Bacterial Meningitis Part 2 Flashcards
true or false
bacterial meningitis is considered a medical emergency
TRUE
if untreated, there is a 100% mortality rate and empiric antibiotics need to be started WITHIN 1 HOUR
as mentioned, empiric antibiotics need to be started promptly - within 1 hour
name 3 things that this antibiotic should be
should be bacteriCIDAL
high doses given IV
must penetrate the CNS (low molecular weight, low protein binding, lipophilic)
true or false
in meningitis, it is harder for an antibiotic to penetrate the meninges
FALSE - actually easier bc of damage and inflamed meninges
the barrier is slightly disrupted
aside from empiric antibiotics, what else should a patient with bacterial meningitis be given
lot of fluids and electrolyes, antipyretics and analgesics
(possible corticosteroids?)
as a recap, name the 3 most likely organisms to cause bacterial meningitis in neonates (less than 1 month)
NAME 2 THERAPIES THAT CAN BE USED
group b strep (strep agalactiae)
listeria monocytogenes
enteric gram negatives (e. coli, klebsiella, enterobacter)
Normally, ampicillin + cefotaxime
if cefotaxime not available, can do:
ampicillin + aminoglycoside (BUT NEEDS THERAPEUTIC DRUG MONITORING)
WHY do aminoglycosides need therapeutic drug monitoring
cause nephrotoxicity and ototoxicity
as recap, name the 4 most likely pathogens to cause bacterial meningitis in 1 month-23 months
WHAT TREATMENT IS USED TO COVER ALL
group B strep (still a little)
neisseria meningitidis
streptococcus pneumoniae
h. influenzae
vancomycin + a 3rd gen cephalosporin like ceftriaxone and cefotaxime
which bacterial meningitis drug CANNOT be used in neonates
ceftriaxone - causes hyperbilirubinemia and kernicterus (brain damage) fatally precipitates with calcium
as a recap, which organisms are most responsible for bacterial meningitis in 2-50 years?
what is treatment?
neisseria meningitidis
streptococcus pneumoniae
same as for 1-23 months:
vancomycin + 3rd gen cephalosporin (ceftriaxone or cefotaxime)
as recap, what organisms likely responsible for bacterial meningitis in pts greater than 50?
what is treatment?
listeria monocytogens
gram negative bacilli (enteric gram negatives - e.coli, klebsiella, enterobacter)
strep pneumoniae
neisseria meningitidis
treatment is vancomycin + 3rd gen cephalosporin (ceftriazone or cefotaxime) + ampicillin
true or false
listeria monocytogenes is a gram negative organism
FALSE - gram positive
that’s why ampicillin added to empiric therapy for >50 yrs
empiric therapy for closed head trauma
as recap, what 3 organisms likely to cause?
strep pneumoniae
h. influenzae
group A beta-hemolytic strep
vanomycin + 3rd gen cephalosporin (ceftriaxone or cefotaxime)
empiric therapy of choice for penetrating head trauma/post neurosurgery OR CSF shunt
vancomycin
+cefepime or ceftazidime (not rly used - bc of resistance) or meropenem (really for ESBL - depends on pt factors)
as recap, what are likely organisms for penetrating head trauma or post neurosurgery
staph epi
staph aureus
gram negative bacilli (e. coli, klebsiella, PSEUDOMONAS)
as recap, what are likely organisms in CSF shunt condition
staph epi
staph aureus
p. acnes
gram negative bacilli (e. coli, klebsiella, pseudomonas)
is pseudomonas gram (+) or (-)
(-)
60 yrs old man admitted to hospital for suspected community acquired bacterial meningitis
which empiric therapy is most appropriate
vancomycin + ceftriaxone + ampicillin
NEED ampicillin to cover listeria
21 yr old female college student admitted to hospital for suspected bacterial meningitis
NKA - what empiric therapy?
