CNS

Question 1

What the diagnostic factors from a CSF analysis that defines bacterial meningitis?

Answer 1

High WBC 1000-5000
Neutrophil predominance
High protein 100-500 (normal 20-60)
Low glucose <40 (normal glucose 45-80)
CSF/blood glucose ratio <0.4 (normal 0.6)

Question 2

What is the CSF opening pressure for bacterial meningitis?

Answer 2

Abnormal: > 200 mm H20

Question 3

What are the most common bacterial pathogens for bacterial meningitis?

Answer 3

< 1 month: L. monocytogenes, Klebsiella spp, S. agalactiae, E. coli

1-23 months: H. influenzae, S. pneumoniae, N. meningitidis, S. agalactiae, E. coli

2-50: N meningitidis, S pneumoniae

> 50 Listeria monocytogenes, GNR, N. meningitidis, S pneumoniae

Question 4

What are the empiric antibiotic regimens per age group for bacterial meningitis?

Answer 4

< 1 month: Ampicillin + Cefotaxime OR ampicillin + Gentamicin

1-23 months: 3rd generation cephalosporin (CTX or cefotaxime) + vancomycin

2-50: 3rd generation cephalosporin (CTX or cefotaxime) + vancomycin

> 50: Ampicillin + 3rd generation cephalosporin + vancomycin

*If alcoholic, immunocompromised - add ampicillin for listeria coverage

Question 5

What is the clinical data supporting steroid use in pediatric bacterial meningitis?

Answer 5

Use of pediatric H. influenzae meningitis

- Use of dexamethasone associated with less hearing loss and other neurologic sequelae

Question 6

What is the clinical data supporting steroid use in adult bacterial meningitis?

Answer 6

Use of S. pneumoniae meningitis

- Dexamethasone 0.15 mg/kg IV Q6H x 2-4 days reduced bacterial meningitis mortality

Question 7

What is the recommended duration of antibiotic treatment for community acquired bacterial meningitis?

Answer 7

Community acquired
N. meningitidis or H. influenzae: 7 days
S. pneumoniae: 10-14 days
S. agalactiae: 14-21 days
GNR: 21 days
Listeria monocytogenes: > 21 days

Question 8

What is the recommended duration of antibiotic treatment for hospital acquired bacterial meningitis?

Answer 8

CoNS or P acnes (no pleocytosis, normal glucose, few clinical symptoms): 10 days
CoNS or P acnes (with pleocytosis, low glucose, clinical symptoms): 10-14 days
S aureus or GNR regardless of findings: 10-14 days, some recommend 21 days for GNR

Question 9

What are the prophylactic regimens for bacterial meningitis?

Answer 9

H. influenzae: Rifampin
N. meningitidis: Rifampin or ciprofloxacin (adults) or ceftriaxone
S. agalactiae: PCN G IV, Ampicillin

Question 10

What is the N. meningitis vaccination schedule?

Answer 10

Primary ACWY: 1 dose and 1 additional dose if before 16 yo

Primary B: 2 doses Bexsero or 3 doses Trumenba

• Age 16-23
• Age 10 if at risk of meningococcal exposure from outbreak

Question 11

What is the H. influenzae vaccination schedule?

Answer 11

Primary (2 doses): 2 and 4 mo with booster (1 dose): 12-15 months for PedvaxHIB or Comvax

Primary (3 doses): 2, 4, and 6 months
Booster (1 dose): age 12-15 months for ActHIB, Hiberix, Pentacel or MenHibRix

Question 12

What is the S. pneumoniae vaccination schedule?

Answer 12

Prevnar (PCV13):

• Primary (4 doses): age 2, 4, 6, and 12-15 months
• Additional (1 dose): age > 65 years

Pnemovax (PPSV23)
- Age > 65 years (must wait > 1 year after PCV13, or > 8 weeks if patient has immunocompromised condition)

Question 13

What is the CSF opening pressure in viral encephalitis?

Answer 13

< 200 mm H20

Question 14

What is CSF analysis for a typical viral encephalitis case?

Answer 14

WBC: 50-1000
Mononuclear
Glucose > 45 (45-80)
Protein < 200 (protein 20-60)

Question 15

How would you treat HSV encephalitis?

Answer 15

ACA 10 mg/kg IV Q8H for 14-21 days

Question 16

How would you treat VZV encephalitis?

Answer 16

ACA 10-15 mg/kg IV Q8H for 10-14 days +/- steroids

Question 17

How would you treat CMV encephalitis?

Answer 17

GCV 5 mg/kg IV Q12H and Foscarnet 90 mg/kg IV Q12H with induction phase 2-3 weeks with maintenance

Question 18

How would you treat HHV6? For how long?

Answer 18

GCV and/or FOS for 14-21 days