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Spring 2025 Therapeutics V > Exam 5: Central Nervous System (CNS) Infections > Flashcards

Exam 5: Central Nervous System (CNS) Infections Flashcards

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1
Q

What is a normal WBC level in the CNS?

A

<5

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2
Q

What is a normal protein level in the CNS?

A

<50

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3
Q

What is a normal glucose level in the CNS?

A

30-70 (2/3 peripheral)

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4
Q

What are the 2 barriers in the CNS?

A

Blood-Brain Barrier
(harder to penetrate and comes first)

Blood-CSF Barrier

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5
Q

How does lipid solubility affect drug penetration into CNS?

A

More lipid soluble= Penetrate better

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6
Q

How does ionization affect drug penetration into CNS?

A

Only unionized drugs diffuse

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7
Q

How does protein binding affect drug penetration into CNS?

A

Only free drug penetrates

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8
Q

How does molecular weight affect drug penetration into CNS?

A

Low molecular weight drugs penetrate better

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9
Q

How does the degree of meningeal inflammation affect drug penetration into CNS?

A

Penetration of some drugs is enhanced with inflammation

-penetration will decrease as healing progresses

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10
Q

Which drugs require Meningeal inflammation to penetrate the CSF?

A

Penicillins
Some cephalosporins (3rd and 4th gen)
Aztreonam
Meropenem *only
Colistin
Vancomycin

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11
Q

Which drugs do not achieve therapeutic concentrations in the CNS with or without inflammation?

A

Macrolides
Aminoglycosides
B-lactamase inhibitors
Some cephalosporins (1st and 2nd gen)
Clindamycin
Tetracyclines (Except Doxy)
Echinocandins

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12
Q

Which of the following antibiotics does NOT achieve therapeutic concentrations in the CSF, even in the presence of inflamed meninges?
A. Cefazolin
B. Penicillin G
C. Ceftriaxone
D. Ertapenem
E. A and D

A

E. A and D

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13
Q

Which of the following is not a characteristic that effects CNS penetration?
A. Excretion
B. Molecular weight
C. Protein binding
D. Ionization

A

A. Excretion

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14
Q

Who most commonly gets meningitis?

A

The very young and The very old

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15
Q

How does meningitis get into the CSF?

A

Hematogenous spread –> Go from bloodstream into the subarachnoid space

1st step: nasopharyngeal colonization
-pathogens adhere to epithelial surface and enter blood stream
-penetrate through the BBB by transcellular penetration or paracellular penetration
-organisms multiply to invade the BCSFB

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16
Q

What is the other way that meningitis can enter the CNS?

A

Direct inoculation

-rare
-through ventricular shunt or drain, skull fracture, trauma

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17
Q

How do we diagnose meningitis?

A

Obtain cerebrospinal fluid
-3 tubes (chemistry, hematology, and microbiology testing) obtained by lumbar puncture

Elevated opening pressure (200-500) often observed

Head CT or MRI to rule out a mass or lesion

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18
Q

When do we start empiric meningitis therapy?

A

Immediately after a lumbar puncture is performed

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19
Q

What CNS WBC count indicates bacterial meningitis?

A

> 1000-5000

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20
Q

What CNS differential indicates bacterial meningitis?

A

> 80% neutrophils

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21
Q

What CNS protein level indicates bacterial meningitis?

A

> 150

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22
Q

What CNS glucose level indicates bacterial meningitis?

A

<50

</= 0.4 CSF to blood

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23
Q

Which of the following findings would be expected in the cerebrospinal fluid (CSF) analysis and culture of a patient with suspected acute bacterial meningitis?

A. Low glucose concentration (< 50% of serum glucose concentration)
B. Low protein concentration (< 50 mg/dL)
C. A predominance of monocytes in the white blood cell count differential
D. Negative Gram stain and culture
E. Low white blood cell count (< 5 cells/mm3

A

A Low glucose concentration (<50% of serum glucose concentration)

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24
Q

Mortality with meningitis normally occurs how quickly?

