancy- increased risk for listeria) (HIV- salmonella)
6) Crowded living conditions
7) Recent exposure to others
8) Cigarette exposure and history of ear implanatation
9) Travel- ie, meningitis belt in sub-saharan Africa

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20
Q

S/S are different with certain patient populations such as:

A

1) adults
2) infants
3) elderly
4) immunosuppresed

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21
Q

Classic Triad clinical presentation:

A

1) Headache & altered Mental Status
2) Neck stiffness
3) Fever

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22
Q

Clinical presentation for Adults:

A

1) Headache, fever, chills
2) Meningismus
3) Altered consciousness
4) seizures
5) N/V
6) Rash
7) photophobia
8) myalgia
9) sweating

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23
Q

Clinical presentation for Children:

A

1) irritability
2) temperature instability
3) lethargy, grunting, high pitched cry
4) feeding intolerance
5) N/V/D
6) seizures
7) rash
8) apnea
9) BULGING FONTANELLE (when skull isn’t fused and pressure causes swollen forehead)

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24
Q

Clinical presentation in Elderly:

A

1) Confusion
2) Mental status changes
3) Lethargic
4) Possible afebrile
5) Concurrent infections
- pneumonia
- sinusitis
- bronchitis

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25
Q

Most elderly present with what bacteria causing meningitis?

A

S. pneumoniae, BUT some may also acquire gram negative pathogens

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26
Q

Clinical pres of Neutropenic patients:

A

1) impaired immune function
2) impaired inflammation response
3) non- specific symptoms

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27
Q

Three signs of meningitis inflammation:

A

1) Kernig’s sign
2) Brudzinski’s sign
3) Jolt accentuation of headache

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28
Q

How do you perform the Kernig sign test?

A

Flex patients legs at the hip and knee, then straighten knee & report resistance or pain

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29
Q

How do you perform the Brudzinski sign test?

A

Patient supine, flex head and neck towards chest- watch for resistance and pain, and flexion of hips and knees

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30
Q

Jolt accentuation of headache test:

A

move head from right to left- document pain

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31
Q

What is KEY in meningitis diagnosis?

A

Early Identification

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32
Q

Diagnosis is based on what?

A

1) Patient history & assessment- identify causative agents
2) CT scan of head and MRI of brain
3) Clinical presentation
4) CSF results from CSF analysis & lumbar puncture
5) Blood cultures (CBC, serum electrolytes, serum glucose, BUN, CrCL, liver profile (renal fxn ))

IN ADDITION:

6) Blood, nasopharynx, resp, urine and skin cultures
7) Serum Procalcitonin (marker for inflammation)
8) Special clinical conisderations
- Acid Fast Bacilli (test for TB)
- Venereal disease research lab (VDRL)
- Fungal culture

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33
Q

How is CSF produced?

A

85% in the 3rd & 4th lateral ventricle of the choroid plexus

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34
Q

How much CSF is produced per day in children?

A

40-60 mL/ day

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35
Q

How much CSF is produced per day in adults?

A

500 mL/day

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36
Q

How does CSF flow?

A

Unilaterally- skull to spinal chord and down

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37
Q

You can give antibiotics to patients empirically for meningitis because:

A

ABX do not change the CSF for 24-48 hours so they won’t affect the initial cultures drawn

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38
Q

What test do you perform for collection of CSF?

A

Lumbar puncture (needle inserted between the 3rd and 4th lumbar vertebrae)

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39
Q

LP is C/I in patients with evidence of:

A

1) focal neurological exam
2) intracerebral pressure
3) thrombocytopenia
4) bleeding diathesis

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40
Q

When meningitis is suspected, what do you do first?

