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PR3151 Finals > Bacterial Meningitis and Clostridiodes Difficile > Flashcards

Bacterial Meningitis and Clostridiodes Difficile Flashcards

1
Q

What drugs may cause BM?

A

Co-trimoxazole, ibuprofen

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2
Q

What are the predisposing factors for BM? (8)

A
  • Head trauma
  • CNS shunts
  • Neurosurgical patients
  • CSF fistula or leak
  • Local infections (sinusitis, otitis media, pharyngitis)
  • Immunosuppression
  • Splenectomized pts
  • Congenital defects
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3
Q

Risk factors for BM?

A
  • Prolonged close contact with infected pts
  • Travel to endemic areas
  • Invasion of mucosal surface (ie respiratory tract), then hematogenous spread to brain
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4
Q

Clinical presentations of BM?

A
  • Fever, chills
  • Classic triad: headache, backache, nuchal (neck) rigidity
  • Mental status changes (Irritability)
  • Photophobia
  • N/V, anorexia, poor feeding habits (infants)
  • Petechiae or purpura (Neisseria meningitidis meningitis)
  • Kernig sign
  • Brudzinski sign
  • Bulging fontane
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5
Q

What are the values of glucose, protein and WBC for a normal CSF?

A

Glucose: 2.6 - 4.5 mmol/L
CSF : blood > 0.66

Protein < 0.4g/L

WBC < 5 cells/mm^3

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6
Q

What are the values of glucose, protein and WBC for CSF with BM?

A

Glucose very low
CSF : blood < 0.4

Protein raised > 1.5g/L

WBC raised > 100 cells/mm^3

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7
Q

What are the values of glucose, protein and WBC for CSF with viral meningitis?

A

Glucose: normal to slightly low

Protein: normal to mildly raised

WBC raised (5-1000 cells/mm^3)

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8
Q

For BM, what are the pathogens we need to treat for neonates (<1 month)? (BEL)

A
  • Group B Streptococcus (Strep. agalactiae)
  • Listeria monocytogenes
  • E. coli
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9
Q

For BM, what are the pathogens we need to treat for infants and children (1-23 months)? (BENS)

A
  • Strep. pneumoniae
  • Group B Streptococcus (Strep. agalactiae)
  • Neisseria meningitidis
  • E. coli
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10
Q

For BM, what are the pathogens we need to treat for children and adults (2-50y/o)? (SN)

A

Strep. pneumoniae
Neisseria meningitidis

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11
Q

For BM, what are the pathogens we need to treat for adults > 50 y/o? (NALS)

A

Strep. pneumoniae
Listeria monocytogenes
Neisseria meningitidis
Aerobic gram -ve bacilli (E coli., Klebsiella spp etc)

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12
Q

When do we start empiric Abx for BM?

A

ASAP, within 1h

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13
Q

Tx for BM in neonates (< 1 month)?

A

Ceftriaxone + Ampicillin

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14
Q

Tx for BM in infants, children (1-23 months)?

A

Ceftriaxone + Vancomycin

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15
Q

Tx for BM in children, adults (2-50 y/o)?

A

Ceftriaxone + Vancomycin

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16
Q

Tx for BM in adults > 50 y/o?

A

Ceftriaxone + Vancomycin + Ampicillin

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17
Q

For culture-directed Tx of BM for Strep. pneumoniae, what is the Tx and duration?

A
  • Penicillin susceptible: Pen G or Ampicillin
  • Penicillin resistant, cephalosporin susceptible: Ceftriaxone
  • Penicillin, cephalosporin resistant: vancomycin + rifampicin

Treat for 10-14 days

18
Q

For culture-directed Tx of BM for Neisseria meningitidis, what is the Tx and duration?

A
  • Penicillin susceptible: Penicillin or Ampicillin
  • Penicillin resistant or mild allergy: Ceftriaxone

Treat for 5-7 days

19
Q

For culture-directed Tx of BM for Listeria monocytogenes, what is the Tx and duration?

A
  • Penicillin G or Ampicillin
  • Penicillin allergy: co-trimoxazole, meropenem

Treat for ≥ 21 days

20
Q

For culture-directed Tx of BM for Group B Strep (Strep. agalactiae), what is the Tx and duration?

A
  • Penicillin G or Ampicillin
  • Penicillin, mild allergy: ceftriaxone

Treat for 14-21 days

21
Q

What other medication can we prescribe for BM?

When is it recommended?

What are the benefits and risks?

A

Adjunctive corticosteroid Tx

Recommended for pts with bacterial meningitis beyond neonatal age (6w onwards)

Benefits:
- Less hearing loss and other neurologic sequelae in H. influenzae and S. pneumoniae meningitis
- ↓ mortality in S. pneumoniae meningitis

Risks:
- May ↓ abx penetration (which ↑ due to inflamed meninges)
- ADRs: mental status changes, hyperglycemia, HTN

22
Q

Dosage and administration for dexamethasone for BM?

