Bbaqteriuli meningiti

Thanks to Gary R. Strange, MD, MA, FACEP

Professor and Head, Dept of Emergency Medicine
University of Illinois at Chicago
CASE PRESENTATION
• 18 Tvis bavSvi moyvanilia mSoblebis mier:
o 4 dRis xangrZlivobis cxeleba
o 2 dRea Wirveulobs da uaresdeba
o asocirebulia:
 umadoba
 gulisreva
 Rebineba
 diarea
F fizikuri gasinjva:
• bavSvi wevs sawolze, odnav leTargiulia
• tiris gasinjvisas, maSinac roca deda iyvans xelSi
• temperatura 39.0C
• guliscema: 130/min
• saturacia: 98%
fizikuri gasinjva:
• kani mSralia, cxeli, gamonayari ar arisHH
• travmis niSnebi ar aris, lorwovani garsebi mSralia
• kiseri:
o rigidoba ar aris
o Kernigi - uaryofiTi
o Brudzinski – dadebiTi kiTxvis niSnis qveS
fizikuri gasinjva:
• Kernig’s sign:
o tkivili 90 gradusiT fexebis moxrisa da Semdeg gaxrisas
o dadebiTia baqteriuli meningitis mqone pacientebis 43%
• Brudzinski’s sign:
o kisris pasiuri moxrisas fexebis moxra
o dadebiTia baqteriuli meningitis dros 66%
Ffizikuri gasinjva:
• gulis tonebi naTeli, riTmuli, Suilebi ar aris
• filtvebi: vezikuluri sunTqva bilatralurad
• muceli rbili, umtkivneulo
• nevrologiuri gasinjva:
o leTargiuli/reagirebs gaRizianebaze
o amoZravebs oTxive kidurs roca astimulireb
o refleqsebi simetriulia
o kranialuri nervebi norma
Yyvelaze swori midgoma:
• lab. Kkvlevebi: ssa, bioqimia, sisxlis daTesva,
monitorireba
• Tavis tvini kt, lumbaluri punqcia
• iv antioibotikoTerapiis dawyeba
epidemiologia axalSobilebSi
• 0.6 – 1.3 cases/1000 live births
• Etiology
o Group B Streptococcus
o Gram-Negative Enteric Bacilli
 Escherichia coli, Klebsiella spp, Enterobacter spp,
Salmonella spp
o Listeria monocytogenes
• Incidence essentially unchanged in the past
20 years
Eepidemiologia bavSvebSi:
• 1990: children between 2 months and 5
years of age accounted for ¾ of all cases
o 67% due to Haemophilus influenzae type b
o 25% due to Streptococcus pneumoniae
o 10% due to Neisseria meningitidis
• 2002: children 2 mos – 5 yrs are < ½ of
cases
o Streptococcus pneumoniae is the most common
cause between 2 mos and 2 years of age
 Decreasing after introduction of heptavalent vaccine
o Neisseria meningitidis is the most common
offender in the 2 – 18 year age group
gamomwvevebi imunokompromentirebul pirebSi:

