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Meningitis and Encephalitis Flashcards

1
Q

Inflammation/infection of the membranes surrounding the brain and spinal cord

A

Meningitis

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2
Q

Acute inflammation/infection of brain parenchyma

A

Encephalitis

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3
Q

Gram + cocci

A

Streptococcus pneumonia

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4
Q

Gram - coccobacilli

A

Haemophilus influenzae

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5
Q

Gram - cocci

A

Neisseria meningitidis

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6
Q

Gram - bacilli

A

Gram negative bacteria (E.coli, Klebsiella, Pseudomonas)

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7
Q

Gram + bacilli

A

Listeria monocytogenes

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8
Q

Risk factors for Meningitis

A 
Sickle cell anemia
Asplenic status
Cochlear implants
Head trauma
Immunosuppression
Mastoiditis, URT infection, Otitis media 
Exposure to cigarette smoke
Alcoholism
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9
Q

Incidence trend

A

Decreasing due to introduction of vaccines
Shift from young to adult population due to vaccines
1986: 4.9 cases per 100,000
1998: 2 cases per 100,000
2007: 1.4 cases per 100,000

Age Distribution
18 yrs: 20.8, 51.5

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10
Q

Vaccines

A

Haemophilis influenza Type B (more virulent form; cause of epiglottitis)
S. pneumoniae
N. meningitidis

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11
Q

Sequelae

A 
MC after S. pneumo infections 
~30% develop neuro sequelae
Sensorineural hearing loss
Hydrocephalus
Focal sensory motor defects
Seizure disorder
Death 2-30%, avg 20%
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12
Q

Adheres to the skull

A

Dura mater

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13
Q

Lies between the dural and pia maters

A

Arachnoid mater

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14
Q

Lies directly over brain tissue

A

Pia mater

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15
Q

Between arachnoid and pia mater; This becomes inflammed w/meningitis

A

Subarachnoid space

-CSF flows thru this space

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16
Q

CSF flows thru this space

A

Subarachnoid space

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17
Q

Where and how is CSF produced

A

Largely made by the choroid plexus in the lateral and fourth ventricle

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18
Q

CSF flow

A

Unidirectionally, down the spinal cord

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19
Q

CSF Amounts

A

Differ by age:
Infants: 40-60ml
Children: 60-100ml
Adults: 110-160ml

Important for determining different drug concentrations in the CSF for Tx

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20
Q

Injecting drugs into the CSF cavity

A

Intrathecal

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21
Q

Injecting drugs into ventricles

A

Intraventricular (Increased risk of increased endotoxin release into the CNS–not for meningitis tx)

MC for neurosurgery or shunt infections

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22
Q

Factors that INCREASE penetration of abx into the CSF

A 
Meningeal inflammation
Low molecular weight medication
Lipid soluble compounds (lipid bilayer)
Compounds that remain unionized at physiologic pH
Low protein bound medications
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23
Q

Medications with therapeutic levels in CSF +/- Inflammatoin

A

Sulfonamides/Trimethoprim
Chloramphenicol (misc abx, not used often)
Rifampin
Metronidazole
Isoniazid, Pyrazinamide, Ethionamide (for TB)

