Neurosciences 251

I. Typical Cerebrospinal Fluid Qualitative & Quantitative Analysis Profile of Different Etiologies of Meningitis

BACTERIAL TUBERCULAR VIRAL FUNGAL NORMAL

Opening
20-25 cm H2O 18-25 cm H2O 9-20 cm H2O 18-30 cm H2Oa 8-20 cm H2O
Pressure

clear, straw- cloudy, straw- cloudy, cloudy, straw-

Color clear
colored colored serosanguinousb colored

Presence of
(-) (-) (+) (-) (-)
RBCs

100-5000 100-500 90-200 180-300 0-5

WBC Count
cells/microL cells/microL cells/microL cells/microL cells/microL

Lymphocytic
predominance
Differential PMN Lymphocytic Lymphocytic Mononuclear
(initial PMN
Count predominance predominance predominance predominance
predominance
may occur)

200 - 500 50 - 300 50 - 300 50 - 300

Protein < 45 - 50 mg/dL
mg/dLc mg/dL mg/dL mg/dL

Decreased but
Normal or only Decreased or
Glucose < 40 mg/dLd not as much as 60% of serum
slightly increased normal
bacterial

CSF: Serum Normal to

Normal Low Low > 2/3
Glucose Ratio Increased
a Fungal meningeal infections, particularly caused by Cryptococcus, usually have very elevated opening pressure,
usually more than 25 cm H2O
b Red blood cells can be found in the CSF of a patient with viral meningoencephalitis as the common pathogen, Herpes

Simplex virus, can cause hemorrhagic necrosis

c Proteins are particularly high in bacterial infections because of the severe inflammation they cause, often increasing the

amount of inflammatory protein, like C-reactive proteins, in the CSF

d Glucose becomes particularly low in bacterial infections as the bacterial division and growth are fueled by the available

glucose in the CSF

References:
Deisenhammer, F. et al. Guidelines on routine cerebrospinal fluid analysis. Report from an ENFS task force.
2006. Eur J Neurol, 13(9): 913-922.
Hastin, M.M. 2010. CSF Analysis. Michigan Medical Confluence. Accessed on 4 Oct 2018 <https://wiki.med.
umich.edu/display/NEURO/CSF+Analysis>
Hasun, R. et al. 2017. Meningitis Workup. Medscape. Accessed on 4 Oct 2018 <https://emedicine.
medscape.com/article/232915-workup#c12>
Seehusen, D.A. et al. 2003. Cerebrospinal Fluid Analysis. Am Fam Physician, 68(6): 1103-1109
II. Most Common Pathogens Affecting Patients by Profile

BACTERIA Patient Profile

Patients of extremes of age, who are alcoholics, ICC status, with sickle cell
Streptococcus pneumoniae
anemia, with basilar skull fracture, or status-post splenectomy (most common)

In patients recovering from an upper respiratory tract infection or children

Haemophilus influenzae
recovering from an ear infection

Neisseria meningitides In children and adolescents; very rare in patients over 50 years old, ICC patients

Staphylococcus aureus,
In post-operative neurosurgery patients
Groups A & D Streptococcus

Klebsiella, Proteus,
In patients status-post lumbar puncture, spinal anesthesia, or shunting surgeries
Pseudomonas

III. Empiric Treatment for Bacterial Meningitis based on Patient Age

AGE GROUP COMMON PATHOGENS INITIAL DOSE OF ANTIMICROBIAL THERAPY

Ampicillin (150 mg/kg/day q8)


Streptococcus agalactiae,
+
Neonates, within 1st week Escherichia coli, Listeria
Gentamicin (5 mg/kg/day q12) or Cefoxatime
monocytogenes
(100-150 mg/kg/day q8 or 12)

Ampicillin (200 mg/kg/day q6 or 8)


Neonates, 1st-6th weeks
Listeria monocytogenes,
+
Streptococcus agalactiae, Gram-
Aminoglycoside (q8) or Cefoxatime (150-200 mg/
negative bacilli
kg/day q6 or 8)

Cefoxatime (225-300 mg/kg/day q 6 or 8) or

Streptococcus pneumoniae, Ceftriaxone (80-100 mg/kg/day q 12 or 24)
Infants and children
Neisseria meningitides +