• Staphylococcus spp
• Gram-Negative Enteric Bacilli
• Pseudomonas aeruginosa
epidemiologia:
• Yyvelaze xSiria zrdasrulebSi:
o studentebi, romlebic cxovroben saerTo sacxovrebelSi
o samxedroebi
epidemiologia:
• Conjugate polysaccharide Haemophilus influenzae
type b vaccine introduced in 1991
• Heptavalent pneumococcal conjugate vaccine
introduced in 2000
o Covers 80% of invasive serotypes
o Projected to prevent 12,000 cases/year
MENINGOCOCCAL VACCINES
• 5 Major Serogroups Cause Disease
o A, B, C, Y, W-135
• Polysaccharide vaccines effective for groups A, C,
Y, W-135 in older children & adults
• Poor response in young children
• No vaccines of serogroup B
MENINGOCOCCAL VACCINES
• Conjugation of polysaccharide vaccine to a protein
carrier increases efficacy in infants and young
children
• Conjugate serogroup C vaccine in use in UK since
1999: very effective in young children
• Conjugate vaccine for A, C, Y & W-135 under
development
MENINGOCOCCAL VACCINES
• Use for 1st Year College Students Controversial in
the Past
o No cost savings
 Low # of cases
 High cost of vaccination
o From individual perspective, may be worthwhile
 MENINGOCOCCAL VACCINES
2005 AAP RECOMMENDATIONS
• Administer MCV4 to
o 11-12 year olds, especially if at increased risk
o Students entering high school or at age 15
o College freshmen who will be living in dormitories
 paTofiziologia:
• hematogenuri gavrceleba
o qalas fuZis motexiloba
o gavrceleba mezobeli struqturebidan: yuri, sinusebi, orbitebi
o iatrogenuli
paTofiozologia:
• paTologiuri cvlilebebi ganpirobebulia:
o TviTon gamomwvevis zemoqmedebiT
o imunuri pasuxiT infeqciaze
simptomebi:
• Kklasikuri niSnebi:
o Tavis tkivili
o fotofobia
o kisris kunTebis rigidoba
o cnobierebis Secvla
o daWimuli yiflibandi
o gulisreva
o Rebineba
meningialuri gaRizianebis niSnebi:
o kisris kunTebis rigidoba:
o Brudzinski Sign:
o Kernig Sign:
o bavSvebi xSirad ewinaaRmdegebian ar undaT siaruli
an xelSi ayvana
o am niSnebis ar arseboba ar gamoricxavs
meningitis diagnozs
o axalSobilebSi da mcire asakis bavSvebSi
informatiuli ar aris
 SYMPTOMS OF BACTERIAL
MENINGITIS
ROTHROCK
Clinical Feature Untreated (175) Pretreated (83)

Mean Duration of 4.6 days 2.9 days

Symptoms
Fever 99% 95%
Lethargy or 87% 95%
Irritability
Vomiting 71% 54%
URI symptoms 55% 46%
Seizure 22% 23%
 Bbaqteriuli meningitis niSnebi:

cxeleba 82-96%
leTargia 17-95%
Wirveuloba 18-40%
Rebineba 20-100%
daWimuli 18-40%
yiflibandi
 Bbaqteriuli meningitis niSnebi:

cnobiirebis Secvla 53-78%

gulyra 4-23%
Ffokaluri 5-6%
Nnevr. niSnebi
 Bbaqteriuli meningitis niSnebi:

rigidoba 27-95%
Kernig’s Sign 0-36%
Brudzinski’s 10-83%
> 1 meningiuri 26-93%

All signs less common in neonates except fontanelle

Kklinikuri suraTi axalSobilebsa da
bavSvebSi
• naklebad TvalsaCino niSnebi da simptomebi
• umadoba, cudad Wama
• Wirveuloba, agznebadoba
• ganuwyveteli tirili
• araaqtiuroba
Kklinikuri suraTi:
• SeumCnevlad dawyeba (90%)
o maRalia Sansi rom daiwyos araspecifiuli simptomebiT
o tipiuria pnevmokokuri infeqciisaTvis
• fulminanturi dawyeba(10%)
o tipiuria meningokokuri infeqciisaTvis
o SeiZleba progresirebdes Zalian swrafad, ganviTardes
peteqiebi, purpura, kardio-vaskuluri kolafsi
diferenciuli diagnozi adreuli stadiaze:
• gastroenteriti
• zemo sasunTqi gzebis infeqcia
• pnevmonia
• Sua yuris anTeba
• virusuli infeqcia
diferenciuli diagnozi gvian stadiaze:
• encefaliti
• subduruli/subaraqnoiduli hemoragia
 travmuli
 spontanuri
• tvinis abscesi
• intoqsikacia
• gulyrebi
• diabeturi ketoacidozi an sxva raime metaboluri
darRveva
• hipoTireozi
mkurnaloba: arastabiluri pacienti
• ABC!! Pprioriteti sasicocxlo maCveneblebis
stabilizacia
• lumbaluri punqcia unda Catardes pacientis
stabilizaciisa da antibiotikis administraciis Semdeg
• Soki: swrafi iv an ZvalSida infuzia, kristaloidis xsnari
20 ml/kg sanam vitaluri niSnebi ar dastabilurdeba
• vitaluri maCveneblebis normalizaciis Semdeg
SeamcireT siTxis infuzia, radgan siTxiT gadavirTvam
SeiZleba gaaRrmavos tvinis SeSupeba
intrakraniuli hipertenzia marTva:
• niSnebi: cnobierebis donis gauareseba, mxedvelobis
dvrilis SeSupeba, Rebineba, bradikardia, hipertenzia,
daWimuli yiflibandi
• Mkurnaloba:
o Tavis aweva 30 gradusiT
o hiperventilacia PCO2 30 - 35 mmHg
o Mannitol, 0.5 – 1 g/kg
stabiluri pacienti marTva:
• Llaboratoriuli testebi:
o ssa
o eleqtrolitebi
o glukoza
o kreatinini, Sardovana
o sisxlis daTesva
• Llumbaluri punqcia da liqvoris analizi
Lliqvori – norma:
• leikocitebi: 0-7 wbc/mm3 (0% PMNs)
• glukoza: 40-80 mg/dL (> 50% of Blood Sugar)
• cila: 5-40 mg/dL
Lliqvoris interpretacia:
• virusuli etiologia:
o dabali leikocitebi
o ZiriTadad mononuklearuli ujredebi
o glukoza norma
o cila norma
• baqteriuli etiologia:
o momatebuli leikocitebi
o ZiriTadad polimorfulbirTviani leikocitebi
o dabali leikocitebi
o maRali cila
sawyisi antibiotikoTerapia
axalSobilebi:
• Ampicillin, 100 mg/kg
da
• Aminoglycoside
o Gentamicin, 2.5 mg/kg an
o Cefotaxime, 50 mg/kg
sawyisi antibiotikoTerapia bavSvebi da
mozardebi:
• Cephalosporin
o Ceftriaxone, 100 mg/kg
an
o Cefotaxime, 50 mg/kg
• alternativa:
o Amoxicillin, 100 mg/kg
da
o Chloramphenicol, 25 mg/kg
sawyisi antiobiotikoTerapia mozrdilebi:
• Cephalosporin
o Ceftriaxone, 2 grams IV
an
o Cefotaxime, 2 grams IV
sawyisi antibiotikoTerapia Tu
dadasturebulia an eWvia pnevmokokur
infeqciaze:
• SeiZleba iyos rezistentuli penicilinisa da cefalsporinebis
mimarT
• vankomicini erTaderTi antibiotikia romelic moqmedebs
pnevmokokis yvela Stamze
o daamateT Vancomycin 15 mg/kg
steroidebis gamoyeneba:
• deqsametazonis 0.15 mg/kg IV Seyvena pirveli doza
antibiotikis win an masTan erTad amcirebs intrakraniul
wnevas da tvinis SeSupebas.
• mniSvnelovnad amcirebs nevrologiuri garTulebebis
risks, mag. siyrue
Ggamosavali:
• letaloba: 20-40%
• nevrologiuri deficiti: 20%
ra unda gvaxsovdes!
• vaqcinacia H flu & Pneumococcus efeqturia da
amcirebs meningitis SemTxvevebis sixSires
• dResdReisobiT baqteriuli meningiti yvelaze xSiria
mozardebsa da axalgazrdebSi
gagrZeleba:
• klasikuri niSnebi da simptomebi xSirad ar aRiniSneba,
maT Soris mozardebSic
• bavSvebSi aRiniSneba zedmeti Wirveuloba
• daiwyeT antiobiotikoTerapia diagnostikuri kvlevebis
dawyebamde, Tu pacienti gamoiyureba toqsiurad
• Tavis CT kvleva lumbalur punqciamde aucilebelia
mxolod im SemTxvevaSi Tu eWvia moculobiT
warmonaqmnze
gagrZeleba:
• empiriuli antibiotikoTerapia axalSobilebSi:
o Ampicillin & Aminoglycoside
an
o Ampicillin & Cefotaxime
• empiriuli antbiotikoTerapia
mozardebi/mozrdilebi
o Ceftriaxone & Vancomycin
• steroidebis gamoyeneba:
deqsametazoni unda iyos gamoyenebuli pirvel doza
antibiotikTan erTad