Meningitis Flashcards
clinical classic 3 presentation of acute bacterial meningitis
high fever, neck stiffness and AMS
Common organism for bacterial meningitis in ages 2-50 yrs
Streptococcus pneumoniae and Neisseria meningitidis
Empiric abx for patients from 2-50 yrs with acute bacterial meningitis
vancomycin and 3rd gen cephalosporin
cover cephalosporin resistant strep and reg Strep
Common organisms that cause bacterial meningitis >50 yrs
Strep pneumoniae, N meningitidis, Listeria
Empiric abx for patients from >50 yrs with acute bacterial meningitis
Vancomycin, ampicillin and 3rd generation cephalosporin
Common organisms that cause bacterial meningitis in immunocompromised pts
Strep pneumoniae, N meningitidis, Listeria and GRAM NEGATIVE RODS
Empiric abx for immunocompromised pts with acute bacterial meningitis
vancomycin + ampicillin + cefepime
Common organisms that cause acute bacterial meningitis in patients who recently had neurosurgery/ penetrating skull trauma
gram negative rods, MRSA,
coagulase negative Staph
Empiric abx for patients who have suspected bacterial meningitis and had recen neurosurgery or skull penetrating injury
vancomycin and cefepime
Who needs a CT scan prior to lumbar puncture in the rule out of meningitis?
AMS, new seizure, focal deficit, immunocompromise, CNS dx or papilledema
Also give abx prior to LP or CT scan.
What drug is given before first dose of abx for patients with suspected bacterial meningitis?
dexamethasone 10 mg
(reduces neurological sequelae and lowers risk for hearing loss) and mortality in those with pneumococcal meningitis.
STOP steroids if CSF gram stain or culture or blood culture) indicates infection with a non penumoccocal organism.
herpes encephalitis presentation
high fever, AMS, seizure, and/or focal neurological deficits and rarely associated w/ neck stiffness or nuchal rigidity.
85% of cases of HSV will have gential lesions
Medication used to treat herpes encephalitis
acyclovir.
In patients who have suspected meningitis or HSV encephalitis what can you give?
can give vancomycin + rocephin and acyclovir as empiric if strong enough suspicion but never give acyclovir alone.
cause of meningococcal meningitis
neisseria meningitidis
presentation of meningococcal meningitis
nonspecific fever, headache, vomiting, myalgias, sore throat, and within 12-24 hrs see petechiae, purpura, meningeal signs and AMS
treatment of meningococcal meningitis
ceftriaxone
complications of meningococcal meningitis
shock,
DIC,
adrenal hemorrhage
precautions and prevention of spread of meningococcal meningitis
droplet precautions (wear surgical mask within 6 feet) and chemoprophylaxis for close contacts
house hold members
roommates of intimate contacts
child care center workers
persons directly exposed to respiratory or oral secretions
person seated next to affected person for >8 hrs (airline traveler)
What is chemoprophylaxis for close contacts with meningococcal meningitis?
rifampin, ciprofloxacin, and ceftriaxone
how to treat protein C deficiency and purpura fulminans related to Neisseria meningitidis?
protein c concentrate
how often to vaccinate asplenic patients?
vaccinate asplenic patients 14 days prior to and post splenectomy and revaccinate every 5 years
Gram positive bacilli seen on CSF and immunocompromised pt with meningitis. What abx do you use to treat?
ampicillin only
it’s going to be Listeria. Affects neonates, adults>50 yrs and immunocompromised pts.
Can give penicillin G too. Sometimes can have aminoglycoside added for synergy.
who is at greater risk for meningococcal dx?
apslenic pts
need booster vaccine for meningococcus every 5 years for boster.
if suspecting meningitis first thing you should do for management
IV antibiotics and adjuvant dexamethasone.
CT scan can take up to 6 hrs and LP also takes a while. Can still have pathogens culture after 4-10 hrs of antibiotic initiation.
