Therapy of Meningitis Flashcards by Sarah Assaf

What are the goals of meningitis treatment?

1) Eradication of infection
2) Improvement of signs and symptoms
3) Prevention of the development of neurologic sequelae, such as seizures, deafness, coma, and death.

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When treating meningitis, it is important to:

1) Prevent the disease through timely introduction of vaccination and chemoprophylaxis

2) Understand antibiotic selection and the issues surrounding antibiotic penetration into the CNS

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Until a pathogen is identified, immediate ___ antibiotic coverage is needed for meningitis.

Empirical

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Why should the first dose of antibiotics should NOT be withheld, even when lumbar puncture is delayed or neuro-imaging is being performed?

Because changes in the CSF after antibiotic administration usually take up to 12 - 24 hours to occur.

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Continued therapy after the first dose of antibiotics should be based on the assessment of:

1) Clinical improvement
2) Culture results
3) Susceptibility testing results

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What should you do once a pathogen is identified?

Antibiotic therapy should be tailored to the specific pathogen

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What are the most likely organisms causing meningitis in people <1 month old?

1) Streptococcus agalactiae
2) Gram-negative enterics:
a) E. coli
b) Klebsiella spp
c) Enterobacter spp
3) Listeria monocytogenes

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What are the most likely organisms causing meningitis in people 1-23 months old?

1) Streptococcus pneumoniae
2) Neisseria meningitidis
3) Haemophilus influenzae
4) Streptococcus agalactiae

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What are the most likely organisms causing meningitis in people 2-50 years old?

1) Neisseria meningitidis
2) Streptococcus pneumoniae

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What are the most likely organisms causing meningitis in people >50 years old?

1) Streptococcus pneumoniae
2) Neisseria meningitidis
3) Gram-negative enterics:
a) E. coli
b) Klebsiella spp
c) Enterobacter spp
4) Listeria monocytogenes

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Empirical therapy for meningitis in people <1 month old?

1) Ampicillin + Cefotaxime
2) Ampicillin + Aminoglycoside

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Empirical therapy for meningitis in people 1-23 months old?

Vancomycin + 3rd generation Cephalosporin (Cefotaxime or Ceftriaxone)

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Empirical therapy for meningitis in people 2-50 years old?

Vancomycin + 3rd generation Cephalosporin (Cefotaxime or Ceftriaxone)

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Why do we give Vancomycin as empirical therapy for meningitis in people 1 month old-death?

To cover penicillin-resistant Strep. pneumoniae

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Empirical therapy for meningitis in people >50 years old?

Vancomycin + Ampicillin + 3rd generation Cephalosporin (Cefotaxime or Ceftriaxone)

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What are the common gram positive organisms that can cause meningitis?

1) Streptococcus pneumoniae
2) Staphylococcus aureus
3) Group B Streptococcus
4) Staph. epidermidis
5) Listeria monocytogenes

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What is the duration of treatment for Streptococcus pneumoniae?

10-14 days

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What is the duration of treatment for Staphylococcus aureus?

14-21 days

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What is the duration of treatment for Group B Streptococcus?

14-21 days

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What is the duration of treatment for Staph. epidermidis?

14-21 days

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What is the duration of treatment for Listeria monocytogenes?

≥ 21 days

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First choice antibiotics for Penicillin susceptible Streptococcus pneumoniae?

1) Penicillin G
OR
2) Ampicillin

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Alternative antibiotics for Penicillin susceptible Streptococcus pneumoniae?

1) Cefotaxime
2) Ceftriaxone
3) Cefepime
4) Meropenem

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First choice antibiotics for Penicillin resistant Streptococcus pneumoniae?

Vancomycin + Cefotaxime or Ceftriaxone

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Alternative antibiotics for Penicillin resistant Streptococcus pneumoniae?

Moxifloxacin

First choice antibiotics for Ceftriaxone resistant Streptococcus pneumoniae?

Vancomycin + Cefotaxime or Ceftriaxone

Alternative antibiotics for Ceftriaxone resistant Streptococcus pneumoniae?

Moxifloxacin

First choice antibiotics for Methicillin susceptible Staphylococcus aureus?

1) Nafcillin OR 2) Oxacillin

Alternative antibiotics for Methicillin susceptible Staphylococcus aureus?

1) Vancomycin OR 2) Meropenem

First choice antibiotics for Methicillin resistant Staphylococcus aureus?

Vancomycin

Alternative antibiotics for Methicillin resistant Staphylococcus aureus?

1) TMP-SMX OR 2) Linezolid

First choice antibiotics for Group B Streptococcus?

1) Penicillin G OR 2) Ampicillin ± Gentamicin

Alternative antibiotics for Group B Streptococcus?

