Acute Bacterial Meningitis

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1 : Meningitis Dr. Shatdal Chaudhary
2 : Inflammation of the leptomeninges of the brain and the spinal cord.
3 : Very Important to make Early recognition Rapid institution of therapy Life saving Fewer sequlae
4 : Bacterial Viral ( aseptic) TB Fungal Chemical Parasitic ? Carcinomatous
5 : Meningitis Definition Bacterial meningitis is an inflammatory response to bacterial infection of the pia-arachnoid and CSF of the subarachnoid space Epidemiology Incidence is between 3-5 per 100,000 More than 2,000 deaths annually in the U.S. Relative frequency of bacterial species varies with age.
6 : Meningitis Epidemiology Neonates (< 1 Month) Gm (-) bacilli 50-60% Grp B Strep 20-40% Listeria sp. 2-10% H. influenza 0-3% S. pneumo 0-5%
7 : Meningitis Epidemiology Children (1 month to 15 years) H. influenzae 40-60% Declining dramatically in many geographic regions N. meningitidis 25-40% S. pneumo 10-20%
8 : Meningitis Epidemiology Adults (> 15 years) S. pneumo 50% N. Meningitidis 25% Group B Streptococci 15% Gm (-) Bacilli 1-10% S. aureus 5-15% H. influenzae 1-3% >60 include Listeria monocytogenes, E. coli, Pseudomonas
9 : S. pneumonae Most common organism in adult Esp associated with Pneumonia Sinusitis Otitis media Alcoholism Diabetes Splenectomy Hypergammaglobinemia, complement def basilar skull fracture
10 : N. meningitidis Epidemic Esp in young adults Gram neg bacilli Chronic UTI Pt’s with chronic disease diabetes, Cirrhosis, alcoholism, neurosurgical procedure
11 : H influenzae More in childrens Decline due to Hib vaccination L monocytogenes <1month and >60 yrs Immuno-compromised Food borne infection with contaminated milk and Cheese Group B streptococcus/ S. agalactiae Esp in neonates and >50yr
12 : Staph aureus Following invasive neurosurgical procedure
13 : Meningitis Pathogenesis Nasopharyngeal colonization Nasopharyngeal epithelial cell invasion Bloodstream invasion Bacteremia with intravascular survival Reaches in intraventricular choroid plexus Crossing of the BBB and entry into the CSF Survival and replication in the subarachnoid space
14 : Meningitis Pathology Hallmark Exudate in the subarachnoid space Accumulation of exudate in the dependent areas of the brain Large numbers of PMN’s Within 2-3 days inflammation in the walls of the small and medium-sized blood vessels Blockage of normal CSF pathways and blockage of the normal absorption may lead to obstructive hydrocephalus
15 : Nasopharyngeal colonization Local invasion Bacteremia Meningeal invasion Bacterial replication in the subarachnoid space Release of bacterial components (cell wall, LOS) Cerebral microvascular endothelium Macrophages, neutrophils, other CNS Cells Cytokines Subarachnoid space inflammation Cerebral vasculitis Increased CSF outflow resistance Hydrocephalus Interstitial edema Increased intracranial pressure Decreased cerebral blood flow and loss of cerebrovascular autoregulation Cytotoxic edema Cerebral infarction Increased BBB permeability Vasogenic edema
16 : Meningitis Clinical Manifestations: Patients can present as acute fulminant illness(hrs) or subacute infection that progressively worsens over several days Fever Head Ache Neck rigidity Nausea, Vomiting Photophobia Cerebral dysfunction Confusion, delirium, decreased level of consciousness, Seizures
17 :
18 : Meningitis Clinical Manifestations – Nuchal rigidity: Passive or active flexion of the neck Patient unable to touch chin to chest Kernig’s Sign Pt supine with flexed knee has increased pain with passive extension of the same leg
19 : Brudzinski’s Sign Supine pt with neck flexed will raise knees to take pressure off of the meninges Present in 50% of acute bacterial meningitis cases
20 : Meningitis Clinical Manifestations – Meningococcemia: Prominent rash Diffuse maulopapular rashe involving trunk and lower extremities
21 : Raised ICP Cushing reflex Cranial Nerve Palsies IV, VI, VII Seizures Papilledema
22 : Meningitis Diagnosis Assess for increased ICP Papilledema Focal neurologic findings Defer LP until CT scan or MRI obtained if any of above present If suspect meningitis and awaiting neuroimaging Obtain BC’s and start empiric Antibiotics and steroids
