Meningitis 🩻 Flashcards
(5 cards)
EBL: Following his admission Amartya makes a full recovery, his mother has been chatting to other parents and teachers at the school who are surprised that not all cases of meningitis present with the stereotypical non-blanching rash and are concerned that meningitis may be contagious.
Discuss the main points to raise awareness of the symptoms of meningitis in school children which covers the above concerns
Model:
Symptoms in children:
Red flag combination of symptoms (NICE): fever, headache, neck stiffness and altered
consciousness.
Other symptoms:
Non blanching rash (expect students to relate glass test to audience). Often later in disease
progression.
Pale, mottled, cyanosis of skin – harder to detect in darker skin tones.
Irritability, lethargy, reduced feeding, unusual behaviour.
Photophobia
Seizures
Tachypnoea
Unexplained body pain
Causes:
Overall in the UK, Neisseria meningitidis (meningococcus), Streptococcus pneumoniae
(pneumococcus), and Haemophilus influenzae type b (Hib) are the most common causative
organisms of acute bacterial meningitis in children aged 3 months or older and adults. The
bacteria that can cause meningitis commonly live in the back of the nose or throat
Some causes of bacterial meningitis are more likely to affect certain age groups:
• Newborns: Group B Streptococcus, Streptococcus pneumoniae, Listeria
monocytogenes, E. coli
• Babies and young children: S. pneumoniae, Neisseria meningitidis, Haemophilus
influenzae, Group B Streptococcus, Mycobacterium tuberculosis
• Teens and young adults: N. meningitidis, S. pneumoniae
• Older adults: S. pneumoniae, N. meningitidis, H. influenzae, group B Streptococcus,
L. monocytogenes
Viral meningitis is most commonly caused by enteroviruses that normally only cause a mild
stomach infection, the mumps virus and the herpes simplex virus.
Fungal meningitis is much less common than the bacterial or viral forms. Healthy people
rarely get it. Individuals are more likely to get this form of meningitis if they have a problem
with their immune system, such as AIDS.
Meningococcal disease is the leading infectious cause of death in early childhood.
There are 12 capsular groups of meningococci — B, C, W, and Y were historically the most
common in the UK, however, after the introduction of the meningococcal C vaccination
programme, group B (MenB) now accounts for many cases.
MenB is responsible for most invasive meningococcal disease cases in people aged under
25 years.
In children aged 3 months or older, N. meningitidis, S. pneumoniae, and Hib are the most
common causative organisms.
Transmission (is it contagious?)
Bacterial meningitis and meningococcal disease are transmitted by aerosol, droplets, or
direct contact with secretions from the upper respiratory tract. Transmission usually requires
either frequent or prolonged close contact.
Meningitis almost always results from a bacterial or viral infection that begins somewhere
else in the body, such as the ears, sinus or throat. Most cases of meningitis occur alone, and
the risk of a second, related case is usually very small. It is rare to “catch” meningitis from
someone who has the disease. Meningitis is more of a danger for people with certain
medical conditions, such as a damaged or missing spleen, long-term disease, or immune
system disorders.
Fewer than 2% of invasive meningococcal disease (IMD) cases are considered to result
from close contact with a primary IMD case.
Neisseria meningitidis is usually commensal. Prevalence increases through childhood from
around 5% in infants to a peak of 24% in 19 year olds, decreasing in adulthood to around
8%. The mean duration of carriage in settings where prevalence is stable is around 21
months.
The incubation period is usually 3–5 days.
The onset of disease can vary from fulminant with acute and overwhelming symptoms to
insidious with mild prodromal symptoms.
N. meningitidis capsular group B (MenB) is the most common cause of meningococcal
disease in people aged under 25 years.
In 2015, a four-component MenB vaccine was included in the routine UK immunization
schedule, and a MenACWY conjugated vaccine was introduced to replace the MenC
conjugate vaccine previously given at 14 years of age. For more information, see the CKS
topic on Immunizations - childhood.
Streptococcus pneumoniae — some serotypes of pneumococcus may be carried in the
nasopharynx without symptoms, with disease occurring in a small proportion of infected
people.
The incubation period is usually 1–3 days.