1) Ceftriaxone OR 2) Cefotaxime

First choice antibiotics for Staph. epidermidis?

Vancomycin

Alternative antibiotics for Staph. epidermidis?

Linezolid

First choice antibiotics for Listeria monocytogenes?

1) Penicillin G OR 2) Ampicillin ± Gentamicin

Alternative antibiotics for Listeria monocytogenes?

1) Trimethoprim-sulfamethoxazole OR 2) Meropenem

What are the common gram negative organisms that can cause meningitis?

1) Neisseria meningitidis 2) Haemophilus influenzae 3) Enterobacteriaceae 4) Pseudomonas aeruginosa

What is the duration of treatment for Neisseria meningitidis?

7-10 days

What is the duration of treatment for Haemophilus influenzae?

7-10 days

What is the duration of treatment for Enterobacteriaceae?

21 days

What is the duration of treatment for Pseudomonas aeruginosa?

21 days

First choice antibiotics for Penicillin susceptible Neisseria meningitidis?

1) Penicillin G OR 2) Ampicillin

Alternative antibiotics for Penicillin susceptible Neisseria meningitidis?

1) Cefotaxime OR 2) Ceftriaxone

First choice antibiotics for Penicillin resistant Neisseria meningitidis?

1) Cefotaxime OR 2) Ceftriaxone

Alternative antibiotics for Penicillin resistant Neisseria meningitidis?

1) Meropenem OR 2) Moxifloxacin

First choice antibiotics for β-lactamase negative Haemophilus influenzae?

Ampicillin

Alternative antibiotics for β-lactamase negative Haemophilus influenzae?

1) Cefotaxime 2) Ceftriaxone 3) Cefepime 4) Moxifloxacin

First choice antibiotics for β-lactamase positive Haemophilus influenzae?

1) Cefotaxime OR 2) Ceftriaxone

Alternative antibiotics for β-lactamase positive Haemophilus influenzae?

1) Cefepime OR 2) Moxifloxacin

First choice antibiotics for Enterobacteriaceae?

1) Cefotaxime OR 2) Ceftriaxone

Alternative antibiotics for Enterobacteriaceae?

1) Cefepime 2) Moxifloxacin 3) Meropenem 4) Aztreonam

First choice antibiotics for Pseudomonas aeruginosa?

Cefepime/Ceftazidime ± Tobramycin

Alternative antibiotics for Pseudomonas aeruginosa?

1) Ciprofloxacin 2) Meropenem 3) Piperacillin-tazobactam + 1) Tobramycin 2) Colistin 3) Aztreonam (1 of each)

What is CRITICALLY important in treatment of meningitis?

Supportive care (administration of fluids, electrolytes, antipyretics, and analgesics)

Which prophylaxis and monitoring may be needed in some patients?

1) VTE prophylaxis 2) Intracranial pressure (ICP) monitoring

What may be needed to maintain an ICP of less than 15mmHg?

Mannitol 25% or hypertonic 3% saline

Why is Dexamethasone a commonly used adjunctive therapy in the treatment of meningitis?

Corticosteroids inhibit the production of and reduce: 1) TNF 2) PAF 3) IL-1 4) Potent proinflammatory cytokines 5) Cerebral edema 6) High ICP 7) Neuronal injury 8) Vasculitis

Treatment with corticosteroids reduces __, ___ and ___ in adults with community-acquired bacterial meningitis.

Severe hearing loss, Mortality, and Neurological sequelae

Adjunctive steroids are effective in reducing inflammation and improving clinical outcomes in some causes of meningitis such as:

1) Strep. pneumoniae (mortality) 2) **H.** influenzae (**h**earing loss) 3) N. meningitidis (arthritis) 4) **M.** tuberculosis (**m**ortality)

The use of corticosteroid therapy can be detrimental in:

1) L. monocytogenes 2) Cryptococcus neoformans

Dexamethasone should NOT be initiated after:

The first dose of antibiotics

With adjunctive dexamethasone use, signs and symptoms of ___ should be monitored carefully.

1) GI bleeding 2) Hyperglycemia

Bacterial Brain Abscesses arising from spread of infection from oropharynx, middle ear, and paranasal sinuses are commonly caused by:

Streptococci and Oral anaerobes: a) Actinomyces spp. b) Bacteroides spp. c) Fusobacterium spp. d) Peptostreptococcus

Bacterial Brain Abscesses arising postoperatively or those following head trauma are commonly caused by:

1) Staphylococci 2) Aerobic 3) Gram-negative bacilli

Bacterial Brain Abscesses in immunocompromised patients are commonly caused by:

1) P. aeruginosa 2) Nocardia spp.

