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Meningitis resident survival guide

From Wikidoc - Reading time: 4 min

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD[2]


Overview

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Meningitis is characterized by inflammation of the leptomeninges. Meningitis causes are divided to infectious and non-infectious processes. Infectious causes include bacterial, viral, fungal, protozoal and, treponemal. Non-infectious causes, such as systemic illnesses, may involve the CNS (e.g. neoplasms or connective tissue diseases). These causes can include sarcoidosis, systemic lupus erythematosus (SLE), and wegener's or certain drugs (e.g. nonsteroidal antiinflammatory drugs, intravenous immunoglobulin, intrathecal agents, and trimethoprim-sulfamethoxazole).The classic symptom triad of meningitis is headache, neck stiffness, and fever.

Causes

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Life Threatening Causes

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Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Common Causes

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Bacterial:[1]

Viral:[2]

Fungal:

Diagnosis

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Adapted from IDSA guidline

 
 
 
Suspicion for bacterial meningitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
Immuncompromised, new onset seizure, History of CNS dis, altered consciousness, papilledema, focal neuorologic deficit, delay in performance of diagnostic of LP
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
Blood culture stat,CTscan
 
 
 
Blood culture and LP stat
 
 
 
 
 
 
 
 
 
 
Negative CTscan
 
 
 
 
 
 
 
 
 
 
 
 
LP
 
 
 
  • Cerebrospinal Fluid Analysis:
Cerebrospinal fluid level Normal level Bacterial meningitis[3] Viral meningitis (except SARS-CoV-2 meningitis) [3] SARS-CoV-2 associated meningitis Fungal meningitis Tuberculous meningitis[4] Neoplastic meningitis[5]
Cells/ul < 5 >300 10-1000 10-1000 10-500 50-500 >4
Cells Lymphocyte Leukocyte > Lymphocyte Lymphocyte > Leukocyte Lymphocyte > Neutrophil Lymphocyte > Leukocyte Lymphocyte > Leukocyte Lymphocyte > Leukocyte
Total protein (mg/dl) 45-60 Typically 100-500 Normal or slightly high Normal or slightly high High Typically 100-200 >50
Glucose ratio (CSF/plasma)[6] > 0.5 < 0.3 > 0.6 > 0.6 <0.3 < 0.5 <0.5
Lactate (mmols/l)[7] < 2.1 > 2.1 < 2.1 NA >3.2 > 2.1 >2.1
Others Intra-cranial pressure (ICP) = 6-12 (cm H2O) CSF gram stain, CSF culture, CSF bacterial antigen PCR of HSV-DNA, VZV RT-PCR for detection of viral RNA i n CSF ( not approved by FDA) CSF gram stain, CSF india ink PCR of TB-DNA CSF tumour markers such as alpha fetoprotein, CEA

Treatment

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Adapted from IDSA guidline

 
 
 
Suspicion for bacterial meningitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immuncompromised, new onset seizure, History of CNS dis, altered consciousness, papilledema, focal neuorologic deficit, delay in performance of diagnostic of LP
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood culture stat
 
 
 
 
Blood culture and LP stat
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dexamethasone and empirical antibiotic therapy
 
 
 
 
 
 
Dexamethasone and empirical antibiotic therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative CTscan of headPositive CT scan
 
 
 
 
 
Csf findings c/w bacterial meningitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform LP
 
Continue therapy or consider alternative diagnosis
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue therapy
 
 
 