23 : Obtain CT scan before lumbar puncture in patients with: Immunucompromised state History of CNS disease New onset seizures Papilledema Altered level of consciousness Focal neurologic signs
24 : LP-CSF Tube # 1 Protein Glucose Tube # 2 Gram stain Culture Tube # 3 Cell count differential Tube # 4 Store ( PCR, viral studies etc)
25 : Meningitis Diagnosis CSF Findings : Opening pressure Appearance Cell count differential Glucose Protein Gram stain culture
26 : Opening pressure: high, > 180 mmH20 Cloudy 1000-5000 cells/mm3 with a neutrophil predominance of about 80-95% Glucose<40mg/dl, CSF/serum glucose <.6 Protein elevated( >45mg/dL)
27 :
28 : CSF Gram’s stain Positive in >60% CSF Culture Positive in >80%
29 : Gram-positive diplococci-pneumococcal meningitis
30 : Gram-negative diplococci-meningococcal meningitis
31 : Gram-positive cocci-clusters-staphylococcus meningitis
32 : Gram-negative coccobacilli-haemophilus influenza meningitis
33 : Gram-positive rods-listeria monocytogenes meningitis
34 : Meningitis Diagnosis Rapid Tests latex agglutination test CIE (Counter immunoelectrophoresis) Broad base bacterial PCR CT/MRI Little role in DIAGNOSIS of menigitis Obtain if suspect increased ICP
35 : Meningitis Diagnosis Additional Tests CBC Blood cultures: 50-75 % positive Blood Sugar CXR Electrolytes and renal function
36 : Meningitis Differential Diagnosis CNS infections (abscess, encephalitis) Viral/ Tb/ Lyme meningitis Ricketsial infections Cerebral vasculitis Subarachnoid hemorrhage Neurosyphilis
37 : Meningitis Treatment Regimens Empirical antimicrobial therapy: Based on age and underlying disease status Empiric antibiotic regimines Neonates (<1 months) Ampicillin plus Cefotaxime Infants (1-3 month) Third generation cephalosporin + Ampicillin Immuno Competent Adults (>3mo and adult <55 yrs) Third generation cephalosporin (Ceftriaxone, Cefotaxime, Cefepime) + Vancomycin
38 : Meningitis Older adults(>55 yrs) and adults of any age with alcoholism or other debilitating ilnesses Ampicillin + combination with third generation ceph + Vancomycin. Postneurosurgical Pt’s/ Hospital acquired/ Post traumatic/ Neutropenic patient Vancomycin plus ceftazidime or meropenem plus Ampicillin until cultures are available
39 : Antibiotics-for specific bacteria S. Pneumonia Vancomycin 1g IV bid plus Ceftriaxone 2g IV bid for 14 days Discontinue Vancomycin if strepto not cephalosporin-resistant N. Meningitis Penicillin G 4 million units IV q4hrs for 7 days H. Influenza Ceftriaxone 2g IV q12hrs for 7 days L. Monocytogenes Ampicillin 2g IV q4hrs for 2-4 weeks if immunocompetent, for 6-8 weeks if immunocompromised PLUS Gentamicin 1-2mg/kg IV q8hrs until patient improves for 10-14 days, monitoring of ototoxicity and nephrotoxicity Group B Streptococci (agalactiae) Penicillin G 4 million units IV q4hrs for 2-3 weeks Enterobacteriacae Ceftriaxone 2g IV q12hrs plus Gentamicin 1-2mg/kg IV q8hrs for 3 weeks Pseudomonas Ceftazidime 2g IV q8hrs plus Gentamicin 1-2mg/kg for 3 weeks
40 : Meningitis Treatment Duration of Treatment Dependent on infecting organism Average of 10-14 days Gm (-) bacilli, Listeria for 3 weeks Meningococal- 7 days
41 : Meningitis Treatment Steroids 20 min before or along with antibiotics. Do not give steroids after antibiotic treatment. iv Dexamethasone 10 mg 6 hrly x 4 days Treatment of raised ICP Treatment of Seizures
42 : Meningitis Prognosis Mortality rate 3-7% for H influenzae and meningococcal, gr B Streptococcal 15 % for L monocytogenes Pneumococcal Meningitis Associated with the highest mortality rate 20-30% Permanent neurologic sequelae 1/3 of pts Hearing loss Mental retardation Seizures Cerebral Palsy
43 : Prevention Vaccines Pneumococcal vaccine Over age 65 and for chronically ill, Splenectomy Meningococcal vaccine Tetravalent vaccine ( type A,C,Y,W-135) H. influenza vaccine For children (routine), adults prior to splenectomy
44 : Chemprophylaxis Basilar skull fracture-underlying dural tears Prophylactic antibiotics not proven to reduce meningitis N.Meningitidis Household contacts, intimate contacts, children, coworkers, young adults in dormitories Rifampin 2 days -oral bid -max 600mg (adults), Ciprofloxacin Adults- 500mg oral one dose Azithromycin 500 mg stat Ceftriaxone: Single IM dose-under 15 years 125mg, over 15 years 250mg
