Bacterial meningitis: Difference between revisions
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* Chronic otitis media |
* Chronic otitis media |
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| − | ==Clinical |
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* Typically, an acute onset of headache with fever and vomiting after viral prodrome |
* Typically, an acute onset of headache with fever and vomiting after viral prodrome |
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* Bacterial vs. aseptic/viral meningitis |
* Bacterial vs. aseptic/viral meningitis |
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Revision as of 10:20, 20 July 2020
Background
- Bacterial infection of meninges
Microbiology
- Adults 1
- Streptococcus pneumoniae (70%)
- Neisseria meningitidis (15%): more in young adults
- Group B Streptococcus (10%)
- Haemophilus influenzae (10%)
- Listeria monocytogenes (5%): more in elderly ≥65 years, immunocompromised, alcoholics, and diabetes
- Infants ≤2 months old 1
- Group B Streptococcus (90%)
- Listeria monocytogenes, Streptococcus pneumoniae, others including Gram-negative bacilli
- Infants 2 months to 2 years 1
- Streptococcus pneumoniae (50%)
- Group B Streptococcus (20%)
- Neisseria meningitidis (15%)
- Haemophilus influenzae (10%)
- Head trauma or neurosurgery
- Staphylococcus aureus
- Gram-negative bacilli
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 Manifestations
- 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
Duration of therapy by organism
| Organism | Duration (days) |
|---|---|
| Neisseria meningitidis | 7 |
| Haemophilus influenzae | 7 |
| Streptococcus pneumoniae | 10-14 |
| Streptococcus agalactiae | 14-21 |
| Gram-negative bacilli | 21 |
| Listeria monocytogenes | ≥21 |
First- and second-line antimicrobials by organism
| Organism | First-line | Second-line |
|---|---|---|
| Streptococcus pneumoniae (penicillin MIC ≤0.06) | penicillin G or ampicillin | third-generation cephalosporin or chloramphenicol |
| 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 |
| Neisseria meningitidis (penicillin MIC ≥0.12) | third-generation cephalosporin | chloramphenicol, fluoroquinolone, or meropenem |
| Listeria monocytogenes | ampicillin or penicillin G | [[TMP-SMX] or meropenem |
| Streptococcus agalactiae | ampicillin or penicillin G | third-generation cephalosporin |
| E. coli and other Enterobacteriaceae | third-generation cephalosporin | ampicillin, meropenem, aztreonam, TMP-SMX, or ciprofloxacin |
| 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 |
| 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 |
Recommended 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
- 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.