 
  • Adapted from IDSA guidlines.
Predisposing factor Common bacterial pathogen Antimicrobial therapy
1 month Streptococcus agalactiae, Escherichia coli, Listeriamonocytogenes, Klebsiellaspecie Ampicillin plus cefotaxime or ampicillin plus anaminoglycoside
1–23 months Streptococcus pneumoniae, Neisseria meningitidis,S. agalactiae, Haemophilus influenzae, E. coli Ampicillin plus cefotaxime or ampicillin plus anaminoglycoside
2–50 years,150 years N . meningitidis, S. pneumoniae,S. pneumoniae, N. meningitidis, L. monocytogenes,aerobic gram-negative bacill Vancomycin plus a third-generation cephalosporin,Vancomycin plus ampicillin plus a third-generationcephalosporina,
Head traumaBasilar skull fracture S. pneumoniae, H. influenzae,group Ab-hemolyticstreptococci Vancomycin plus a third-generation cephalospori
Penetrating trauma Staphylococcus aureus,coagulase-negative staphylo-cocci (especiallyStaphylococcus epidermidis),aer-obic gram-negative bacilli (includingPseudomonasaeruginosa) Vancomycin plus cefepime, vancomycin plus ceftazi-dime, or vancomycin plus meropenem
Postneurosurgery Aerobic gram-negative bacilli (includingP. aeruginosa),S . aureus, coagulase-negative staphylococci (es-peciallyS. epidermidis) ancomycin plus cefepime, vancomycin plus ceftazi-dime, or vancomycin plus meropenem
CSF shunt Coagulase-negative staphylococci (especiallyS. epi-dermidis), S. aureus,aerobic gram-negative bacilli(includingP. aeruginosa), Propionibacterium acnes ancomycin plus cefepime, vancomycin plus ceftazi-dime, or vancomycin plus meropenem


Microorganism Recommended therapy Alternative therapies Duration oftherapy, days
Streptococcus pneumoniae Vancomycin plus a third-generationcephalosporina, Meropenem , fluoroquinolonec 7
Neisseria meningitidis Third-generation cephalospori Penicillin G, ampicillin, chloramphenicol, fluoro-quinolone, aztreonam 7
Listeria monocytogenes Ampicillindor penicillin G Trimethoprim-sulfamethoxazole, meropenem 10-14
Streptococcus agalactiae Ampicillindor penicillin G Third-generation cephalosporin 14-21
Haemophilus influenzae Third-generation cephalospori Chloramphenicol, cefepime , meropenem ,fluoroquinolon 21
Escherichia coli Third-generation cephalospori Cefepime, meropenem, aztreonam, fluoroquino-lone, trimethoprim-sulfamethoxazole >21

Do's

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  • Administration of empiric antibiotic to suspicious patients immediately after the performance of lumbar puncture or/and blood cultures sampling.

Don'ts

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  • Do not delay the delivery of empiric antibiotic for clinical investigation.

References

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  1. ↑ Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS; et al. (1993). "Acute bacterial meningitis in adults. A review of 493 episodes". N Engl J Med. 328 (1): 21–8. doi:10.1056/NEJM199301073280104. PMID 8416268.
  2. ↑ Chigusa S, Moroi T, Shoji Y (2017). "State-of-the-Art Calculation of the Decay Rate of Electroweak Vacuum in the Standard Model". Phys Rev Lett. 119 (21): 211801. doi:10.1103/PhysRevLett.119.211801. PMID 29219400.
  3. ↑ 3.0 3.1 Negrini B, Kelleher KJ, Wald ER (2000). "Cerebrospinal fluid findings in aseptic versus bacterial meningitis". Pediatrics. 105 (2): 316–9. PMID 10654948.
  4. ↑ Caudie C, Tholance Y, Quadrio I, Peysson S (2010). "[Contribution of CSF analysis to diagnosis and follow-up of tuberculous meningitis]". Ann Biol Clin (Paris). 68 (1): 107–11. doi:10.1684/abc.2010.0407. PMID 20146981.
  5. ↑ Le Rhun E, Taillibert S, Chamberlain MC (2013). "Carcinomatous meningitis: Leptomeningeal metastases in solid tumors". Surg Neurol Int. 4 (Suppl 4): S265–88. doi:10.4103/2152-7806.111304. PMC 3656567. PMID 23717798.
  6. ↑ Chow E, Troy SB (2014). "The differential diagnosis of hypoglycorrhachia in adult patients". Am J Med Sci. 348 (3): 186–90. doi:10.1097/MAJ.0000000000000217. PMC 4065645. PMID 24326618.
  7. ↑ Leen WG, Willemsen MA, Wevers RA, Verbeek MM (2012). "Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice". PLoS One. 7 (8): e42745. doi:10.1371/journal.pone.0042745. PMC 3412827. PMID 22880096.
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