vanco + 3rd gen cephalosporin (ie - ceftriaxone)
no concern with listeria
cefazolin is what generation cephalosporin
1st
therefore, cannot be used for 21 y/o with suspected meningitis - need vanco + THIRD GEN
3 week old infant brought to ER for refusal to nurse and irritability
suspected bacterial meningitis
what empiric antibiotics? (NKA)
ampicIllin + cefotaxime
(COULD BE AMINOGLYCOSIDES IF CEFOTAXIME NOT AVAILABLE)
DO NOT USE CEFTRIAXONE - NEONATE HYPERBILIRUBI
If culture comes back and comes streptococcus pneumoniae, what should be started if:
-penicillin susceptible
-penicillin ressitant
WHAT IS DURATION
penicillin suceptible: pen G or ampicillin
pen resistant - vanco + cefotaxime or ceftriaxone
10-14 days
culture comes back as group B strep
what is 1st line antibiotics and for what duration
14 - 21 days
pen g or ampicillin
culture comes back staph aureus
1st line antibiotic if:
MSSA
MRSA
what duration
14-21 days
MSSA - nafcillin or oxacillin
MRSA - vancomycin
culture comes back staph epi
what is 1st line antibiotics and for how long
14-21 days
vancomycin
culture comes back listeria monocytogenes
what are 1st line ab and for what duration
21+ days, pen g or ampicillin
culture comes back neisseria meningitidis
pen susceptible
pen ressitant
what is treatment and for how long
7-10 days
susceptible - pen g or ampicillin
resistant - cefotaxime or ceftriaxone (3rd gen)
culture comes back pseudomonas
what is treatment and for how long
cefepime or ceftazidime (not rly used bc resistance)
21 days
culture comes back enteric gram negative
what are AB and for how long
21 days
cefotaxime or ceftriaxone (3rd gen)
culture comes back h. influenzae
-b-lactamase negative
-b-lactamase positive
what is treatment and for how long
7-10 days
negative - ampicillin
positive - cefotaxime or ceftriaxone
role of dexamethasone in bacterial meningitis and why is it a little controversial
used as adjunctive to antibiotics to modulate the inflammatory response – inflammation causes a lot of the morbiditiy like hearing loss, neurologic complications, and even mortality
little controversial because there’s some concern that using dexamethasone reduces the penetration of the antibiotic into the CNS by reducing the meningeal inflammation
BUT GUIDELINES STILL RECOMMEND DEXAMETHASONE - -NOT ENOUGH EVIDENCE
Give 3 patient scenarios in which the IDSA recommends giving dexamethasone
-infants and children with H. Influenzae meningitis
-infants and children with pneumococcal meningitis (weigh risks and beneftis)
-adults with pneumococcal meningitis
when is dexamethasone administered in bacterial meningitis patients
before or with the 1st dose of antibiotics
dose of dexamethasone for bacterial meningitis
0.15mg/kg every 6 hours for 2-4 days
MAX IS 10MG A DAY
what should be monitored when bacterial meningitis patient is on dexamethasone? they should be discontinued if what?
monitor for GI bleed and hyperglycemia
discontinue if other pathogens are identified - dont NEED ot continue for the 2-4 days
antimicrobial chemoprophylaxis is recommended for whom and for what meningitis
MENINGOCOCCAL MENINGITIS
for close contacts
name some things that consider a person as a “close contact” and should get antimicrobial chemoprophylaxis
-directly exposed to oral secretions during 7 days before symptom unset and until 24 hrs after starting AB
-day care contacts, hosehold members, roomates, kissing, mouth-mouth, endotracheal intubation (whoever performed it)
when should antimicrobial chemoprophylaxis for close contacts to meningococcal meningitis patients be intiated?
ASAP
ideally less than 24 hrs after indentifying the OG pt
3 drug and doses used for antimicrobial chemoprophyalxis for close contacts to meningococcal meningitis patients
cipro - 500mg ONCE
rifampin - 600mg Q12 x 2 days
ceftriazone - 250mg IM ONCE (FOR PREGNANCY)
true or false
adjunctive use of corticosteroids is NOT recommended for streptococcus pneumoniae in children
FALSE
recommended in strep pneumoniae for both kids and adults
true or false
adjunctive corticosteroids are recommended for meningitis due to H. influenzae in children
TRUE
true or false
adjunctive corticosteroids are NOT recommended in adults with meningitis due to nisseria monocytogenes
TRUE - not recommended
only for adults with pnemococcal meningitis (strep pneumoniae)
someone was in contact with index patient of bacterial meningitis. they drove them to work for a 10 min car ride 2 weeks ago
is prophylactic chemotherapy warrented?
NO
69 year old brought to ER with altered mental status. lumbar puncture with CSF analysis showed elevated white blood cells, elevated protein, and low glucose
what empiric therapy should be started
vanomycin
ceftriaxone
ampicillin
dexamethasone
we use dexamethasone still. only used for strep pneumoniae bacterial meningitis, but we can still start empirically, if the cultures come back and its NOT strep pneumoniae, then we can discontinue
patient was started on vancomycin, ceftriaxone, ampicillin, and dexamethasone empirically
cultures come back as neisseria meningitidis PENICILLIN RESISTANT
what is appropriate course of action
de-escalate to CEFTRIAXONE - 3rd gen cephalosporin - good against gram negative
discontinue dexamethasone (not strep pneumoniae) and start chemoprophylaxis for ciprofloxacin for close contact