Invasive pneumococcal disease (IPD) including meningitis, septicaemia, and pneumonia, is
a major cause of morbidity and mortality, particularly in young children, people who are
immunocompromised, and the elderly.
Pneumococcal vaccination is offered to all adults aged over 65 years and to all children (as
part of the routine UK childhood immunization programme), as well as to other high-risk
groups. For further information, see the CKS topics on Immunizations - childhood and
Immunizations - pneumococcal.
Although over 90 different capsular types have been characterized, around 69% of invasive
infections are caused by the 10 most prevalent subtypes.
Ours:
Strongly suspect bacterial meningitis in people with all the symptoms in the red flag combinations
Fever
Headache
Neck stiffness
Altered level of consciousness or cognition (including confusion or delirium)
Other symptoms
Vomiting
Photosensitivity
cold hands and feet
confusion
breathing quickly
muscle and joint pain
pale, mottled or blotchy skin (this may be harder to see on brown or black skin)
being very sleepy or difficult to wake
fits (seizures)
Bulging fontanelle in infants
Strongly suspect meningococcal disease in people with any of these red flag combinations:
Haemorrhagic, non-blanching rash with lesions larger than 2 mm (purpura).
Rapidly progressive and/or spreading non-blanching petechial or purpuric rash.
Any symptoms and signs of bacterial meningitis.
EBL: The usual protocol for meningitis treatment at a local hospital involves ten days of intravenous antibiotics. Which antibiotic regimens achieve therapeutic concentrations in the cerebrospinal fluid and which should be avoided? The paediatric infectious disease consultant would like to know if there is a way of reducing this by designing a novel oral formulation or if there is a currently available oral antibiotic which would penetrate the blood-brain barrier?
https://pmc.ncbi.nlm.nih.gov/articles/PMC9854442/
(Pubmed study)
Good CSF Penetration:
Benzylpenicillin (penicillin G) / penicillin V
Cycloserine: Good CSF penetration of inflamed meninges
Cefotaxime: Adequate CSF penetration. Advantageous ( longer effects)
Poor CSF penetration:
Macrolides: Azithromycin, Clarithromycin, Erythromycin, Fidaxomicin
Glycopeptide:
Teicoplanin ( The high protein binding of teicoplanin restricts CSF penetration after IV administration), Vancomycin (Vancomycin is highly hydrophilic and may reach sub therapeutic CSF concentration at conventional doses, but adequate concentrations at increased doses)
Cefixime: Cefixime crosses the blood brain barrier of inflamed meninges, but at limited concentrations and should therefore not be used to treat meningitis
Oral antibiotics such as moxifloxacin and levofloxacin can penetrate the blood–brain barrier, they are not typically used as first-line treatment for meningitis, particularly in paediatric patients. Systemic and inhaled fluoroquinolones are associated with a risk of serious, disabling, long-lasting and potentially irreversible adverse reactions.
The ideal compound to treat CNS infections is of small molecular size, is moderately lipophilic, has a low level of plasma protein binding, has a volume of distribution of around 1 liter/kg, and is not a strong ligand of an efflux pump at the blood-brain or blood-CSF barrier.
Nanoparticles
Model
Antimicrobial drug levels in the CSF are completely dependent on penetration from serum,
as they are not metabolized in the CSF. Exit of drugs from the CSF is managed by the
choroid plexus via energy-dependent pumps, which transport molecules one way back to
serum. Ensuring an adequate drug level at the site of infection, the CNS, is crucial in
achieving cure but challenged by the presence of the blood–brain barrier (BBB) and blood–
cerebrospinal fluid barrier (BCSFB). The intrinsic role of those barriers, very similar
physiologically, is primarily to protect the brain and spinal cord from compounds in the
general circulatory system.
Hydrophilic antibiotics, such as beta-lactams, penetrate poorly through the BBB, but CSF
penetration is significantly increased in the presence of inflammation. In contrast, lipophilic
antibiotics such as quinolones, enter the CSF more efficiently and their penetration is not
inflammation dependent.
Both ceftriaxone and cefotaxime are effective in treating bacterial meningitis, but ceftriaxone
can be administered as a single daily dose.