Brain abscesses are commonly ___, thus, empiric antimicrobial therapy should include antibiotics with activity against grampositive, gram-negative, and anaerobic microorganisms.

Polymicrobial

Brain abscesses are commonly polymicrobial, thus, empiric antimicrobial therapy should include antibiotics with activity against:

1) Gram-positives 2) Gram-negatives 3) Anaerobics

Empirical Therapy for brain abscesses include:

1) Vancomycin + a third- or fourth-generation Cephalosporin + Metronidazole OR 2) Vancomycin + Carbapenem (Meropenem)!!!

When should de-escalation of therapy be performed?

Once a causative organism is identified

Duration of brain abscess therapy is based on:

1) Causative pathogen 2) Size of abscess 3) Use of surgical treatment 4) Response to therapy

Duration of brain abscess therapy is usually prolonged to:

4-8 weeks

The following categories require a longer duration of brain abscess therapy (6-8 weeks or longer):

1) Patients with an abscess with organized capsule with evidence of tissue necrosis 2) Patients with a multiloculated abscess 3) Patients with lesions in vital locations such as the brain stem or the motor strip (particularly if not surgically drained) 4) Immunocompromised patients 5) In case of needle aspiration rather than open surgical excision

Anticonvulsant therapy is recommended for at least ___, because seizures are common complication of brain abscesses.

1 year

What are common complications of brain abscesses?

Seizures

Which Anticonvulsants are recommended post-brain abscess?

1) Phenytoin 2) Carbamazepine 3) Valproate 4) Levetiracetam

The benefit of Dexamethasone in the treatment of brain abscess is unclear and not routinely recommended, UNLESS there are signs of:

1) Cerebral edema 2) Imminent brain herniation

Cryptococcus neoformans mainly infects which types of patients?

Impaired immunity

How is Cryptococcus neoformans acquired?

By inhalation of spores from the environment

First line drugs for Cryptococcus neoformans meningitis?

Amphotericin B + Flucytosine (for 2 weeks)

Why is Flucytosine poorly tolerated?

1) Bone marrow suppression 2) GI distress

Careful monitoring of what are recommended to avoid flucytosine-associated toxicities?

1) CBC 2) Therapeutic drug monitoring (TDM) 3) Dose adjustment for patients with renal insufficiency

Amphotericin B and flucytosine are ___(fungistatic/fungicidal)

Fungicidal

____ at higher doses (3-5 mg/kg/day) can be used for HIV-positive patients with or predisposed to renal dysfunction and are recommended for organ-transplant recipients.

Lipid formulations of Amphotericin B

Second line drugs for Cryptococcus neoformans meningitis?

Amphotericin B + Voriconazole

Drug combination for M. Tuberculosis?

1) Isoniazid 2) Rifampin 3) Pyrazinamide 4) Ethambutol (for the first 2 months)

Which drugs are continued after 2 months for M. Tuberculosis?

1) Isoniazid 2) Rifampin

Duration of treatment for M. Tuberculosis?

9-12 months

Duration of treatment for Rifampin resistant M. Tuberculosis?

18-24 months

Duration of treatment for M. Tuberculosis in HIV-positive individuals?

≥24 months

__ may replace other rifamycins (rifampin) to minimize drug interactions with protease inhibitors and nonnucleoside reverse-transcriptase inhibitors.

Rifabutin

The spread of some types of bacterial meningitis can be prevented by:

Administering prophylactic antimicrobials to contacts of patients with bacterial meningitis

What does administering prophylactic antimicrobials to contacts of patients with bacterial meningitis do?

1) Prevents transmission of the bacteria to susceptible hosts 2) Eradicates the organism from the nasopharynx of those who are already colonized

Chemoprophylaxis therapy is recommended for close contacts of patients infected with:

1) H. influenzae 2) N. meningitidis

Who are "Close contacts"?

House-hold or day-care members who sleep or eat in the same dwelling as the index patient.

Do health care workers require chemoprophylaxis?

NO, unless CPR or close contact is performed

Chemoprophylaxis for Neisseria meningitidis?

1) Ciprofloxacin (Once) 2) Rifampin (2 days)

Chemoprophylaxis for Neisseria meningitidis in pregnant women?

Ceftriaxone

Female adults on oral contraceptive pills need ___(higher/lower) doses of Ciprofloxacin.

Higher

Chemoprophylaxis for Haemophilus influenzae?

Rifampin

Chemoprophylaxis for Haemophilus influenzae in pregnant women?

Not indicated

Vaccination of contacts and index may be indicated for which organisms?

1) Haemophilus influenzae type b 2) Pneumococcal meningitis 3) Neisseria meningitidis Groups C, A, Y and W135