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24
Q

Medications with therapeutic levels WITH inflammed meninges

A 
B LACTAMS: 
Penicillin G
Nafcillin
Cefotaxime
Ceftriaxone
Ceftazidime
Imipenem
Meropenem
Vancomycin
Linezolid -  VRE
Aztreonam - Gram - specialist
Ciprofloxacin
Fluconazole - Antifungal
Ganciclovir - Antiviral
Acyclovir - Antiviral
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25
Medications with NON-Therapeutic levels in CSF +/- inflammation
``` Aminoglycosides First generation cephalosporins Second generation cephalosporins (Except cefuroxime) Clindamycin Amphotericin - Antifungal ```
26
Pathophysiology of Bacterial Meningitis | Sources of Infection
Contiguous spread: Sinusitis, otitis media, birth defects Hematogenous: Bacteremia seeding meninges Direct inoculatoin: Trauma, neurosurgical comps Reactivation of latent disease: HSV, TB
27
CNS response to infection
Contact w/bacterial cell wall components triggers cytokine release (TNF alpha, IL-1, PAF); Platelet activating factor (PAF) triggers clotting cascade, forming microthrombi; Cytokine cascade stimulated vasodilation and vascular permeability; Compromised BBB allows entry of neutrophils and other blood components --->CEREBRAL EDEMA -> Increased ICP --> Decreased cerebral blood flow --> Signs/sxs of meningitis AND Ischemic and direct tissue damage
28
Signs/Sxs of Meningitis
HA, fever, neck stiffness, altered mental status, seizures, abnormal CSF findings [Adults >65 have more muted signs/sxs]
29
Diagnostic tests for meningitis
Lumbar puncture: CSF cell count, chemistries, gram stain, culture Blood culture Rapid diagnostic methods: Latex fixation, enzyme immunoassay, PCR
30
CSF Findings
NORMAL: BACTERIAL MENINGITIS WBC 80 Protein <60% SBG) Gram stain 75-90%+
31
Likely Meningitiis Pathogens in Age <1 month
Group B Streptococcus, E.coli, L.monocytogenes, Klebsiella species
32
Likely Meningitis Pathogens in Age 1-23 months
S.pneumoniae, N. menigitidis, Group B Strep, H.flu, E. coli
33
Likely Meningitis Pathogens in Age 2-50 yrs
N. menigitidis, S. penumoniae
34
Likely Meningitis Pathogens in Age >50 yrs
S. pneumoniae, N meningitidis, L monocytogenes, Gram - bacilli (EKP)
35
Treatment Goals
Eradicate infection: rapid initiation of Abx is importnat Improve signs and sxs: analgesics, fluids, antipyretics Prevent development of neurologic sequelae and survive
36
See Management Algorithm for Adults w/Suspected Bacterial meningitis
Note: Do not delay abx start up if LP needs to be delayed (delayed abx leads to increased morbidity and mortality) *It takes 12-24 hours to see changes in CSF after starting Abx (can still do a LP later within 24 hours)
37
NEGATIVE CSF Gram Stain or Gram Stain NOT Available: | Age <1mo Common Pathogens
Group B Streptococcus E. coli L monocytogenes Klebsiella sp
38
NEGATIVE CSF Gram Stain or Gram Stain NOT Available: | Age <1mo Antimicrobial Therapy
Ampicillin + Cefotaxime OR Ampicillin + Aminoglycoside (synnergistic effect)
39
NEGATIVE CSF Gram Stain or Gram Stain NOT Available: | Age 1-23 mo Common Pathogens
``` S. pneumo N menigitidis Group B strep H flu E coli ```
40
NEGATIVE CSF Gram Stain or Gram Stain NOT Available: | Age 1-23 mo Antimicrobial Therapy
Vancomycin + 3rd Gen Cephalosporin (Cefotaxime or Ceftriaxone)
41
NEGATIVE CSF Gram Stain or Gram Stain NOT Available: | Age 2-50 yrs Common Pathogens
N menigitidis | S penumoniae
42
NEGATIVE CSF Gram Stain or Gram Stain NOT Available: | Age 2-50 yrs Antimicrobial Therapy
Vancomycin + 3rd Gen Cephalosporin (Cefotaxime or Ceftriaxone)
43
NEGATIVE CSF Gram Stain or Gram Stain NOT Available: | Age >50 yrs Common Pathogens
S pneumoniae N meningitidis L monocytogenes Gram - bacilli
44
NEGATIVE CSF Gram Stain or Gram Stain NOT Available: | Age >50 yrs Antimicrobial Therapy
Vancomycin + Ampicillin + 3rd Gen Cephalosporin
45
POSITIVE CSF Gram Stain Gram + Diplococci
S. pneumoniae Ceftriaxone or Cefotaxime + Vanco + Dexamethasone
46
POSITIVE CSF Gram Stain Gram - Diplococci
N meningitidis Ceftriaxone or Cefotaxime
47
POSITIVE CSF Gram Stain G + Bacilli
L monocytogenes Ampicillin +/- Gentamycin
48
POSITIVE CSF Gram Stain Gram - Bacilli
H flu, Coliforms, Pseudomonas aeruginosa Ceftazidime or Cefepime +/-Gentamycin (All cover Pseudomonas)
49
PATHOGEN IDENTIFICATION & SENSITIVITY KNOWN Group B Strep (Gram + cocci)
Penicillin G or Ampicillin Alt: Ceftriaxone or Cefotaxime 14-21 Days
