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infectious disease 2 > Bacterial Meningitis > Flashcards

Bacterial Meningitis Flashcards

1
Q

What age has the highest pediatric risk factor for bacterial meningitis?

A

Highest in age < 2 years (esp age < 3 months)

B/c less developed immune system

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2
Q

What are pediatric risk factors?

A
  • Incomplete immunization (add Hib, pneumococcal)
  • Immunocompromised
  • Cranial structural defects
  • Medical devices like CSF shunts, cochlear implants
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3
Q

What are some immunocompromised risk factors?

A
  • Hypogammaglobulinaemia
  • Complement deficiency
  • Common variable immunodeficiency
  • Sickle cell disease
  • Asplenia
  • Immunosuppressive meds
  • HIV
  • Cancer
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4
Q

What are some perinatal risk factors?

A
  • Premature
  • Low birth weight
  • Premature rupture of membranes
  • Mother has group B strep colonization
  • Chorioamnionitis
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5
Q

What is the source of entry?

A
  • Nasopharyngeal colonization followed by inflammation (i.e., URT) which allows access to bloodstream, results in bacteremia and hematogenous spread to the CNS
  • Direct inoculation (CSF catheter, trauma)
  • Para meningeal focus (middle ear infection, paranasal sinus infection)
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6
Q

How does the pathogen evade the immune system?

A
  • Bacteria secretes enzymes that degrade protective immunoglobulins in nasal secretions that otherwise inhibit colonization
  • Bacteria with polysaccharide capsules resist neutrophil phagocytosis
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7
Q

What are some diagnostic markers in the CSF?

A
  • WBC: 1000-5000
  • Differential: > or equal to 80
  • Protein: 100-500 mg/dl
  • Glucose: < 40 mg/dl
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8
Q

Viral meningoencephalitis

A

Treatable “common” viral meningitis limited to Herpes Simplex Virus (HSV)

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9
Q

What are some clinical suspicion of viral meningoencephalitis?

A
  • Focal neurologic deficits
  • Seizures
  • Depressed mental status
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10
Q

How do you treat viral meningoencephalitis?

A

IV acyclovir added until HSV is eliminated
* PCR available in 24-48 hours

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11
Q

What pathogens are associated with bacterial meningitis?

A
  • S. pneumoniae
  • N. meningitidis
  • H. influenzae
  • group B Streptococcus (Streptococcus agalactiae)
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12
Q

What is the best empiric antimicrobial regimen?

A

Ceftriaxone and vancomycin

Vancomycin + third gen cephs (cefotaxime or ceftriaxone)

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13
Q

What are some empiric antibiotic consideration?

A
  • SOA
  • PK
  • PD: Bactericidal effect desired in CF
  • Allergies
  • Timing: Should NOT be delayed, even if LP is not done
  • W/ or w/o inflammation
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14
Q

S. Pneunoniae

A
  • Gram neg and diplococcus
  • # 1 US cause after intro of Hib vaccine
  • Neurologic complications are common in survivors, esp infants and children
  • Impact of PCN resistance due to altered PBP
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15
Q

Haemophilus influenza

A
  • Gram-negative rods
  • WAS the most common cause of meningitis in children 6 months - 3 years
  • Spread via infected sinuses or bacteremia from a local focus (AOM)
  • 30-40% of isolates are ampicillin-resistant beta-lactamases (therefore 3rd and 4th gen cephs provide options due to stability
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16
Q

N. meningitidis

A
  • Gram-negative diplococcus
  • Leading cause of bacterial meningitis in children and young adults
  • Direct person-to-person spread in close contacts from asypmtomatic carrier, Winter-sparing predominance, Purpuric or petechial lesion
17
Q

What is the dosing for ceftriaxone?

A

80-100 mg/kg/day divided every 12 to 24 hours
* MAX dose: 4,000 mg/day
* Loading dose (ex: 1200 mg IV) and maintenance

18
Q

What is the dosing of Vancomycin?

A

15 mg/kg/dose every 6 hours

19
Q

What is the AUC: MIC target level for S. aureus induced bacterial meningitis?

A

400, potentially up to 600

20
Q

Trough based monitoring

A
  • 15-20 mg/L
  • Infants, children, and adolescents: 7 to 10 mg/L have been associated with AUCs>400
21
Q

What is the monitoring plan for efficacy?

A
  • Vital signs: continuous in ICU, every 4 hours on units
  • Neurological exam: every 4-6 hours
  • WBC & differential: daily
  • Check results of CSF and blood culture daily, expect gram stain w/in 24hrs; preliminary culture results in 24-48 hours; sensitivity data in 24-48 hours
22
Q

What are some toxicity adverse effects of Ceftriaxone?

A
  • Hypersensitivity-rash, fever, SOB
  • N/V, diarrhea
  • Phlebitis: swelling and pain at infusion site
  • White plaques in mouth: oral flush (also vaginal in females, skin esp. diaper areas)
23
Q

What are some toxicity adverse effects of Vancomyin?

A
  • Flushing, itching, blood pressure, hives (Vancomyin infusion reaction)
  • Daily BUN and SCr for nephtrotoxicity, I/O’s with IV fluids
  • Vancomycin trough as surrogate for efficacy
    * After 3-4 doses (approx. steady-state)-target 15-20 mg/L
    * Repeat 2x/week, sooner if dose change OR renal function change
24
Q

Corticosteroid

A
  • Timing prior to or at the same as the administration of antibiotics (Ideally, within 4 hours of presumptive diagnosis)
  • No significant decrease in mortality but significant decrease in the rate of hearing loss
25
Q

Dexamethasone

A
  • Lower rates of hearing loss in H. influenzae meningitis BUT conjugate vaccines reduce rates of hearing loss after H. influenzae meningitis
  • Infants > 6 weeks and children: IV 0.15 mg/kg/dose every 6 hours for the first 2 to 4 days of antibiotic treatment
  • Start it 10 to 20 minutes before with the first dose of antibiotic
  • Do NOT give it if antibiotics have already been administered
  • Children < 5 years not vaccinated for Hib should receive adjunctive therapy with it before or at the same time as the first dose of antimicrobial therapy
26
Q

Anti-Infective Prophylaxis

A
  • For N. meningitidis and H. influenzae
  • Rifampin 20 mg/kg/dose (MAX: 600 mg) once a day for 4 days
  • Alternatives:
    • Ciprofloxacin 500 mg for adults and children > 12 years old
    • Ceftriaxone 250 mg IM for 1 time in adults, 125 mg IM for 1 time in children < 12 years
27
Q

What are the patient counseling for Rifampin?

A
  • Urine and body fluid discoloration (orange/red)
  • Staining potential to clothes, contact lenses
  • Drug interaction with oral contraceptives
28
Q

What is the PK considerations of an antibiotic?

A
  • Distribution to the CF (has to hydrophobic b/c hydrophillic drugs have poor penetration)
  • Presence of inflammation increases distribution to CSF
  • Maximal “highest” doses required (optimize CNS penetration and achieve and maintain effective CSF concentrations
  • Parenteral IV route REQUIRED
29
Q

What should give a patient with inflammation for their empiric antibiotic therapy?

A

3rd and 4th gen cephs, penicillins, vancomycin

infectious disease 2 (7 decks)

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