Penicillin, ampicillin, and amoxicillin are frequently used for treating Listeria infections but do
not use dexamethasone as this increases resistance in Listeria.
EBL: Describe how a diagnosis of meningitis would be established in a laboratory
Students should refer to PHE UK standards for Microbiology Investigations: “Investigation of Cerebrospinal Fluid” to answer this question
The diagnosis of meningitis in a laboratory setting primarily relies on the investigation of cerebrospinal fluid (CSF) that is obtained via lumber puncture. Once collected, the CSF sample is immediately sent to microbiology laboratory and kept at room temp to preserve viable organisms.
The initial macroscopic examination assesses the CSF’s appearance —> cloudy or turbid fluid suggests a high white blood cell which indicates infection (possibly bacterial meningitis), while a yellow tinge may indicate bleeding or elevated protein levels.
Then they perform a microscope test to check how many white blood cells are in the fluid - as increased neutrophils could indicate bacterial meningitis. They can also use a stain to look for bacteria directly (gram-staining).
They can then try to grow any bacteria from the CSF to see exactly which bug is causing the illness to help doctors choose the right antibiotic.
PCR can also be used to detect bacteria/virus DNA.
Low glucose in CSF shows possible meningitis
High protein in CSF supports idea of infection aswell
Model
Diagnosis of meningitis is best established by laboratory examination of the CSF. This is
usually obtained by lumbar puncture. Blood cultures and pharyngeal swabs may be useful in
addition to CSF examination in the diagnosis of meningococcal meningitis and serology may
allow retrospective diagnosis on acute and convalescent sera. In patients for whom lumbar
puncture is contraindicated, every effort must be made to establish a microbiological
diagnosis by other means. This is desirable both for epidemiological purposes and for the
appropriate management of contacts of cases. The diagnosis of meningitis from the
examination of CSF includes the following:
• Complete cell count
• Differential leucocyte count
• Examination of Gram-stained smear
• Microbial Culture
• Determination of glucose (<60% blood glucose) and protein (elevated levels)
concentrations. These are usually performed by clinical biochemistry departments
• PCR where appropriate (i.e. for viruses)
• Antigen testing (e.g. if Cryptococcus fungi is suspected)
Specimens should be collected preferably before antimicrobial therapy is started, but this
must not be delayed unnecessarily pending lumbar puncture.
Collect specimens other than swabs into appropriate marked leak proof containers and place
in sealed plastic bags.
Specimens should be transported and processed as soon as possible. Time between
collection to microscopy and culture should occur within a maximum of 2 hours.
Divide sample for different tests.
Perform total White Blood Cell (WBC) and Red Blood Cell (RBC) counts on the uncentrifuged specimen.
Conduct differential leucocyte count by either use of a counting chamber or staining and
fixing depending on level of blood stain in the specimen.
Gram stain the specimen to help identify any bacteria present.
For all CSF, inoculate a range of specific agar plates (e.g. chocolate agar and blood agar for
N. meningitidis and other bacteria, fastidious anaerobic agar for anaerobic bacteria,
Sabaroud Dextrose agar for fungi) with centrifuged deposit (due to low numbers of
microorganisms). Conduct micro culture at Containment Level 2 unless infection with a) N.
meningitidis or b) a Hazard group 3 microorganism is suspected. Use Aseptic Technique
throughout.
Cell count Report:
Numbers of RBCs x 106 per litre and
Report numbers of PMNs and lymphocytes x 106 /L or
Report PMNs and lymphocytes as percentages of the total WBC (which is reported as x
106).
In certain cases, referral to cytology for identification of mononuclear and other cells may be indicated. Gram stain Report on organisms detected and presence or absence of pus cells.
Gram stain
Report on organisms detected and presence or absence of pus cells.
Microscopy & Culture Results
Results of cell counts and stains should be communicated immediately, within two hours of
receiving the specimen and made available on the clinical users’ results viewing system.
Where such facilities are not available, written, or computer-generated reports should follow
preliminary/verbal reports within 24 hours.
