Bacterial meningitis: Difference between revisions

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==Background==
==Background==


*Bacterial infection of meninges and subarachnoid space
*Bacterial infection of meninges and subarachnoid space (i.e. [[meningitis]])


===Microbiology===
===Microbiology===
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**Adults
**Adults
***[[Ceftriaxone]] 2g bid plus [[vancomycin]] 1g q12h +/- [[ampicillin]] 2g 14h if >50
***[[Ceftriaxone]] 2g bid plus [[vancomycin]] 1g q12h +/- [[ampicillin]] 2g 14h if >50
***[[Dexamethasone]] 10mg q6h x72h (stopped if not [[Streptococcus pneumoniae]])
***[[Dexamethasone]] 10mg q6h x72h (stopped if not [[Streptococcus pneumoniae]] or [[Haemophilus influenzae]])
****Prevents severe hearing loss, neurologic sequelae, and mortality in pneumococcal meningitis
****Prevents severe hearing loss, neurologic sequelae, and mortality in pneumococcal meningitis
****Continue for 3-4 days
***Consider empiric [[acyclovir]], as well, until confirmed to be bacterial
***Consider empiric [[acyclovir]], as well, until confirmed to be bacterial
**>65 years old
**>65 years old
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|''[[Neisseria meningitidis]]'' (penicillin MIC ≥0.12)||third-generation cephalosporin||[[chloramphenicol]], fluoroquinolone, or [[meropenem]]
|''[[Neisseria meningitidis]]'' (penicillin MIC ≥0.12)||third-generation cephalosporin||[[chloramphenicol]], fluoroquinolone, or [[meropenem]]
|-
|-
|''[[Listeria monocytogenes]]''||[[ampicillin]] or [[penicillin G]]||[[TMP-SMX] or [[meropenem]]
|''[[Listeria monocytogenes]]''||[[ampicillin]] or [[penicillin G]]||[[TMP-SMX]] or [[meropenem]]
|≥21 days
|≥21 days
|-
|-
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|10 days
|10 days
|}
|}

===Antimicrobial Dosages===
===Antimicrobial Dosages===
{| class="wikitable"
{| class="wikitable"

Latest revision as of 13:35, 27 October 2023

Background

  • Bacterial infection of meninges and subarachnoid space (i.e. meningitis)

Microbiology

Risk factors

Clinical Manifestations

  • Typically, an acute onset of headache, neck stiffness, fever, and photophobia
    • Headache or neck pain (70-80%)
    • Fever (75%)
    • Altered level of consciousness (70%)
  • Clinical signs
    • Brudzinski's sign (unhelpful)
    • Kernig's sign (may be specific)
    • Jolt test (very sensitive)
    • Seizures or focal neurological deficits (rare, poor prognosis)
    • Rash (petechial or purpuric with Neisseria)
  • Ask about recent travel and sick contacts

Investigations

  • Lumbar puncture after CT head (if needed), sent for Gram stain, culture, viral PCR, cell count with differential, protein, ± cryptococcal antigen, ± fungal cultures
  • Lab
    • CBC with differential
    • Electrolytes
    • Liver enzymes
    • Blood cultures
  • Imaging
    • CT head to rule out abscess or increased ICP
    • MRI head if suspicion for herpes encephalitis
      • Temporal lobe enhancement (usually unilateral)

CSF Interpretation

  • Gram stain positive
  • Glucose <1.0
  • CSF:blood glucose <0.23
  • Protein >2.2
  • WBC >2000
  • PMNs >1180

Management

  • Blood cultures before antibiotics, if possible
  • Start empiric antibiotics and dexamethasone
  • CT head if reduced or altered level of consciousness
  • Lumbar puncture
  • Adjust antibiotics based on Gram stain and cultures

