Meningitis resident survival guide

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

## Contents

* 1 Overview
* 2 Causes
* 2.1 Life Threatening Causes
* 2.2 Common Causes
* 3 Diagnosis
* 4 Treatment
* 5 Do's
* 6 Don'ts
* 7 References

## 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.

* Bacterial
* Viral
* Fungal

### Common Causes

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Bacterial:[1]

* Streptococcus pneumoniae
* Neisseria meningitis
* Hemophilus influenza
* Group B streptococcus
* Listeria monocytogenes

Viral:[2]

* Enteroviruses
* Herpes simplex viruses 1 and 2
* Arboviruses

Fungal:

* Cryptococcus neoformans
* Aspergillus sp.
* Blastomyces dermatitidis
* Coccidioides immitis
* Candida spp.
* Histoplasma capsulatum
* Sporothrix schencki

## Diagnosis

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Adapted from IDSA guidline

| Suspicion for bacterial meningitis|

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| 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]

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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 head| Positive 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

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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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)