Bacterial meningitis: Difference between revisions

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* Lumbar puncture
  
* Lumbar puncture
 
* Adjust antibiotics based on Gram stain and cultures
  
* Adjust antibiotics based on Gram stain and cultures
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===Antimicrobial dosages===
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{| class="wikitable"
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! Antimicrobial
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! 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]]
  +
|
  +
|
  +
|
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| 6-8 g divided q6-8g)
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|-
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| [[cefepime]]
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|
  +
|
  +
| 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]]
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|
  +
|
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| 80-100 mg/kg divided q12-24h
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| 4 g divided q12-24h
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|-
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| [[chloramphenicol]]
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| 25 mg/kg divided q24h
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| 50 mg/kg divided q12-24h
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| 75-100 mg/kg divided q6h
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| 4-6 g divided q6h
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|-
  +
| [[ciprofloxacin]]
  +
|
  +
|
  +
|
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| 800-1200 mg divided q8-12h
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|-
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| [[gatifloxacin]]
  +
|
  +
|
  +
|
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| 400 mg divided q24h
  +
|-
  +
| [[gentamicin]]
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| 5 mg/kg divided q12h
  +
| 7.5 mg/kg divided q8h
  +
| 7.5 mg/kg divided q8h
  +
| 5 mg/kg divided q8h
  +
|-
  +
| [[meropenem]]
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|
  +
|
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| 120 mg/kg divided q8h
  +
| 6 g divided q8h
  +
|-
  +
| [[moxifloxacin]]
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|
  +
|
  +
|
  +
| 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]]
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| 0.15 mU/kg divided q8-12h
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| 0.2 mU/kg divided q6-8h
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| 0.3 mU/kg divided q4-6h
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| 24 mU divided q4h
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|-
  +
| [[rifampin]]
  +
|
  +
| 10-20 mg/kg divided q12h
  +
| 10-20 mg/kg divided q12-24h
  +
| 600 mg divided q24h
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|-
  +
| [[tobramycin]]
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| 5 mg/kg divided q12h
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| 7.5 mg/kg divided q8h
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| 7.5 mg/kg divided q8h
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| 5 mg/kg divided q8h
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|-
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| [[TMP-SMX]]
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|
  +
|
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| 10-20 mg/kg divided q6-12h
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| 10-20 mg/kg divided q6-12h
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|-
  +
| [[vancomycin]]
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| 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==
  
==Complications==

Revision as of 20:30, 29 June 2020

Background

  • Bacterial infection of meninges

Microbiology

Risk factors

  • Immunosuppression
  • Diabetes
  • Splenic dysfunction or splenectomy (e.g. sickle cell)
  • Alcoholism
  • Recent neurosurgery
  • CSF leak
  • Shunt infections
  • Head trauma
  • Chronic otitis media

Clinical Presentation

  • Typically, an acute onset of headache with fever and vomiting after viral prodrome
  • Bacterial vs. aseptic/viral meningitis
  • 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 (purpuric with Neisseria)
  • Ask about recent travel and sick contacts

Investigations

  • 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)
  • Other
    • Lumbar puncture after CT head

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
  • Start empiric antibiotics and dexamethasone
    • Infants
    • Children
    • Adults
      • Ceftriaxone 2g bid
      • vancomycin 1g q12h
      • +/- ampicillin 2g 14h if >50
      • Dexamethasone 10mg q6h x72h
      • +/- acyclovir
    • >65 years old
      • Treat like immunocompromised
  • CT head if reduced or altered level of consciousness
  • Lumbar puncture
  • Adjust antibiotics based on Gram stain and cultures

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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