A

Administer 10-20 mins before or at the same time as the first abx dose

Adult dose: 10mg q6h up to 4 days

Stop if pt discovered not to have BM or if bacteria causing meningitis is not H. influenzae or S. pneumoniae

23
Q

What are the 3 drugs used for chemoprophylaxis of BM?

A

Rifampicin, ciprofloxacin and ceftriaxone

Rifampicin:
- Adults: 600mg q12h x 4 doses
- Children: 10mg/kg q12h x 4 doses
- Infants (<1 month): 5mg/kg q12h x 4 doses

Ciprofloxacin:
- Adult: 500mg PO x 1 dose

Ceftriaxone:
- 125-250mg IM x 1 dose

24
Q

What are the risk factors of CDAD? (11)

A
  • Advanced age > 65 y/o
  • Multiple/ severe co-morbs
  • Immunosuppression
  • History of CDI
  • GI surgery
  • Tube/ enteral feeding
  • Prior hospitalisation (past 1 year)
  • Duration of hospitalisation
  • Residence in nursing home/ long-term care facilities
  • Use of abx
  • Gastric acid suppressive therapy (PPIs, H2RAs, antacids)
25
Q

Can all abx potentially cause CDAD development?

Which abx have high risk of causing CDAD?

When is the risk the highest?

A

Yes.

Clindamycin > 3rd and 4th gen cephalosporins > FQs (esp ciprofloxacin)

Risk highest while receiving abx but still elevated risk up to 12w

26
Q

Which abx may actually be protective against CDAD?

A

Doxycycline/ tigecycline

27
Q

Should we test/ treat asymptomatic CDAD pts?

A

No.

Only test and treat for CDI in symptomatic pts

28
Q

What does diagnosis of CDAD require?

A

Presence of diarrhoea (≥ 3 loose stools in 24h)
OR
Radiographic evidence: ileus, toxic megacolon

PLUS

Positive stool test result for C. diff or its toxins
OR
Colonoscopic or histopathologic evidence

29
Q

Before testing pts for CDAD, what must we ensure?

Should we repeat test to see if pts have been cured?

A

Before testing, ensure that pt has not received laxative 48h prior to sending test

No. Just look for improved clinical response.

30
Q

Clinical presentation of CDAD? (what is the cardinal s/sx?)

A

Cardinal symptom: watery diarrhoea (≥ 3 loose stools in 24h)

31
Q

What are the s/sx of MILD CDAD? (objective and subjective)

A

Objective:
- diarrhoea
- abdominal cramps

Subjective:
(non-severe)
- WBC < 15 x 109/L AND
- SCr < 133 μmol/L = 1.5mg/dL

32
Q

What are the s/sx of MODERATE CDAD? (objective and subjective)

A

Objective:
- fever
- diarrhoea
- nausea
- malaise
- abdominal cramps, distension
- leukocytosis
- hypovolemia (dehydration s/sx)

Subjective:
Use own clinical judgement → in-between mild → severe CDI

33
Q

Tx for MILD/ MODERATE CDAD? (first-line and alternatives)

A

First-line:
- PO fidaxomicin 200mg BD (not avail in SG)
- PO vancomycin 125mg QDS

Alternative:
- PO metronidazole 400mg TDS

34
Q

What are the s/sx of SEVERE CDAD? (objective and subjective)

A

Objective:
- fever
- diarrhoea
- diffused abdominal cramps, distenison

Subjective:
- WBC ≥ 15 x 109/L OR
- SCr ≥ 133 μmol/L = ≥ 1.5mg/dL

35
Q

First-line Tx for SEVERE CDAD?

A
  • PO fidaxomicin 200mg BD
  • PO vancomycin 125mg QDS
36
Q

What are the s/sx of FULMINANT CDAD? (objective and subjective)

A

Objective:
- hypotension/ shock OR

Subjective (radiographic evidence):
- ileus OR
- megacolon

37
Q

First-line Tx for FULMINANT CDAD?

A
  • IV metronidazole 500mg q8h
    PLUS
  • PO vancomycin 500mg QDS
    +/-
  • PR vancomycin 500mg QDS (rectal route enema)
38
Q

How long is the duration of Tx for CDAD?

A

Treat for 10 days, may extend to 14 days if s/sx not completely resolved

39
Q

Risk factors for recurrent CDAD?

A
  • Administration of other abx during of after initial Tx of CDI
  • Defective humoral immune response against C. diff toxins
  • Advanced age
  • Severe underlying disease
  • Continued use of PPIs
40
Q

Tx for first recurrence of CDAD if fidaxomicin or vancomycin was used for initial episode?

A
  • PO fidaxomicin 200mg BD x 10d
  • PO fidaxomicin 200mg BD x 5 days then 200mg EOD x 20d

(FYI) vancomycin tapered/ pulsed dose

41
Q

Tx for first recurrence of CDAD if metronidazole was used for initial episode?

A

PO vancomycin 125mg QDS x 10d

PR3151 Finals (11 decks)

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