Therapy of Meningitis Flashcards
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.
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
Until a pathogen is identified, immediate ___ antibiotic coverage is needed for meningitis.
Empirical
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.
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
What should you do once a pathogen is identified?
Antibiotic therapy should be tailored to the specific pathogen
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
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
What are the most likely organisms causing meningitis in people 2-50 years old?
1) Neisseria meningitidis
2) Streptococcus pneumoniae
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
Empirical therapy for meningitis in people <1 month old?
1) Ampicillin + Cefotaxime
2) Ampicillin + Aminoglycoside
Empirical therapy for meningitis in people 1-23 months old?
Vancomycin + 3rd generation Cephalosporin (Cefotaxime or Ceftriaxone)
Empirical therapy for meningitis in people 2-50 years old?
Vancomycin + 3rd generation Cephalosporin (Cefotaxime or Ceftriaxone)
Why do we give Vancomycin as empirical therapy for meningitis in people 1 month old-death?
To cover penicillin-resistant Strep. pneumoniae
Empirical therapy for meningitis in people >50 years old?
Vancomycin + Ampicillin + 3rd generation Cephalosporin (Cefotaxime or Ceftriaxone)
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
What is the duration of treatment for Streptococcus pneumoniae?
10-14 days
What is the duration of treatment for Staphylococcus aureus?
14-21 days
What is the duration of treatment for Group B Streptococcus?
14-21 days
What is the duration of treatment for Staph. epidermidis?
14-21 days
What is the duration of treatment for Listeria monocytogenes?
≥ 21 days
First choice antibiotics for Penicillin susceptible Streptococcus pneumoniae?
1) Penicillin G
OR
2) Ampicillin
Alternative antibiotics for Penicillin susceptible Streptococcus pneumoniae?
1) Cefotaxime
2) Ceftriaxone
3) Cefepime
4) Meropenem
First choice antibiotics for Penicillin resistant Streptococcus pneumoniae?
Vancomycin + Cefotaxime or Ceftriaxone
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 (hearing loss)
3) N. meningitidis (arthritis)
4) M. tuberculosis (mortality)
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
