Meningitis

Question 1

Background

Answer 1

NICE defined: infection of the surface of the brain (meninges) by bacteria that have usually travelled there from mucosal surfaces via bloodstream.

• Meningitis and septicaemia can kill in hours.
• Meningitis is the inflammation of the lining around the brain and spinal cord.
• Septicaemia is the blood poisoning form of the disease. Large amounts of bacteria in the blood.
• The two forms of the disease have different symptoms.
• People who recover from meningitis and septicaemia may be left with a range of after effects that dramatically alter their lives.

Question 2

Causative organisms

Answer 2

Older adults:
- Streptococcus pneumoniae (Pneumococcus),
- Neisseria meningitidis (meningococcus),
- Listeria monocytogenes

Adolescents and young adults:
- Neisseria meningitidis,
- Streptococcus pneumoniae

Children and young 3 months and older:
- Neisseria meningitides (meningococcus),
- Streptococcus pneumoniae (pneumococcus)
- Haemophilus influenza type b (Hib)
Organisms normally occur in URTI

Neonates (<28 days):
- Streptococcus agalactiae (Group B streptococcus),
- Escherichia coli,
- S pneumoniae
- Listeria monocytogenes.

Meningitis can also occur as a complication of TB, HIV, AIDS, Sper fungal infection, parasites and cancers.

Question 3

Signs and Symptoms

Answer 3

Start flu like symptoms: intense headache, fever, sore throat, nausea, vomiting, stiff neck and bulging fontanelle in children.
Few hours: delirium, coma and convulsions
Extra in infants: irritability, tiredness and poor feeding

Meningitis:
- Rash (anywhere)
- Fever/vomiting
- Drowsy and less responsive
- Cold hands and feet/shivering
- tachycardia / unusual breathing
- Stomach/Joint/Muscle pain

Septicaemia:
- Rash (anywhere)
- Fever/vomiting
- Drowsy and less responsive
- Severe headache
- Stiff neck
- Photophobia

Question 4

Diagnosis

Answer 4

2 aspects:
- Physical examination AND
- Histological test

Physical examination:
- Kernig’s and Brudzinski’s signs
Kering- Place patient supine. Flex leg at hip and knee. THEN try extend leg while his is flexed. If pain is experienced and possible spasm in hamstring and resists further extension = meningeal irritation

Brudzinski- Place patient supine. place hand on back of their neck and lift head towards chest. IF meningeal irritation They will flex HIPs and KNEEs in response.

Histological test:
- Spinal fluid examination using spinal tap (lumbar puncture)
- CRP and/or WCC
- For definite diagnosis CSF shows Low glucose, Increased WBC and increased CRP. CSF analysis helps find causative bacteria.
- PCR test can be done

Question 5

Treatment meningitis

Answer 5

Depends on causative organism

Initial empirical therapy:
- Transfer to hospital ASAP
- Meningococcal disease sus, before transfer = benzylpenicillin sodium
ALT cefotaxime
ALT penicillin allergy: Chloramphenicol

• IN hospital adjunctive dexamethasone before or with 1st dose of antibacterial but not after 12 hrs of antibacterial start.
  AVOID IF SEPTIC SHOCK,

IN hospital aetiology unknown:
TREATMENT FOR ALL AGES - 10 days

3 months to 59 yrs - Cefotaxime or ceftriaxone
- Can + vancomycin if prolong or multiple use of antibacterial in last 3 months or travelled in last 3 months outside of UK with highly penicillin/ cephalosporin-resistant pneumococci.

Adult 60 or +:
Cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin)
- Can + vancomycin (if same as above)

Neonate and 1-3 months -
Same as 60+ BUT duration 14 days

Meningitis caused by meningococci:
ALL ages
Benzylpenicillin sodium or cefotaxime (or ceftriaxone)
ALT IF allergy Chloramphenicol
- Treatment duration 7 days

Meningitis caused by pneumococci: ALL AGES
Cefotaxime (or ceftriaxone)
- Can + Dexamethasone (same condition as with empirical)
- IF penicillin-sensitive, replace cefotaxime with benzylpenicillin
- Microorganism penicillin/ cephalosporin resistant +vancomycin and if need rifampicin
- Treatment duration 14 days

Meningitis caused by Haemophilus influenzae:
ALL AGES
Cefotaxime (or Ceftriaxone)
ALT IF History of allergy or microorganism resistant -
= Chloramphenicol
- Can add Dexamethasone (same condition as with empirical)
- Treatment duration 10 days
H. influenzae type B give rifampicin for 4 days before hospital discharge to <10 years OR those in contact with vulnerable people at home.

Meningitis caused by Listeria:
ALL AGES
Amoxicillin (or ampicillin) + gentamicin
ALT IF allergy to penicillin =
Co-trimoxazole
- Treatment duration 21 days
- Consider stopping gentamicin after 7 days

Meningitis caused by group B streptococcus:
CHILDREN ONLY
Benzylpenicillin sodium + gentamicin OR cefotaxime (or ceftriaxone) alone
- Treatment duration minimum 14 days and stop gentamicin after 5 days