Meningitis

Question 1

Define meningitis

Answer 1

Inflammation of the meninges (including the subarachnoid space or spinal fluid), the membranes that surround the brain and spinal cord

Question 2

Define encephalitis

Answer 2

Inflammation of the brain

Question 3

Define meningoencephalitis

Answer 3

Inflammation of the meninges and the brain

Question 4

Define myelitis

Answer 4

Inflammation of the spinal cord

Question 5

Define encephalomyelitis

Answer 5

Inflammation of both the brain and the spinal cord

Question 6

What are the two types of meningitis?

Answer 6

Bacterial meningitis (clinical and laboratory evidence of meningeal inflammation with positive bacterial cultures)

Aseptic meningitis (meningeal inflammation with negative bacterial cultures, including viruses, atypical bacteria, and fungi, or there can be drug-induced causes, ie NSAIDs, sulfonamides, and carbamazepine)

Question 7

Risk factors for meningitis?

Answer 7

Newborns (less than 2 months) or adults over age 50
Asplenia (functional or anatomic)
Anatomic defects
Immunocompromised (diabetes, cancer, alcoholism, organ transplantation, HIV/AIDS)
Genetic susceptibility

Question 8

Who requires a CT scan?

Answer 8

Immunocompromised state
History of CNS disease
New onset seizure
Papilledema
Abnormal level of consciousness
Focal neurologic deficit

Question 9

What is required for diagnostic work-up?

Answer 9

History and physical exam (age, weight, allergy history, antibiotic history)
Identify risk factors that can determine therapy options
Blood cultures x 2 from 2 different sites
Lumbar puncture: gram stain, culture, and cell analysis

Question 10

When should we not do a lumbar puncture?

Answer 10

Patients with elevated intracranial pressure because there is a risk for brain herniation and death

Question 11

What is the most common bacteria that causes meningitis in adults?

Answer 11

Strep pneumoniae

Question 12

What are the primary goals of treating meningitis?

Answer 12

Eradicate the infection
Amelioration of signs and symptoms
Prevent development of neurologic sequelae (Seizures, deafness, coma, death)

Question 13

Treatment strategy for Penicillin susceptible S pneumoniae meningitis?

Answer 13

MIC would be less than 0.06 mcg/mL

Treatment: Penicillin G or Ampicillin

alternative: Cefotaxime, ceftriaxone, cefepime, or meropenem

Duration: 10-14 days

Question 14

Treatment strategy for Penicillin reisistant S pneumoniae meningitis?

Answer 14

MIC would be greater than 0.06 mcg/mL

Vancomycin + cefotaxime or ceftriaxone

Alternative: Moxifloxacin

Duration: 10-14 days

Question 15

Treatment strategy for Ceftriaxone resistant S pneumoniae meningitis?

Answer 15

MIC greater than 0.5 mcg/mL

Vancomycin + cefotaxime or ceftriaxone

Alternative: Moxifloxacin

Duration: 10-14 days

Question 16

Is chemoprophylaxis for S pneumoniae meningitis recommended?

Answer 16

Chemoprophylaxis of those who come in contact with infectious person is not recommended

Question 17

What does meningitis caused by strep pneumoniae lead to?

Answer 17

Can cause neurologic complications (ie coma/seizures)

Question 18

What does meningitis caused by neisseria meningitidis lead to?

Answer 18

Can lead to deafness and transiently impaired eye movements

Question 19

Is chemoprophylaxis for Neisseria meningitidis meningitis recommended?

Answer 19

Yes, those in close contact, ie individuals who frequently sleep and eat in the same dwelling.

Indicated for:
Household contacts
Daycare contacts
Intimate contacts
Healthcare workers with secretion contact

Question 20

Treatment options for Neisseria meningitidis?

Answer 20

Penicillin G or ampicillin (Pen susceptible)
Cefotaxime or ceftriaxone (Pen resistant)

Alternative:
Cefotaxime or ceftriaxone
Meropenem or moxifloxacin (pen resistant?)

Duration 7-10 days

Question 21

Prophylaxis options for Neisseria meningitidis?

Answer 21

Adults: Rifampin 600 mg every 12 hours for 2 days
Ceftriaxone 250 mg IM for 1 dose
Ciprofloxacin 500 mg PO for 1 dose

Children
Rifampin 10 mg/kg every 12 hours for 2 days in children 1 month and older
Ceftriaxone 125 mg IM x 1 dose for children younger than 12
Ciprofloxacin 250 mg PO x 1 dose for children over 12 years of age

Question 22

What meningococcal vaccinations are available? Who are they recommended in?

Answer 22

Menactra, Menveo, Menhibrix

Recommend routine vaccination of children at age 11 through 12 years with booster at 16 years (don’t need booster in healthy individuals who got the vaccine at or after age 16)

High risk patients should also be vaccinated, and should be revaccinated every 5 years while at risk for meningococcal disease

Question 23

What are the hallmarks of H influenzae type B meningitis?

Answer 23

Fever, decreased mental status, stick neck

Question 24

How is H influenzae type B meningitis treated?

Answer 24

Empirically with Ceftriaxone or Cefotaxime until susceptibiltiies are back

B-lactamase negative: Ampicillin first choice, alternatives are cefoxatime, ceftriaxone, cefepime, or moxifloxacin

B-lactamase positive: Cefotaxime or ceftriaxone first choice, alternatives are cefepime or moxifloxacin

Duration 7-10 days

Question 25

Prophylaxis for H Influenzae?