A

1) obtain two sets of blood cultures
2) immediately begin empiric ABX therapy
3) perform CT scan

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41
Q

Analysis of CSF:

A

1) appearance
2) expected cell composition
3) absence of bacteria
4) normal chem of fluid
5) normal pressure <200 mm HgO

42
Q

Normal WBC & bacterial WBC in CSF

A

Normal: <5
Bact: 1,000- 5,000

43
Q

Normal & Bacterial Differential in CSF

A

Normal: >90% (monocytes)
Bact: > 80 PMN

44
Q

Normal & bacterial pH in CSF

A

Normal: 7.3
Bact: 7.1

45
Q

Lactic acid in CSF

A

Normal: 35 mg/dL

46
Q

Protein in CSF

A

Normal: <50
Bact: 100-500

47
Q

Glucose in CSF

A

Normal: 30-70
Bact: <40

48
Q

How many hours until mortality occurs in meningitis?

A

24-48 hours

49
Q

Supportive care treatments are:

A

1) Fluids
2) Electrolytes
3) Antipyretics
4) Analgesics
5) Anti-epileptics

50
Q

When you treat Men empirically, what should you do?

A

1) Continue ABX for 72 hours or when diagnosis of ABM is ruled out
2) Consider adjunctive corticosteroids (dexamethasone) when applicable

51
Q

When pathogen is identified, how do you treat definitively?

A

Therapy based on specific pathogen and continue for appropriate duration.

52
Q

Obstacles to consider when initially treating are?

A

1) Neurological morbidity even after proper treatment
2) Concerns for delay in LP or C/I
3) HIgh mortality if not treated 24-48 hours

53
Q

When should you give the first dose of ABX?

A

ASAP - NEVER withhold if suspected

54
Q

Changes in CSF after empiric ABX apparent after how many hours?

A

12-24 hours

55
Q

What principles should you consider when recommending an ABX regimen?

A

1) Penetration into the CNS
- adequate drug concentration in CNS (exceed MBC > 10 fold)
- bactericidal and dependent on time in the CNS high doses and IV ONLY
2) Dependent on inflammation process
- Low MW
- Low protein binding
- Non-ionized at pH site
- High-lipid SOLUBLE

56
Q

Certain ABX’s do better when there IS what in the brain?

A

inflammation in the brain, due to blases

57
Q

MBC stands for what?

A

Minimum bacterioCIDAL concentration

58
Q

Can you treat ABM orally?

A

HELL NO. IV ONLY!

59
Q

What is DAT?

A

Direct Antimicrobial Therapy

60
Q

When do you use DAT?

A

If MRSA is in the brain, Vancomycin cannot penetrate properly, so you need to insert a shunt in the brain or spine to administer Vanco locally. (Not preferred due to unilateral flow of CSF)

61
Q

What ABX penetrate CSF with or without inflammation?

A

1) Sulfonamides
2) Trimethoprim
3) Chloramphenicol
4) Metronidazole
5) Rifampin
6) Pyrazinamide
7) Ethionamide
8) Cycloserine

62
Q

What ABX penetrate CSF WITH inflammation?

A

1) Acyclovir
2) Nafcillin
3) BL/ BLI
4) FQ
5) Ceftriaxone
6) Imipenem
7) Meropenem
8) Daptomycin
9) Aztreonam
10) Linezolid
11) Synercid
12) Colistin
13) Vancomycin

63
Q

What ABX are poorly entered into the CSF, but can be used empirically for hemo infxns?

A

1) Aminoglyc’s
2) 1st & 2nd gen Ceph’s except cefuroxime
3) Cefoperazone
4) Clindamycin
5) Erythromycin
6) Amphotericin B
7) Ketoconazole
8) Itraconazole

64
Q

N. meningitis symptoms:

A

Asymptomatic carrier state, petechiae or purpuric lesions, rash that worsens after anti-inflamm agents used

65
Q

Colonization of N. meningitis occuring in the ______________ can lead to _______________

A

nasopharynx, bacteremia

66
Q

N. meningitis usually occurs when?

A

winter and spring months

67
Q

What serotypes are identified with N. meningitis?

A

A, B, C, Y, and W-135

68
Q

H. influenzae usually occurs in what population?

A

infants and children who are not vaccinated

69
Q

What complication are common in early H. influenzae meningitis?

A

Neurological complications are common in early disease

70
Q

What serotype is H. influenzae?

