CNS Infections

Question 1

Most common symptoms of bacterial meningitis?

Answer 1

Fever
HA
Nuchal Rigity
Photophobia

*newborns may just be irritable, vomit, poor feeding, inactive.

Question 2

Who is most likely to get meningitis?

Answer 2

< 2 months old (80%)

Question 3

What are the most common orgs for meningitis?

Answer 3

Strep Pneumo, Group B Strep, N. Meningitidis, H flu

• H Flu is more common in < 23 months
• N meningitidis and S. pneumo are most common for those > 2 years of age.

Question 4

CSF findings of bacterial meningitis?

Answer 4

WBC 1000-5000 (normal csf is < 5)
-mostly Neutrophils (normal csf is mostly lymphocytes)
Glucose is low (normal csf is 45-80 mg/dl)
Protein is high (normal csf is 20-60 mg/dl)

Question 5

CSF findings of Viral meningitis?

Answer 5

WBC 50-1000 (normal csf is <5)
-High, but not as high as bacterial infxn
-Mosly mononuclear (normal csf is mainly lymphocytes)
Glucose normal (>45)
Protein normal to slighly elevated (normal is 20-60)

Question 6

Who gets a lumbar puncture?

Answer 6

Everyone suspected of meningitis. However, if pt has risk for herniation (immune compromised, history of CNS dx, etc) delay the LP until after a CT can rule out central mass (risk for herniation). Don’t delay abx or dexamethasone though.

Question 7

Which suspected meningitis patients get empiric antibiotics and dexamethasone?

Answer 7

All of them.

Question 8

What is the most common empiric regimen for meningitis?

Answer 8

High dose rocephin (100 mg/kg divided BID) + Vancomycin 60 mg/kg/day.

For < 1 month olds: Amp + (gent or cefotaxime) [but you
already knew that didn’t you?]

• can use cefotaxime instead of rocephin
• *If healthcare associated, give anti-pseudomonal beta-lactam. (Merrem, ceftaz, cefepime). No steroids?

Question 9

Only one carbapenem has meningitis indication. Which one is it?

Answer 9

Merrem

Question 10

Can you administer beta-lactams intrathecally?

Answer 10

No. Neurotoxic and seizures.

Question 11

What volume should intrathecal dose be?

Answer 11

5-10 ml

Question 12

Who should gets steroids for meningitis?

Answer 12

Empircally? Everyone with community acquired.

Kids with H flu suspected or confirmed
Adults with Strep Pneumo suspected or confirmed.

Question 13

How do you give steroids to patients with meningitis?

Answer 13

0. 15 mg/kg q6h for 2-4 days (10-20 min B4 abx)

* can stop once H flu and Strep pneumo are ruled out

Question 14

Duration of therapy for meningitis?

Answer 14

Community acquired: depends on organism. 7-21 days (or even longer if listeria)

Healthcare acquired: 10-14 days.

*IV the whole time

Question 15

If you come into close contact with people who have meningitis due to certain oraganisms, you need to have antimicrobial prophylaxis. Which organisms and what prophy?

Answer 15

H flu type b (Hib): Rifampin 20 mg/kg (up to 600 mg) daily for 4 days.

Neisseria Meningitidis: Rifampin x 2 days or Cipro 500 mg once or rocephin IM once.

Strep agalactiae (aka Group B Strep): pregnant women who are GBS positive should get intrapartum PCN 5 MU x 1 then 2.5 MU q4h until delivery.

Question 16

What is an abnormal csf openning pressure?

Answer 16

Anything greater than 200 mm H2O

Question 17

What are normal CSF: WBC, Predominant Cell type, Glucose, Protein, CSF/Blood Glucose Ratio?

Answer 17

WBC: = 5 cells/mm3
Predominantly Lymphoytes (>70%)
Glucose usually 45-80
Protein: 20-60 mg/dL
CSF glucose to Blood glucose: 60%

Question 18

Elevates glucose in CSF is indicative of what kind of pathogen?

Answer 18

Viral

Question 19

What if you come into contact with someone who has Neisseria meningitis? Do you need to prophylax? What if you’ve had the vaccine?

Answer 19

Prophylax close contacts (home and daycare, not work, or school), regardless of vaccination status.

Rifampin x 2 days (600 mg BID) OR
Cipro 500 mg PO once OR
Rocephine 250 mg IM once.