Meningitis

By Esubalew &

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 Outlines
• Definition
• Epidemiology
• Risk factors
• Etiology
• Pathophysiology
• Clinical Sign and symptoms
• Diagnosis
• Complications
• Treatment mgt and prevention
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 Introduction
• Central nervous system (CNS) infections
describes a variety of infections involving the
brain and spinal cord and associated tissues,
fluids, and membranes, including meningitis,
encephalitis, brain abscess, and postoperative
infections.

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 Introduction…
• Meningitis is one of CNS infection which is
considered neurologic emergencies that require
prompt recognition, diagnosis, and management
to prevent death and residual neurologic deficits.
• Improperly treated, CNS infections are associated
with high rates of morbidity and mortality.

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 Anatomy of CNS
• The skull and vertebrae protect the CNS from blunt or
penetrating trauma.
• The meninges consist of three parts: the pia,
arachnoids, and durra maters.
– Dura mater, or pachymeninges, lies directly
beneath and is adherent to the skull.
– Pia mater lies directly over brain tissue.
– Arachnoid, the middle layer
– The subarachnoid space, located between the
arachnoid and the pia mater, is the conduit for CSF.

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 Meningitis

• By definition, Meningitis is an inflammatory disease

of the leptomeninges, the tissues surrounding the
brain and spinal cord.

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 Epidemiology
• Approximately 1.2 million cases of acute bacterial
meningitis occur every year around the world,
resulting in 135,000 deaths.
• Overall mortality rates for patients with meningitis
range from 2%-30% depending on the causative
microorganism, approaching 20% in most cases of
bacterial meningitis.
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 Risk factors
• Recent exposures/contact with meningitis

• URTI
• Immunoglobulin deficiency, cancer, HIV/AIDS

• Neurosurgery, head trauma, CSF shunt

• Cigarette smoke,
• Close living conditions

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 Etiology
• Infectious
– Bacteria & viruses===acute meningitis
– Fungi =============chronic meningitis
• Noninfectious
• malignancy, medications, autoimmune disease
(such as lupus), and trauma

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 Bacterial meningitis

• Bacterial meningitis reflects infection of the

arachnoids mater and the CSF in both the
subarachnoid space and the cerebral ventricles

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 PATHOPHYSIOLOGY

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 Sign /symptoms
 Classical symptoms
 Headache
 Nuchal rigidity (stiff neck)
 Fever
 Nausea
 Altered mental status (i.e., confusion, lethargy)
 Focal neurologic defects (Brudzinski’s sign and
Kernig’s sign)
 Seizures
 Malaise, restlessness
 Photophobia and phonophobia
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 Sign/symptoms…

Kernig's Signs Brudzinski's signs

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 Diagnosis
 CSF examination via LP
– Cloudy CSF
– Decreased glucose
– Elevated protein
– Elevated WBC count
– Culture and sensitivity
Gram stain
 Polymerase chain reaction (PCR;
 Head CT scan and MRI
 BF
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 Mean Values of Components of Normal and Abnormal CSF

Type Normal Bacterial Viral Fungal TB

WBC <5 1,000–5,000 100– 40–400 100–500

(cells/mm3) 1,000

Protein <50 100–500 30–150 40–150 ≤40–150

(mg/dL)
Glucose 50%–66% <40 (<60% <30–70 <30– <30–70
(mg/dL) (CSF/Serum) serum value) 70

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 Neurologic complications
• Impaired mental status
• Increased ICP and cerebral edema
• Seizures
• Focal neurologic deficits (hemiparesis)
• Cerebrovascular abnormalities
• Hearing loss
• Intellectual impairment
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 Treatment
• Goals
– To prevent death and residual neurologic deficits,
– To eradicate or control causative microorganisms,
– To reduce clinical signs and symptoms, and to
prevent future infections.