Vancomycin (60 mg/kg/day q6)

Cefoxatime (8-12 g/day q 4 or 6) or Ceftriaxone (4

Streptococcus pneumoniae,
g/day q 12 or 24)
Adults Neisseria meningitides, Listeria
+

monocytogenes
Vancomycin (60 mg/kg/day q8 or 12)

Cefoxatime (8-12 g/day q 4 or 6) or Ceftriaxone (4

g/day q 12 or 24)
Streptococcus pneumoniae,
+
Elderly Neisseria meningitides, Listeria
Ampicillin (12 g/day q4)
monocytogenes
+

Vancomycin (30-60 mg/kg/day q8 or 12)
a Gentamicin (7.5 mg/kg/day q8), tobramycin (7.5 mg/kg/day q8), or amikacin (30 mg/kg/day q8)
IV. Treatment for Specific Pathogens Causing Meningitis

PATHOGEN STANDARD ALTERNATIVE

Haemophilus influenzae

Cefotaxime or Ceftriaxone; Cefepime;

β-Lactamase (-) Ampicillin Chloramphenicol; Aztreonam;
Fluoroquinolone

Cefepime; Chloramphenicol;
β-Lactamase (+) Cefotaxime or Ceftriaxone
Aztreonam; Fluoroquinolone

Cefotaxime or Ceftriaxone
 Cefotaxime or Ceftriaxone

BLNAR +
 +
Meropenem Fluoroquinolone

Neisseria meningitides

Cefotaxime or Ceftriaxone;
Penicillin MIC < 0.1 μg/mL Penicillin G or Ampicillin
Chloramphenicol

Chloramphenicol; Fluoroquinolone;
Penicillin MIC 0.1-1.0 μg/mL Cefotaxime or Ceftriaxone
Meropenem

Streptococcus pneumoniae

Cefotaxime or Ceftriaxone;
Penicillin MIC < 0.1 μg/mL Penicillin G or Ampicillin
Chloramphenicol

Penicillin MIC 0.1-1.0 μg/mL Cefotaxime or Ceftriaxone Meropenem; cefepime

Penicillin MIC > 2.0 μg/mL or Vancomycin
 Cefotaxime or Ceftriaxone

Cefoxatime or Ceftriaxone MIC > +
 +
1.0 mg/mL Cefotaxime or Ceftriaxone Moxifloxacin

Listeria monocytogenes Ampicillin or Penicillin G Trimethoprim-Sulfamethoxazole

Streptococcus agalactiae Ampicillin or Penicillin G Cefotaxime or Ceftriaxone

Staphylococcus aureus

Vancomycin; Meropenem; Linezolid;

Methicillin sensitive Nafcillin or Oxacillin
Daptomycin

Trimethoprim-Sulfamethoxazole;
Methicillin resistant Vancomycin
Linezolid; Daptomycin

Staphylococcus epidermidis Vancomycin Linezolid

Streptococcus pyogenes Penicillin Cefotaxime or Ceftriaxone

V. Adjunct Therapies
1. Dexamethasone 10 mg IV q6 for 2-4 days, 10-20 minutes before administration fo Ceftriaxone
- to minimize neural degradation/deficits by attenuating inflammatory response
2. Diazepam 5 mg SIVP as needed for frank seizures & Levetiracetam 500 mg/tab 1 tablet every 12 hours (or
other anti-epileptic drugs)
3. Paracetamol 600 mg IV q6 for fever or headache
4. Supportive care
- facilitation of CSF drainage by keeping head midline and raising head of the bed to 30-45 degrees
- compression stockings to prevent deep vein thrombosis

References:
Brouwer, M.C. et al. 2010. Epidemiology, Diagnosis, and Antimicrobial Treatment of Acute Bacterial
Meningitis. Clin. Microbiol. Rev., 23(3): 467-492
Tunkel, A.R. et al. 2004. Practice Guidelines for the Management of Bacterial Meningitis. Clin Infect Diseases, 39(9):
1267-1284.
Tunkel, A.R. 2017. Initial therapy and prognosis of bacterial meningitis in adults. UpToDate. Accessed on 4
Oct 2018 <https://www.uptodate.com/contents/initial-therapy-and-prognosis-of-bacterial-meningitis>