45 : Neurologic complications Cerebrovascular abnormalities Thrombosis Vasculitis Acute cerebral hemorrhage Aneurysm formation Seizures Poor prognostic sign Status epilepticus-permanent neurologic impairment Recurrent seizures within 5 years in survivors
46 : Neurologic complications Focal neurologic deficit Cranial nerve palsy Monoparesis Hemiparesis Gaze preference Visual field defects Aphasia Ataxia Sensorineural hearing loss Intellectual impairment Visuospatial reasoning Speed in attention Executive functioning Reaction speed
47 : Neurologic complications Altered mental status Cerebral edema/coma Increased intracranial pressure Increased intracranial pressure Vasogenic cerebral edema, cytotoxic factors, inflammation Bradycardia and hypertension (cushing reflex) Papilledema Cranial nerve palsy-VI Herniation leading to death
48 : Unusual complications Subdural empyema Mandatory drainage Spinal cord Transverse myelitis Spinal cord infarction Brain abscesses Severe permanent hydrocephalus
49 : Meningitis Conclusion Meningitis is an infectious disease emergency Mortality is often high but can be prevented with appropriate medical therapy If you consider meningitis in your differential, you are committed to an LP and empiric antibiotics within 60 min of patient’s arrival
50 : Aseptic meningitis Causes Same as viral meningitis Some viruses than cause arthropod encephalitis Lyme disease Syphilis Tick- borne diseases Fungal infections (cryptococcal ) Tuberculosis Abscess in CNS ( tissues and endocarditis) Neoplasms (metastatic, leukemia,lymphoma) Drug-induced (NSAIDS, Septra,Vioxx,OKT3 antibodies) Partially treated bacterial meningitis History Travel history,exposure to animals,ticks, TB,sexual history, others that are sick,medication usage Physical exam New rashes, enlarged parotids,vesicles, ulcers, lymphadenopathy, opportunist infections-candida,paralysis CT if focal signs LP Results depend upon etiology, will be gram stain negative, PCR and special staining depending on clinical suspicion required
51 : Aseptic meningitis Management Supportive Suspected bacterial meningitis Empiric antibiotic therapy Suspected viral meningitis Empiric antibiotic therapy for 48 hours if < 1 year age, elderly, immunocompromised, received antibiotics prior to presentation Suspected HSV Start acyclovir-10mg/kg IV q 8 hrs Unclear etiology Obtain blood and CSF cultures Start empiric antibiotics or repeat LP in 6 hours Patient improved-cultures negative discontinue antibiotics (usually 72hrs) Repeat LP in patient with progressive symptoms or unclear diagnosis
52 : Brucellosis Organisms of the genus Brucella Small, gram negative, aerobic coccobacilli
53 : Epidemiology Animal infection Cattle (B. abortus), sheep and goats (B. melitensis), swine (B.suis) Human infection Most common in US (B. melitensis), in California (B. abortus) Acquired Direct inoculation-handling animal carcasses (open wounds) Conjunctiva Inhaled infected aerosols Ingestion of contaminated food Raw milk Cheese (from unpasteurized milk) Raw meat
54 : Clinical manifestation Symptoms Fever of unknown origin Night sweats Malaise Anorexia Arthralgias Fatigue Weight loss Depression Localized disease Osteoarticular Sacroiliitis Genitourinary Epididymoorchitis Neurobrucellosis Meningitis Papilledema,optic neuropathy,radiculopathy,stroke, ICH Endocarditis Hepatic abscess
55 : Diagnosis Culture Blood Localized sites bone marrow and liver Serologic tests To detect antibody Serum agglutination Complement fixation Antibrucella coombs ELISA (enzyme-linked immunosorbent assay) To detect DNA PCR Recommended PCR-ELISA
56 : Treatment Regime A Doxycycline 100 mg po bid for 6 weeks Streptomycin 1g IM daily for 14-21 days Regime B Doxycycline 100 mg po bid and rifampin 600 mg po daily for 6 weeks Osteoarticular disease Regime B and streptomycin-treat up to 5 months Neurobrucellosis Three drugs to cross the blood-brain barrier Regime B and septra-treat until CSF returns to normal Endocarditis Treat for months-three drugs Valve replacement Accidental animal vaccine exposure Full course of antibiotic treatment
57 : Prevention Vaccination of domesticated herds Serologic testing of animals Slaughter of infected animals Protection of slaughter house workers Pasteurization of milk


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