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 General Treatment Principles
• Administration of fluids, electrolytes, antipyretics,
analgesics.
• Prompt initiation of intravenous high-dose
antimicrobial therapy is essential. (emperical therapy)
• Rapid CSF analysis is very important

• Dexamethasone should be administered prior to or at

the same time as the first dose of antibiotic therapy
• Adequate duration of therapy is required to treat
meningitis successfully (21-28 days)
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 Fig.2. Management algorithm for adults with suspected bacterial meningitis,
as recommended by the Infectious Diseases Society of America (IDSA)

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 A. Most likely and empirical therapy for bacterial
meningitis by age group
Age Most Likely Organisms Empirical Therapy

•Gr-B. Streptococcus Ampicillin plus cefotaxime

Neonate •L. Monocytogenes or ceftriaxone or
•G-ve enterics Aminoglycoside
•E.coli

1 mos–4 yrs S. Pneumoniae Vancomycin plus

N. Meningitidis Cefotaxime or
H. influenzae Ceftriaxone
5–60 years
S. Pneumoniae Vancomycin plus
>60 years G-ve enterics Ampicillin plus
L. monocytogenes Cefotaxime or
Ceftriaxone

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B. Pathogen -directed definitive therapy

• Empirical antimicrobial therapy should be modified

on the basis of laboratory data and clinical response.
• If cultures or other diagnostics, such as CSF Gram
stain or antigen or antibody tests indicate a specific
pathogen, therapy should be adjusted quickly as
needed to ensure adequate coverage for the
offending pathogen(s).
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 Pathogen-Based Definitive Treatment for meningitis
Pathogen 1st line Alternative Duration
N.meningitidis Penicillin G 4 miu IV Q4 hrs Ceftriaxone 2 g IV BID 7 days
or or
Ampicillin 2 g IV Q4 hrs Cefotaxime 2 g IV Q4 hrs

Penicillin G or Ampicillin CAPH 10-

S. pneumonia or or 14days
Ceftriaxone 2 g IV BID Meropenem
or or
Cefotaxime 2 g IV Q4 hrs Cefepime 2 g IV TID or

Ampicillin or Cefepime or 7days

H. influenzae Ceftriaxone 2 g IV BID or CAPH
Cefotaxime 2 g IV Q4 hrs Moxifloxacin

L.monocytoge Ampicillin or penicillin G TMP-SMX least 26

nes plus Gentamicin

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 Pathogen-Based…
Pathogen 1st line Alternative Duration

P.aeruginosa Cefepime or Aztreonam or 21 days

Ceftazidime 2 g IV TID Ciprofloxacin 400 mg IV
every 8–12 hours

S.aureus Nafcillin or oxacillin Meropenem 3–4 wks

1.5–3 g every 4hrs or Linezolid 600 mg IV BID
Vancomycin plus or TMP-SM
Rifampin 600 mg PO or
IV daily

S. epidermidis Vancomycin plus Linezolid 3-4wks

rifampin 600 mg PO or
IV daily

Herpes Acyclovir 10 mg/kg IV 14–21

simplex virus every 8 hours days

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 C. Adjunctive Therapy
• The adjunctive agent dexamethasone has been
shown to improve outcomes in selected patient
populations with meningitis.
• Dexamethasone inhibits the release of
proinflammatory cytokines and limits the CNS
inflammatory response stimulated by infection and
antibiotic therapy.

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 Adjunctive…
• Dexamethasone should be initiated 10 to 20 minutes
before or no later than the time of initiation of
antibiotic therapy
• Administer 0.15mg/kg q4hrs for 2-4 days.
• It is not recommended for pts who have already
received antibiotic therapy.

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 Prevention
 Chemoprophylaxis

• Ciprofloxacine ,
• Rifampicine

• Vaccination

• Conjugated Hib
• Polyvallent vaccine
• Oral hygiene
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 .

•Thank you!

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 References

1. Marie A. chisholm-burns, Teery L.Schwinghamer,

pharmacotherapy principle and practice, forth
edition 2016.
2. Davidsons principle and practice of medicine 22
edition 2014.
3. 2013 UpToDate

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