Does a pt with suspected meninigitis need a CT scan prior to LP?
no they don’t.
presentation of West Nile Virus
asymptomatic but 20-40% with symptoms
see encephalitis, meningitis or mixed.
maculopapular rash (20-50% in chest arms, back
acute asymmetric flaccid paralysis
extrapyramidal symptoms (upper>lower extremity)
Parkinsonian symptoms (with rigidity)
Sometimes described as a poliomyelitis like syndrome- see unilateral weakness to quadriplegia and respiratory failure
labs of WNV
CSF pleocytosis with lymphocytic predominance
CT head is normal and MRI may show nonspecific FLAIR enhanced abnormalities
EEG -show frontal and temporal generalized slowing
MRI- shows bilateal enhancement of thalamus and basal ganglia
IgM is detectable in CSF in greater than 90% of pts with WNV neuroinvasive dx at the time of presentation.
Diagnosis of WNV
positive serum IgM antibody (pts with fever only)
CSF positive IgM antibody (pts with CNS dx)
highest incidence of WNV is
summer months due to vector of the mosquito
asymmetrical flaccid paralhysis and extrapyramidal symptoms with fever and sometimes a maculopapular rash and AMS
West Nile infection
where does the west nile virus attack
anterior horn cell (poliomyelitis) rather than transverse leukomyelitis thus will have sparing of ascending (pain and temperature and vibration or proprioception) and descending (pyramidal and extrapyramidal motor system and autonomics)
Treatment of WNV
supportive and prevention of mosquito control
enterovirus causing viral meningitis presentation
happens in summer and early fall and present with severe headache, neck stiffness and photophobia and low grade fever and no mental status changes. NO flaccid paralysis
who gets airborne precautions
TB
varicella and SARS and measles
who gets contact precautions
MRSA, VRE
C diff, E coli O157:H7
parasitic scabies
viral RSV
who gets droplet precautions
H influenzae type B, neisseria meningitidis
mycoplasma pneumoniae
influenzae and adenovirus
Does a partner need Neisseria meningitis prophylaxis if they have been exposed to someone who has it and already had vaccination for Neisseria
yes. doesn’t matter if they had been vaccinated for Neisseria.
Anyone with 3-6 feet for more than 8 hours need repeat prophylaxis with rifampin, ciprofloxacin, and ceftriaxone.
age 2-50 yrs:
most common organisms for meningitis
empiric antibiotics:
strep pneumo
neisseria meningitis
tx with vancomycin and 3rd gen cephalosporin
Age >50 yrs
most common organisms for meningitis
empiric antibiotics:
strep pneumoniae
Neisseria meningitis
listeria
Start vancomycin + ampicillin + 3rd gen cephalosporin
Immunocompromised pt
most common organisms for meningitis
empiric antibiotics:
strep pneumoniae
Neisseria meningitis
listeria
AND gram neg rods
Vancomycin + ampicillin + cefepime
Neurosurgery and penetrating skull trauma
most common organisms for meningitis
empiric antibiotics:
Gram neg rods, MRSA
coagulase neg staph
vancomycin and cefepime
if you can’t use cefepime to treat meningitis what alternate antibiotics can you use?
ceftazidime or meropenum
if you can’t use ampicillin to treat listeria meningitis what can you use instead?
bactrim for listeria.
Why do we not like pipercillin/tazobactam for pseudomonal coverage in meningiditis?
it has poor CNS penetration unlike cefepime which is excellent.
lab findings concerning for HSV encephalitis:
CSF with HSV PCR positive or show lymphocytic pleocytosis
CT or MRI brain shows temporal lobe abnormalities
EEG shows high amplitude slow waves >80% of pts
signs of HSV encephalitis
rapid onset <1 week and fever and headache
see focal neurological deficits (cranial nerve palsies, hemiparesis, ataxis)
see mental status changes and seizures
will giving empiric acyclovir skew results for CSF?
no it won’t it doesn’t affect PCR results even if acyclovir has been given for 7 days
When treating someone with viral meningitis or HSV meningitis and they are on acyclovir what should you also do to their regimen?
need to give IVF fluids of at least 2L/day with goal UOP of 75 cc/hr to reduce renal drug concentration and prevent crystal formation.
Acyclovir is a very poorly soluble medication and you can have AKI develop within 48 hrs of using this medication and so need to prevent this happening.
Can give loop diuretics ot help flush crystals from renal tubules.
consider meningitis when there’s
sinusitis and recent head trauma
