MENINGITIS Flashcards
MANAGEMENT
STAT
CBC, Blood Cultures x 2 prior to antibiotics
EMPIRIC ANTIBIOTICS
Empiric Antibiotics Dosing: 2 - 50 years:
Vancomycin 15-20 mg/kg IV q 12 h
Ceftriaxone 2 g IV q 12 h
Empiric Antibiotics Dosing: > 50 yrs, Alcoholic:
Vancomycin 15-20 mg/kg IV q 12 h
Ceftriaxone 2 g IV q 12 h
Ampicillin 2 g IV q 4 h
Empiric Antibiotics Dosing: Immunocompromised
Vancomycin 15-20 mg/kg IV q 12 h
Ampicillin 2 g IV q 4 h
Meropenem OR
Ceftazidime 2 g IV q 8 h
CORTICOSTEROIDS
before or at the time of antibiotics if S. Pneumonea is suspected
Adult: Dexamethasone 10 mg IV q 6 h x 4 days
Children: Dexamethasone 0.6 mg / kg / d divided q 6 h x 4 days
ACYCLOVIR
suspected viral meningitis
10 mg/kg IV q 8 hr
LUMBAR PUNCTURE
LP Contraindications
Infection at the site of the LP
Coagulation abnormalities
Risk of brain herniation
CSF opening pressure (if done in left lateral decubitus)
Normal Opening Pressure: 50 - 200 mmH20
Tube 1 - cell count, gram stain, xanthocromia
Tube 2 - protein, glucose
Tube 3 - culture & sensitivity, viral studies
Tube 4 - cell count
CT HEAD
Altered mental status (GCS<10)
CNS Disease (CSF Shunt, Hydrocephalus, mass lesion, stroke, or focal infection)
Focal neurological deficit (excluding cranial nerve palsies)
Papilledema
Seizure (new onset within 1 week)
Immunocompromised (HIV, immunosuppressive therapy)
ISOLATE PATIENT:
Droplet Precautions
DOCUMENTATION
CLINICAL FEATURES
95% of patients have 2/4 features:
Neck stiffness (Se 70%)
Headache (Se 50%)
Fever (>38 C) OR hypothermia
Altered mental status
Photosensitivity
RISK FACTORS
Age: ≥65 years old, Neonates
Aboriginal groups, Students living in residence
PMHx: Immunocompromised (16%): HIV, DM; hepatic / renal failure; Comorbid Infection: otitis media or sinusitis (25%), mastoiditis, Pneumonia (12%), Endocarditis, Dental Infection
Recent neurosurgery, Head trauma, shunts
Recent travel to area with endemic meningococcal disease (eg. sub-Saharan Africa)
Alcoholism, IVDU
MENINGEAL IRRITATION MANEUVERS
Lay patient flat, no pillows
Lift head, hold for 10 seconds to examin for neck stiffness
Jolt accentuation (Sn 97% Sp 60%)
Accentuation of headache by horizontal rotation of the head at a frequency of two to three times per second
Brudzinski (Sn 97%)
Spontaneous flexion of the hips during attempted passive flexion of the neck
Kernig’s (Sn 57%)
Inability or reluctance to allow full extension of the knee when the hip is flexed 90 degrees
Neck stiffness
LUMBAR PUNCTURE
Risk / Benefits:
Post LP Headache - occurs in 10-30%
Infection
Bleeding
Back pain or radicular pain or numbness
DDX: CNS INFECTIONS
Meningitis
Encephalitis
Brain Abscess
Epidural Abscess
PROPHYLAXIS
Prophylaxis Indications, Antibiotics
N. Meningitidis
Indications: Close contact (> 8 hrs), contact with oral secretions
Rifampin
Adults: 600 mg PO q 12 hrs x 2 d
Children: 5-10 mg / kg PO q 12 hrs x 2 d
H. Influenza
Indications: Living in household with >= 1 unvaccinated or incompletely vaccinated child age < 4 yrs old
Rifampin 20 mg / kg / d (max 600 mg / d) for 4 days
Group B Strep in Pregnancy
Indications:
Previous baby with group B Strep Infection
Colonization of the perineum or rectal area at 35 - 37 wk GA
Bacterium in pregnancy high risk features: ROM > 18 h, preterm delivery (<37 wk GA)
CSF Findings for Bacterial vs. Viral Meningitis
Bacterial: Turbid, WBC>1000/mm3, ↓Glucose ↑↑Protein, 80-90% neutrophils, +gram stain
Viral: Turbid, WBC 10-500/mm3, Nml glucose, Nml protein, -gram stain
TRUE CSF WBC = measured CSF WBC [(CSF RBC x serum WBC)/serum RBC]
