Meningitis Flashcards
what are the signs and symptoms of meningitis ?
headache
neck stiffness
fever
altered mental status
vomiting confusion
photophobia
seizures
common pathogens of bacterial meningitis ?
streptococcus pneumonia
neisseria meningitis
haemophilus influenza
common in over 60 years old
common pathogens of viral meningitis ?
coxsackievirus
echovirus
polio
HSV1 - viral encephalitis
hsv2 - most common cause viral meningitis
varicella zoster
investigations to order ?
bedside
bloods - FBC , UE , LFT , COAG , CRP
glucose
serum pneumococcal and meningococcal PCR
VBG - with lactate
ECG
monitor urine output - Cather if derailing , and input and output
Blood culture
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LP - if this cannot be done within the first hour, IV antibiotics should be given after blood cultures have been taken
then take LP as soon as possible - ideally within 4 hours of starting therapy
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CT scan is not normally indicated if we are suspecting meningitis
can be used to exclude abcess
meningeal enhancement is seen
MRI more sensitive for viral
when is LP contraindicated ?
signs of severe sepsis or a rapidly evolving rash
severe respiratory/cardiac compromise
significant bleeding risk
signs of raised intracranial pressure
focal neurological signs
papilloedema
continuous or uncontrolled seizures
GCS ≤ 12
what is tested in CSF ?
CSF cell count , glucose, protein, microscopy and culture and sensitivities and lactate
meningococcal and pneumococcal PCR
enteroviral, herpes simplex and varicella-zoster PCR
consider investigations for TB meningitis
CSF analysis
Bacterial
Appearance - cloudy
Glucose - Low (< 1/2 plasma)
Protein - High (> 1 g/l)
White cells - 10 - 5,000 polymorphs/mm³
Viral
Appearance - cloudy / clear
Glucose - 60-80 percent of plasma glucose
Protein - normal or raised
White cells - 15 - 1,000 lymphocytes/mm³
TB
Appearance - cloudy with fibrin webb
Glucose - Low (< 1/2 plasma)
Protein - High (> 1 g/l)
White cells - 30 - 300 lymphocytes/mm³
fungal
same as bacteria however predominantly lymphocytes
empirical management for meningitis ?
Follow local guidelines of the hospital
1) Initial empirical therapy aged < 60 years
IV cefotaxime (or ceftriaxone)
IV dexamethasone
‘consider adjunctive treatment with dexamethasone (particularly if pneumococcal meningitis suspected in adults- if confirmed continued for 4 days), preferably starting before or with first dose of antibacterial, but no later than 12 hours after starting antibacterial
; avoid dexamethasone in septic shock, meningococcal septicaemia, or if immunocompromised, or in meningitis following surgery
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immunocompromised and above > 60
IV cefotaxime (or ceftriaxone)
+
Amoxicillin / ampicillin
+
IV dexamethasone
==========
if pregnant
IV ceftriaxone + IV amoxicillin
IV dexamethasone ( if confirmed or suspected pneumococcal cause)
Management of contacts?
people who have been exposed to a patient with confirmed bacterial meningitis should be given prophylactic antibiotics if they have close contact within the 7 days before onset
oral ciprofloxacin or rifampicin may be used.
The Health Protection Agency (HPA) guidelines now state that whilst either may be used ciprofloxacin is the drug of choice as it is widely available and only requires one dose
meningococcal vaccination should be offered to close contacts when serotype results are available, including booster doses to those who had the vaccine in infancy
for pneumococcal meningitis, no prophylaxis is generally needed.
TB meningitis tx
The standard 12-month regimen, consisting of isoniazid, rifampicin, ethambutol and pyrazinamide daily for the first 2 months
followed by isoniazid and rifampicin daily for an additional 10 months
tx of viral encephalitis
analgesia
fluids
anti-emetics
