Athit Wutthisanwatthana

Acute purulent infection within the subarachnoid space

Etiology

Community-Acquired Bacterial Meningitis

10 15 Streptococcus pneumoniae 50 Neisseria meningitidis Group B streptococci 25 Listeria monocytogenes

Streptococcus pneumoniae
#1 in age > 20 years Predisposing conditions
#1 Streptococcal pneumonia Acute/chronic pneumococcal sinusitis/otitis media Alchoholism Diabetes Complement deficiency Head trauma with basilar skull fracture and CSF rhinorrhea

Mortality ~20%

Neisseria meningitidis
Petechial or purpuric lesion is important clue Some is fulminant Initiated by nasopharyngeal colonization
Asymptomatic carrier Invasive meningococcal disease

Enteric Gram-Negative Bacilli

Diabetes mellitus Cirrhosis Alcoholism Chronic urinary tract infection Craniotomy

Group B Streptococcus
Streptococcus agalactiae Neonates Age > 50 years

Listeria monocytogenes
Acquired by food ingestion Cause of meningitis in
Neonate Pregnant woman Age > 60 year Immunocompromised patient

Haemophilus influenzae
Unvaccinated children and adults

Staphylococcus aureus and Coagulase-Negative staphylococci

Invasive neurological procedures

Pathophysiology

Clinical Manifestation

Clinical Manifestation
Fever Headache Nuchal rigidity Decreased level of consciousness Nausea Vomiting Photophobia Seizures

Increase intracranial pressure

Deceased level of consciousness Papilledema Dilated poorly reactive pupils Sixth nerve palsies Decerebrate posturing Cushing reflex

Rash of meningococcemia
Diffuse erythematous maculopapular rash Petechiae
Trunk Lower extremities Mucous membranes Conjuctivae Palms Soles

Management

Management Algorithm for Adults with Suspected Bacterial Meningitis

Empical Antibiotic
Indication Antibiotic Immunocompetent children > 3 and Cefotaxime/ceftriaxone + adults < 55 vancomycin Adults > 55 and adult of any age with alcholism or other debilitating illness Cefotaxime/ceftriaxone + vancomycin + Ampicillin

Total Daily Dose and Dosing Interval

Antimicrobial agent Ampicillin Cefotaxime Ceftriaxone Vancomycin 2 g IV q 6 h 2 g IV q 6 h 2 g IV q 12 h 1 g IV q 12 h

Contraindication for LP
Absolute
Signs of raised intracranial pressure Local skin infection Evidence of obstructive hydrocephalus, cerebral edema or herniation in CT/MR scan

Contraindication for LP
Relative
Sepsis/hypotension (BP <100/<60 mmHg) Coagulation disorder (DIC, platelet < 50,000, warfarin) Neurological deficit GCS 8 Epileptic seizure

Cerebrospinal Fluid Abnormalities in Bacterial Meningitis

Comparison of CSF of Meningitis

Timing of Antibiotic
As soon as possible Antibiotic few hours before LP will not alter the CSF

Antibiotic Based on Positive Gram Stain

Duration of Treatment (A-III)

Role of Dexamethasone
Decrease inflammatory response Dexamethasone therapy for bacterial meningitis. N Engl J Med 2002
301 cases Unfavorable outcome (15% vs. 25%, p = 0.03) Death (7% vs. 15%, p = 0.04)

Benefit in pneumococcal meningitis subgroup

Unfavorable outcome (26% vs. 52%, p = 0.006) Death (14% vs. 34%, p = 0.02)

Most beneficial in patient with moderate-severe disease on the Glasgow Coma Scale

Recommendation by IDSA
Dexamethasone 0.15 mg/kg q6h for 2-4 days Suspected/proven pneumococcal meningitis (A-I) First dose administered 10-20 min before antibiotic

Dexamethasone and Pneumococcal Meningitis

Concerns in highly penicillin- / cephalosporinresistant strain Dexamethasone diminishes inflammatory response Dexamethasone be administered to all (B-III) Addition of rifampin (B-III)

Indications for Repeated Lumbar Puncture

Any patient who has not responded clinically after 48 h (A-III)