Answer 25

Rifampin 600 mg (20 mg/kg) daily for 4 days

Indicated in all individuals, including adults, in households with at least one unvaccinated or incompletely vaccinated child younger than 48 months

Any unvaccinated child between 12-48 months should receive one dose of the vaccine

Those between ages 2 and 11 months should be given 3 doses of the vaccine

Individuals fully vaccinated are not recommended to receive prophylaxis

Question 26

Describe H influenzae vaccination schedule?

Answer 26

3-4 dose series, depending on formulation

Given at 2, 4, 6 months (primary) and 12-15 months (booster)

One dose may be given to patients over 5 years old with sickle cell, asplenia, or immunocompromising conditions

Question 27

What role does dexamthasone play in menigitis treatment?

Answer 27

Death of bacteria can cause leakage of antigenic compounds; corticosteroids can inhibit the production of TNF and IL-1, both poent proinflammatory cytokines

Biggest impact is decreased incidence of neurologic sequelae (ie hearing loss), some mortality benefit

Mostly used in H influenzae and S pneumoniae

Biggest concern is reduced penetration of antibiotics

Other concerns: GI bleeding, hyperglycemia

Question 28

In what pts do we give dexamethasone?

Answer 28

Adults should be given for pneumococcal meningitis

Children:

• Given to children with H influenzae
• Considered in children with S pneumoniae
• Should NOT be used in neonates or any infant less than 6 weeks old

Dose: 0.15 mg/kg or 10 mg every 6 hours x 4 days

Alternative: 0.15 mg/kg or 10 mg every 6 hours for 2 days or 0.4 mg/kg every 2 hours for 2 days

First dose given 10-20 minutes prior to first antibiotic use

Question 29

Meningitis 1
JW is a 67 year old male who presents to the emergency department with fever (102.5 F), headache, and neck stiffness that has been bothering him for 2 days. PMH: Hypertension, hyperlipidemia. Allergies: NKDA, Weight 65 kg, Height: 5¶6´WBC: 17,600 cells/mm3, Serum creatinine: 1 mg/dL. Based on this patient’s risk factors, which of the following pathogens is more likely to cause his infection? Original Order: 26 ᅞ

A: Streptococcus agalactiae (Group B) ᅞ
B: Haemophilus influenzae type B ᅞ
C: Neisseria meningitidis ᅚ
D: Listeria monocytogenes

Answer 29

D: Listeria monocytogenes

Rationale: Answer: D. Listeria is most likely to occur in neonates, adults over 50, and immunocompromised. Group B Strep and H. influenzae are more common in children less than 2 years of age. Neisseria generally occurs in younger patients (1 mon to 50) and patients with immunocompromising conditions. 0/2.

Question 30

AO is a 1 week-old female neonate who was admitted 3 days ago with bacterial meningitis and started on appropriate empiric antimicrobial therapy. Cultures from the lumbar puncture are now growing Listeria monocytogenes. Allergies: NKDA. Which of the following is the MOST appropriate antimicrobial agent for streamlining AO‘s therapy?

A:Cefotaximeᅚ
B:Ampicillinᅞ
C:Vancomycinᅞ
D:Trimethoprim-sulfamethoxazole

Answer 30

B:Ampicillinᅞ

Rationale: Answer: B. Ampicillin is the drug of choice for Listeria meningitis. Cefotaxime and vancomycin are not active against Listeria. Trimethoprim-sulfamethoxazole is considered an alternative option but is not first line, especially in a neonate

Question 31

KS is a 40 year old male who presents to the ER with fever, headache, and neck stiffness.
Labs: WBC: 22,500 cell/mm3, Serum creatinine: 0.9 mg/dL. Allergies: NKDA. Weight: 70 kg. Height: 5’7”. The lumbar puncture was just drawn and sent to the lab but is still pending.
The ER physician has consulted pharmacy to assist with selecting and dosing antibiotics for empiric therapy of suspected bacterial meningitis. Which of the following regimens is MOST appropriate for KS?

A: Vancomycin 1000 mg IV every 12 hours + Ceftriaxone 1 gram IV every 24 hours
B: Ampicillin 2 grams IV every 4 hours + Cefotaxime 2 grams IV every 4 hours + Vancomycin 1500 mg IV load, followed by 1250 mg IV every 12 hours
C: Ceftriaxone 2 gram IV every 12 hours
D: Ceftriaxone 2 grams IV every 12 hours + Vancomycin 1500 mg IV load, followed by 1250 mg every 12 hours

Answer 31

D: Ceftriaxone 2 grams IV every 12 hours + Vancomycin 1500 mg IV load, followed by 1250 mg every 12 hours

Rationale: Answer: D. This patient is at risk for Streptococcus pneumoniae and Neisseria meningitidis and requires empiric coverage with vancomycin and a 3rd generation cephalosporin. A is incorrect because these are the wrong doses for meningitis. B is incorrect because ampicillin is not needed and is excessive therapy, this patient is not at risk for Listeria. C is incorrect because she needs empiric coverage for S. pneumoniae and N. meningitides until cultures and sensitivities come back, Vancomycin is missing.