CNS Infections Flashcards
What is the initial management of suspected meningitis?
Transfer patient to hospital urgently
*If meningococcal disease is suspected, administer benzylpenicillin sodium before transfer to hospital (as long as this does not delay transfer)
**If a patient with suspected bacterial meningitis without non-balancing rash cannot be transferred to hospital urgently, give benzylpenicillin sodium before transfer
SECOND LINE: cefotaxime (if penicillin allergy); chloramphenicol may be used if history of immediate hypersensitivity reaction to penicillin or cephalosporins
What sign is primarily used to distinguish meningococcal meningitis from other causes of meningitis?
Presence of non-blanching rash
*presence of confirmed meningococcal sepsis is also an indication
What is the antibiotic treatment of suspected meningococcal meningitis OR non-meningococcal bacterial meningitis where patient cannot be transferred to hospital urgently?
IV or IM benzylpenicillin sodium administration (before transfer to hospital as long as this does not delay transfer)
- Child 1-11 mo: 300 mg single dose prior to urgent transfer to hospital
- Child 1-9 yo: 600 mg single dose “ “
- Child 10-17 yo: 1.2 g single dose “ “
- Adult: 1.2 g single dose “ “
SECOND LINE: cefotaxime or chloramphenicol (later in cases of immediate hypersensitivity reaction to penicillins and cephalosporins)
Once in hospital, what adjunct therapy should be considered in cases of meningitis?
Dexamethasone (particularly if pneumococcal meningitis suspected in adults; discontinue if another cause is suspected or confirmed)
Adult dose: 10 mg 6 hourly for 4 days, IV injection
** avoid dexamethasone in septic shock, meningococcal septicemia, if immunocompromised, or in meningitis following surgery
When is dexamethasone administered in cases of meningitis?
In cases of confirmed or suspected pneumococcal meningitis in adults; preferably starting before or with first dose of antibacterial but NO LATER than 12 hours after start of abx
*discontinue if another cause of meningitis is suspected or confirmed
What is the empiric abx of choice in cases of HOSPITAL-acquired meningitis of UNKNOWN etiology for:
- patients 3 mo-50 yo
- patients <3 mo and >50 yo
- 3mo-50 yo: cefotaxime or ceftriaxone for at least 10 days
- patients <3 mo and > 50 yo: cefotaxime or ceftriaxone AND amoxicillin or ampicillin (to cover for listeria) 10 days
- in both cases, consider adding vancomycin if prolonged or multiple use of other abx in the last 3 months, OR if travelled to areas outside the UK with highly penicillin- and cephalosporin-resistant pneumococci in the last 3 mo
What is the treatment of choice for meningitis caused by meningococci?
FIRST LINE: IV Benzylpenicillin sodium OR cefotaxime OR ceftriaxone (IV injection or infusion, 7 days)
*ceftriaxone may also be administered via deep IM injection
SECOND LINE: Chloramphenicol (7 days) if history of immediate hypersensitivity reaction to penicillin or cephalosporins
What is the abx of choice in pneumococcal meningitis?
Cefotaxime or ceftriaxone 14 days
*consider adjunct dexamethasone, preferably starting before or with the first dose of abx, but no later than 12 hours after starting abx (may reduce penetration of vancomycin into CSF)
**if penicillin-sensitive, replace cefotaxime with benzylpenicillin sodium
***if highly penicillin- and cephalosporin-resistant, add vancomycin and if necessary rifampicin
What is the abx of choice for treating meningitis caused by H.influenza?
FIRST LINE:
- Cefotaxime or ceftriaxone (10 days)
SECOND LINE: if history of immediate hypersensitivity to penicillin or cephalosporin, or if resistance to cefotaxime
- chloramphenicol (10 days)
*consider adding dexamethasone, preferably starting before first dose of abx and no later than 12 hours after starting abx
What abx is used as prophylaxis against bacterial meningitis in vulnerable household contacts?
Rifampicin or ciprofloxacin (4 days, PO) for contacts from 7 days pre-symptom onset
*abx prophylaxis typically not given to contacts in cases of confirmed pneumococcal meningitis
What is the abx of choice used against meningitis caused by listeria?
FIRST LINE:
- amoxicillin OR ampicillin AND gentamicin (21 days; consider stopping gentamicin after 7 days)
SECOND LINE:
- co-trimoxazole (21 days) if history of immediate hypersensitivity reaction to penicillin
What are the common causes of meningitis in newborns (0-6 mo)? (3)
- GBS
- E.coli
- Listeria
**bacteria found in the vaginal canal
What are the common causes of meningitis in children 6 mo - 6 yrs? (4)
- Strep pneumo (following pneumonia)
- N.meningitidis
- H.influenza type b
- Enteroviruses (esp. coxsackievirus)
What are the common causes of meningitis in individuals aged 6-60 yo? (4)
- Strep pneumo (following pneumonia)
- N.meningitidis (most common in teens)
- Enteroviruses (esp coxsackievirus, also poliovirus, echovirus)
- HSV-2 (HSV-1 is more commonly implicated in encephalitis)
What are the common causes of meningitis in patients > 60 yo? (3)
- Strep pneumo (following pneumonia)
- Gram (-) rods including E.coli
- Listeria
**note these pathogens are very similar to those causing meningitis in neonates (GBS, E.coli, Listeria); both demographics have reduced immunity and so are more susceptible to infection by listeria and GIT microbes