Antimicrobials By Organism

Organism First-line Second-line Duration
Streptococcus pneumoniae (penicillin MIC ≤0.06) penicillin G or ampicillin third-generation cephalosporin or chloramphenicol 10-14 days
Streptococcus pneumoniae (penicillin MIC ≥0.12) third-generation cephalosporin cefipime or meropenem
Streptococcus pneumoniae (ceftriaxone MIC ≥1) vancomycin plus a third-generation cephalosporin fluoroquinolone
Neisseria meningitidis (penicillin MIC ≤0.06) penicillin G or ampicillin third-generation cephalosporin or chloramphenicol 7 days
Neisseria meningitidis (penicillin MIC ≥0.12) third-generation cephalosporin chloramphenicol, fluoroquinolone, or meropenem
Listeria monocytogenes ampicillin or penicillin G TMP-SMX or meropenem ≥21 days
Streptococcus agalactiae ampicillin or penicillin G third-generation cephalosporin 14-21 days
E. coli and other Enterobacteriaceae third-generation cephalosporin ampicillin, meropenem, aztreonam, TMP-SMX, or ciprofloxacin 21 days
Pseudomonas aeruginosa cefipime or ceftazidime meropenem, aztreonam, or ciprofloxacin
ESBL Gram-negative bacillus meropenem cefepime or a fluoroquinolone
Haemophilus influenzae (β-lactamase negative) ampicillin third-generation cephalosporin, cefepime, chloramphenicol, or a fluoroquinolone 7 days
Haemophilus influenzae (β-lactamase positive) third-generation cephalosporin cefepime, chloramphenicol, or a fluoroquinolone
Staphylococcus aureus (methicillin-susceptible) nafcillin or oxacillin vancomycin
Staphylococcus aureus (methicillin-resistant) vancomycin daptomycin, TMP-SMX, or linezolid
Staphylococcus epidermidis vancomycin linezolid
Enterococcus species (ampicillin susceptible) ampicillin plus gentamicin
Enterococcus species (ampicillin resistant) vancomycin plus gentamicin
Enterococcus species (ampicillin and vancomycin resistant) linezolid
No organism identified ceftriaxone 10 days

Antimicrobial Dosages

Antimicrobial Neonate (≤7 days) Neonate (8 to 28 days) Infants and children Adults
amikacin 15-20 mg/kg divided q12h 30 mg/kg divided q8h 20-30 mg/kg divided q8h 15 mg/kg divided q8h
ampicillin 150 mg/kg divided q8h 200 mg/kg divided q6-8h 300 mg/kg divided q6h 12 g divided q4h
aztreonam 6-8 g divided q6-8g)
cefepime 150 mg/kg divided q8h 6 g divided q8h
cefotaxime 100-150 mg/kg divided q8-12h 150-200 mg/kg divided q6-8h 225-300 mg/kg divided q6-8h 8-12 g divided q4-6h
ceftazidime 100-150 mg/kg divided q8-12h 150 mg/kg divided q8h 150 mg/kg divided q8h 6 g divided q8h
ceftriaxone 80-100 mg/kg divided q12-24h 4 g divided q12-24h
chloramphenicol 25 mg/kg divided q24h 50 mg/kg divided q12-24h 75-100 mg/kg divided q6h 4-6 g divided q6h
ciprofloxacin 800-1200 mg divided q8-12h
gatifloxacin 400 mg divided q24h
gentamicin 5 mg/kg divided q12h 7.5 mg/kg divided q8h 7.5 mg/kg divided q8h 5 mg/kg divided q8h
meropenem 120 mg/kg divided q8h 6 g divided q8h
moxifloxacin 400 mg divided q24h
nafcillin 75 mg/kg divided q8-12h 100-150 mg/kg divided q6-8h 200 mg/kg divided q6h 9-12 g divided q4h
oxacillin 75 mg/kg divided q8-12h 150-200 mg/kg divided q6-8h 200 mg/kg divided q6h 9-12 g divided q4h
penicillin G 0.15 mU/kg divided q8-12h 0.2 mU/kg divided q6-8h 0.3 mU/kg divided q4-6h 24 mU divided q4h
rifampin 10-20 mg/kg divided q12h 10-20 mg/kg divided q12-24h 600 mg divided q24h
tobramycin 5 mg/kg divided q12h 7.5 mg/kg divided q8h 7.5 mg/kg divided q8h 5 mg/kg divided q8h
TMP-SMX 10-20 mg/kg divided q6-12h 10-20 mg/kg divided q6-12h
vancomycin 20-30 mg/kg divided q8-12h 30-45 mg/kg divided q6-8h 60 mg/kg divided q6h 30-45 mg/kg divided q8-12h

Complications

  • Cerebral edema with raised ICP
  • Hydrocephalus
  • Seizures
  • Arterial ischemia or infarction
  • SIADH
  • Subdural effusion or subdural empyema
  • Venous sinus thrombosis
  • Cranial nerve palsies, especially deafness

References

  1. a b c  Michael C. Thigpen, Cynthia G. Whitney, Nancy E. Messonnier, Elizabeth R. Zell, Ruth Lynfield, James L. Hadler, Lee H. Harrison, Monica M. Farley, Arthur Reingold, Nancy M. Bennett, Allen S. Craig, William Schaffner, Ann Thomas, Melissa M. Lewis, Elaine Scallan, Anne Schuchat. Bacterial Meningitis in the United States, 1998–2007. New England Journal of Medicine. 2011;364(21):2016-2025. doi:10.1056/nejmoa1005384.

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