A

Within 24 to 48 hours of onset

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25
Duration of meningitis therapy includes what?
Empiric + Directed therapy length
26
What is the preferred empiric meningitis treatment in neonates (<1 month)?
Ampicillin + Ceftriaxone/Cefepime or Ampicillin + Aminoglycoside (gentamicin)
27
What is the preferred empiric therapy for meningitis for everyone except neonates?
Vancomycin + Ceftriaxone
28
Older Adults (>50) and Immunocompromised Adults need the addition of which drug to their meningitis empiric therapy?
Ampicillin (Vancomycin + Ceftriaxone + Ampicillin)
29
How does Streptococci appear on a Gram Stain?
Gram + Diplococci
30
What are the preferred regimens for meningitis with streptococci?
Sensitive to Penicillin (MIC<0.06) -Penicillin G -Ampicillin PSN Intermediate/Resistant (MIC > 0.12) -Ceftriaxone Cephalosporin Resistant (MIC >/=2) -Vancomycin
31
How long does streptococcus meningitis therapy last?
10-14 days
32
What is the role of steroids in meningitis therapy?
Consider in children > 2 months old with meningitis Use in pneumococcal meningitis in adults Administer before 1st antibiotic dose -decreases incidence of neurologic sequelae
33
How does Staph aureus appear on a Gram stain?
Gram + cocci in clusters
34
What are the therapy options for Staph aureus meningitis?
MSSA -Nafcillin MRSA -Vancomycin
35
What are the necessary trough levels for vancomycin therapy in MRSA meningitis?
Between 15-20
36
How does Listeria appear on a Gram stain?
Gram + Rod, Non-spore forming
37
What is the preferred therapy for Listeria meningitis?
21 days
38
How does Neisseria appear on a Gram stain?
Gram - Intracellular Diplococci
39
What are the preferred therapy options for Neisseria meningitis?
PCN MIC < 0.1 -Penicillin G continuous infusion -Ampicillin PCN MIC 0.1-1: Ceftriaxone
40
How does Haemophilus influenzae appear on a Gram stain?
Gram Negative Coccobacillus
41
What are the treatment options for Haemophilus influenzae menigitis?
B-lactamase Negative: -Ampicillin B-lactamase Positive: -Ceftriaxone
42
What are the treatment options for Enterobacteriaceae meningitis?
Ceftriaxone Cefepime Meropenem
43
A 58-year-old male is admitted for suspected bacterial meningitis (LP with low glucose, elevated bacteria and WBC). He also has a PMH of COPD, CAD, HTN, HLD. What would be the best empiric treatment option? A.Ceftriaxone + vancomycin B.Ceftriaxone + vancomycin + dexamethasone C.Ampicillin + ceftriaxone D.Ampicillin + ceftriaxone + vancomycin E.Ampicillin + ceftriaxone + vancomycin + dexamethasone
E. Ampicillin + Ceftriaxone + Vancomycin + Dexamethasone
44
The same patient has a gram stain done which shows gram positive cocci in pairs and chains. What would be the best course of action? A. Continue ceftriaxone + vancomycin B. Continue ceftriaxone + vancomycin + dexamethasone C. Continue ampicillin + ceftriaxone + vancomycin + dexamethasone D. Continue ceftriaxone + dexamethasone E. Continue ampicilli
B. Continue ceftriaxone + vancomycin + dexamethasone
45
Dexamethasone has been shown to decrease mortality and unfavorable outcome in adults with bacterial meningitis due to any organism. True or False
False -only is useful in meningitis due to Streptococcus pneumoniae (G+ cocci pairs)
46
What are the most common pathogens in fungal meningitis?
Cryptococcus neoformans Cryptococcus gattii
47
What is the most common route of infection for fungal meningitis?
Encapsulated soil fungus contaminated by guano -Inhalation of fungal spore into airways -Direct inoculation
48
What is the WBC level for fungal meningitis?
10-500
49
*What is the Differential for fungal meningitis?
>50% Lymphs
50
What is the protein level for fungal meningitis?
40-150
51
What is the glucose level for fungal meningitis?
<30-70
52
What are the phases of fungal meningitis treatment?
Induction Consolidation Maintenance
53
What is the preferred therapy for the induction phase of fungal meningitis treatment?
Ampho B OR Liposomal Ampho + Flucytosine
54
How long does the induction phase of fungal meningitis treatment last?
2 weeks
55
What is the preferred therapy for the Consolidation phase of fungal meningitis treatment?
Fluconazole
56
How long does the consolidation phase of fungal meningitis treatment last?
8 weeks
57
What is the preferred therapy for the maintenance phase of fungal meningitis treatment?
Fluconazole
58
How long does the maintenance phase of fungal meningitis treatment last?
Non-HIV patient: 6-12 months HIV patient: At least 12 months -AND CD4 > 200 -AND suppression of viral load on ART
59
How long do we have to wait to initiate ART in patients with cryptococcal meningitis and HIV?
5 weeks *especially if CSF has < 5 WBC/mm^3
60
A renal transplant patient is admitted with a 3-week history of headache, photophobia and fever. The LP demonstrates 80 WBC with 90% lymphs, and his serum and CSF cryptococcal antigen titers are positive. Which therapy would be most appropriate for this patient? A. Liposomal ampho B 4 mg/kg IV daily B. Conventional ampho B 1 mg/kg IV daily over 4 hours + flucytosine PO C. Fluconazole 400mg IV QD D. Conventional ampho B 1 mg/kg IV daily over 24 hours + Flucytosine PO E. Caspofungin 50mg IV Q
D. Conventional ampho B 1 mg/kg IV daily over 24 hrs + Flucytosine PO
61
What is the clinical presentation of encephalitis?
Fever Headache *Altered mental status*
62
What is the CNS WBC level for Viral encephalitis?
5-300
63
What is the CNS differential level for Viral encephalitis?
50% lymphs
64
What is the CNS protein level for Viral encephalitis?
30-150
65
What is the CNS glucose level for Viral encephalitis?
<40-70
66
What is an important thing to remember about encephalitis infections?
The majority of cases are benign and self-limiting Full recovery in 7-10 days
67
What is the treatment for HSV encephalitis?
Acyclovir 10 mg/kg Neonates: 20 mg/kg
68
What is the treatment for VZV encephalitis?
Acyclovir 10-15 mg/kg
69
What is the treatment for CMV Encephalitis?
Ganciclovir *can combine with foscarnet -always combine when HIV
70
True/False: All types of viral encephalitis should be treated with Acyclovir 10mg/kg IV every 8 hours
False -most cases of viral encephalitis are benign and self-limiting Only HSV and VZV encephalitis should be treated with high dose acyclovir

Spring 2025 Therapeutics V (41 decks)

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