A

serotype B- vaccine is in the works

71
Q

S. pneumo is common in what age group?

A

All ages

72
Q

Predisposed pneumo infections leading to S. pneumoniae meningitis?

A

pneumonia, sinusitis, otitis media, cochlear implants

73
Q

What occurs more frequently in S. pneumoniae meningitis?

A

Neurological compilations occur more frequently

74
Q

Listeria monocytogenes meningitis is more common in what populations?

A

1) alcoholics
2) immunodeficient patients
3) neonates
4) elderly

75
Q

Listeria meningitis normally occurs when?

A

summer and fall months

76
Q

Listeria meningitis colonization occurs where?

A

GI Tract

77
Q

How is listeria normally contracted?

A

Via food by immunocompromised patients- contaminated coleslaw, raw veggies, milk and cheese

78
Q

Strep. agalactiae is common in what population?

A

neonates & pregnant women

79
Q

A gram stain was obtained in a patient with a suspected acute case of bacterial meningitis, the results showed gram negative diplococci. What bacteria is responsible for the acute infection?

A

N. meningitis

80
Q

A gram stain was obtained in a patient with a suspected acute case of bacterial meningitis, the results showed gram negative diplococci. What can we determine from this information?

A

Lumbar penetration, gram stain

81
Q

Sensitivity of a gram stain % variation:

A

60-90%

82
Q

Specificity of a gram stain is approximately what %?

A

100%

83
Q

A patient <1 month most likely has what meningitis pathogens?

A

E.Coli, Strep agalactiae, Listeria, Enterococcus sp, Salmonell sp, Klebsiella

84
Q

How would you treat a <1 month empirically?

A

Ampicillin PLUS
Ceftriaxone or
Cefotaxime (use if ceftriaxone resistance)
or an aminoglycoside

85
Q

1 month- 4 years of age common pathogens?

A

E. Coli, Strep agalactiae, Listeria, N. Meningitis, H. influenzae,S. pneumoniae

86
Q

Empiric treatment for 1 month- 4 years?

A

Cefotaxime or Ceftriaxone PLUS Vancomycin

87
Q

5-29 yo common pathogens?

A

N. meningitis, H. influenzae, S. pneumo

88
Q

5-29 empiric treatment?

A

Cefotaxime or Ceftriaxone PLUS Vancomycin

89
Q

30-60 yo common pathogens?

A

S. pneumo, N. meningitis

90
Q

30-60 yo empiric treatment?

A

Cefotaxime or Ceftriaxone PLUS Vancomycin

91
Q

> 60 yo common pathogens?

A

S. pneumo, listeria, n. meningitis, Gram Neg. bacilli

92
Q

> 60 yo empiric treatment?

A

Ampicillin PLUS Cefotaxime or Ceftriaxone or an aminoglycoside PLUS Vancomycin

93
Q

CSF Shunt common bacteria?

A

S. epidermis, S. aureus, Gram Neg bacilli

94
Q

CSF Shunt empiric treatment?

A

Vanco + Cefepime or Ceftazidime or Meropenem

95
Q

Adjunctive therapy for men?

A

Empirical corticosteroid therapy

96
Q

Why use corticosteroid therapy in men patients?

A

Inhibits TNF and IL-1

to decrease inflammation, edema, & intracranial pressure

97
Q

Corticosteroids may do what to current ABX?

A

decrease penetration

98
Q

When should you use corticosteroids in patients with men?

A

In children with H. influenzae meningitis

In adults with S. pneumo meningitis

99
Q

When should you administer corticosteroids?

A

MUST admin 10-20 BEFORE or at the SAME time as ABX to prevent neuro complications

100
Q

Administer corticosteroid in adults when:

A

suspected pneumo meningitis, increased intracranial pressure, high concentrations of bacteria in CSF, Change in mental status (Glasgow Coma Scale < II

101
Q

When should you NOT admin dexamethasone?

A

When patient has already received ABX therapy!

102
Q

Prophylaxis for patients with close contact of N. meningitis or H. influenzae?

A

Rifampin

Meningitis (1 decks)

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