50
PATHOGEN IDENTIFICATION & SENSITIVITY KNOWN H flu (Gram - bacilli)
Ceftriaxone Alt: Chloramphenicol, Cipro, Aztreonam 7 Days
51
PATHOGEN IDENTIFICATION & SENSITIVITY KNOWN N meningitidis (Gram - diplococci)
Ceftraixone Alt: Chloramphenicol 7 Days
52
PATHOGEN IDENTIFICATION & SENSITIVITY KNOWN L monocytogenes (Gram + bacilli)
Ampicillin +/- Gentamicin Alt: TMP/SMX, Meropenem >21 Days
53
PATHOGEN IDENTIFICATION & SENSITIVITY KNOWN S. pneumo (G + diplococci) Pen MIC <0.1
Penicillin G or Ampicillin Alt: Ceftriaxone or Chloramphenicol 10-14 Days
54
PATHOGEN IDENTIFICATION & SENSITIVITY KNOWN S. pneumo (G + diplococci) Pen MIC 0.1-1
Ceftriaxone or Cefotaxime Alt: Cefepime or Meropenem 10-14 Days
55
PATHOGEN IDENTIFICATION & SENSITIVITY KNOWN S. pneumo (G + diplococci) Pen MIC >2
Vanco + Ceftriaxone (Or Cefotaxime) Alt: Moxifloxacin 10-14 Days
56
PATHOGEN IDENTIFICATION & SENSITIVITY KNOWN S. pneumo (G + diplococci) Ceftriaxone MIC >1
Vanco + Ceftriaxone (Or Cefotaxime) Alt: Moxifloxacin; If Ceftriaxone MIC >2, Add Rifampin 10-14 Days
57
Dexamethasone Rationale
The subarachnoid space inflammatory response during bacterial meningitis is a major factor contributing to morbidity and mortality; Attenuation of this inflammatory response may diminish many of the pathophysiologic consequences of bacterial meningitis Dexamethasone=Steroid (decreases inflammation and the immune function) -But...may decrease immune function and decrease ability to abx to cross BBB
58
Adjunctive Dexamethasone in Bacterial Meningitis
Infants and Children w/ Haemophilus influenzae Type B Meningitis (only if started before abx) Adults with pneumococcal meningitis (Only if started before abx) Administer at 0.15mg/kg q6h for 2-4 days 15 minutes BEFORE or with first antimicorbial dose to help attenuate the increased inflammation after abx kills bacteria
59
Who should receive meningitis prophylaxis?
Close contacts of patients with either H. flue or Neisseria meningitidis should receive prophylaxis
60
H. flu prophylaxis
Rifampin 600mg PO q24h x 4days
61
Neisseria meningitidis prophylaxis
Ceftriaxone 250mg IM x1 Rifampin 600mg PO q12h x4 doses or Ciprofloxacin 500mg PO x1 (if not resistant)
62
Viral Encephalitis Etiology
``` Enteroviruses (85%) - MC Arboviruses (St. Louis, La Crosse, West Nile) Adenoviruses HSV HIV Influenza Cytomegalovirus ```
63
Viral Encephalitis Clinical Presentation
``` HA Mild fever Nuchal rigidity +/- Malaise Photophobia Decreased LOC Rash (West Nile) Nausea Vomiting ```
64
Viral Encephalitis Clinical Course
Most are self limiting (1-2 wks duration) | West Nile and HSV associated with significant morbidity and mortality
65
Viral Encephalitis Treatment: Enteroviral
Supportive care: Fluids, antipyretics, analgesics
66
Viral Encephalities Tx: West Nile
Supportive care Anti-seizure medication if needed Tx for increased ICP as needed
67
Viral Encephalitis Tx: HSV
Supportive care Anti-seizure medications Acyclovir: 10mg/kg IV q8h for 2-3 weeks (adults)
68
CNS Infection Tx Dosing: | Acyclovir
Adult: 10mg/kg IV q8h Peds: 20mg/kg IV q8h
69
CNS Infection Tx Dosing: | Ampicillin
Adult: 2gm IV q4h Peds: 75mg/kg IV q6h
70
CNS Infection Tx Dosing: | Cefotaxime
Adults: 2gm IV q4-6h Peds: 75mg/kg IV q6-8h
71
CNS Infection Tx Dosing: | Ceftriaxone
Adults: 2gm IV q12-24h Peds: 100mg/kg IV q24h
72
CNS Infection Tx Dosing: | Penicillin G
Adults: 4MU IVq4h Peds: 0.05 million units/kg IV q4-6h
73
CNS Infection Tx Dosing: | SMX/TMP
Adults: 5mg/kg TMP IV q6-12h Peds: 5mg/kg TMP IV q6-12h
74
CNS Infection Tx Dosing: | Vanco
Adults: 15mg/kg IV q8-12h Peds: 15mg/kg IV q6h
75
CNS Infection Tx Dosing: HIGH DOSES
Need high doses so that the conc of the abx is 10-30x MIC to kill bacteria and to cross the BBB and keep therapeutic levels [Normal is 2-4xMIC]
76
SUMMARY
1. The main goals of treating bacterial meningitis are to eradicate the infection, decrease signs and sxs, and prevent neurologic sequelae 2. Empirical coverage w/an appropraite abx should be started ASAP if clinical suspicion of meningitis exists; the first abx dose should not be withheld if LP is delayed 3. Maximize abx doses to optimize CNS penetration 4. Assess close contacts for appropriate prophylaxis 5. Encephalitis cause by West Nile or HSV require specific therapy to prevent morbidity and mortality

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