Report the organisms isolated or
Report absence of growth. CSF samples may be sent to the Meningococcal Reference Unit
(MRU) for examination using molecular methods and serological examination if culture is
negative and meningococcal infection suspected. Specimens for molecular testing for other
organisms may be sent to appropriate laboratories if clinically indicated.
Also, report results of supplementary investigations.
Clinically urgent culture results to be telephoned or sent electronically when available.
Interim/final written report, 16–72 hours stating, if appropriate, that a further report will be
issued. Molecular testing results (if applicable).
Antimicrobial Susceptibility Testing
Report susceptibilities as clinically indicated. Prudent use of antimicrobials according to local
and national protocols is recommended
EBL: What are the prognosis and potential long-term complications of meningitis? What are the relevant lifestyle issues?
Meningitis is an infection of the protective membranes that surround the brain and spinal cord (meninges).
Prognosis is dependant on the type of infection (bacterial, viral, fungal), timing of treatment, and patient factors like age and other comorbidities.
Viral meningitis generally has a good prognosis and the pt will recover on their own. Whilst, Bacterial meningitis is more serious and can be life-threatening. 1in 10 cases can be fatal.
Even with treatment, mortality can be as high as 10–18%, and 1 in 3 survivors may experience long-term complications.
Potential Long-Term Complications:
Hearing loss (most common)
Cognitive impairment (memory, attention, learning difficulties)
Seizures or epilepsy
Motor deficits (e.g. weakness, coordination problems)
Visual impairment
Amputation or tissue damage (in severe septic cases)
Rehabilitation
May need physiotherapy, speech therapy, or occupational therapy for motor/cognitive recovery.
Psychosocial support
Risk of anxiety, depression, or PTSD, especially after severe illness or ICU admission.
Vaccination
Ensure full immunisation (e.g. MenACWY, Hib, pneumococcal, MenB).
Hearing checks
Routine audiology is essential post-meningitis, particularly in children.
Driving restrictions
If seizures have occurred, must inform DVLA; may face a temporary driving ban.
Model
With prompt and adequate antimicrobial treatment and supportive therapy, the outcome of
acute bacterial meningitis is excellent. One in three infected individuals may however have
some form of long-term complications
Factors that affect the prognosis of bacterial meningitis include:
Age — fatality rates are high among people at the extremes of age (neonates and older
people). The case-fatality rates for bacterial meningitis are 4–10% in children and 25% in
adults.
Most deaths occur in the first 24–48 hours.
The causative organism — in England in 2018/19, the case-fatality ratio for invasive
meningococcal disease was 5%.
Case-fatality rates are 3–7% for Haemophilus influenzae and Streptococcus agalactia, 20–
25% for Streptococcus pneumoniae, and 30–40% for Listeria monocytogenes.
Presence of comorbidities.
Severity at presentation.
In children aged up to 18 years with bacterial meningitis, other significant prognostic factors
include:
Symptoms lasting more than 48 hours before admission.
Coma/impaired consciousness.
Prolonged seizures (more than 12 hours after admission).
Prolonged fever (more than 7 days).
Shock.
Peripheral circulatory failure.
Respiratory distress.
Absence of petechiae (petechiae occurs much less with S. pneumoniae).
Male gender.
S. pneumoniae being the causative organism (case fatality rates are higher).
Complications of bacterial meningitis occur in up to 30% of children and up to one-third of
adults and are more common in pneumococcal meningitis than in meningococcal meningitis.
Although overall mortality from acute bacterial meningitis has fallen in recent years, there
has been no change in the rate of complications.
Complications are more common following pneumococcal meningitis and occur in about
30% of people compared with 7% with meningococcal meningitis.
The frequency of complications is much higher in meningococcal septicaemia (up to 57%).
Cerebral infarction occurs in one in four people with bacterial meningitis — this leads to focal
neurological deficits. These are present in 50% of people on admission and develop during
the clinical course in the others.
However, neurological complications may also be caused by other pathologies, such as
subdural empyema, cerebral abscess, or intracerebral bleeding.
Neurological complications include:
Hearing loss (34%).
This has been reported in up to 19% of infants, 13% of children, 12% of adolescents, and
8% of adults with meningococcal meningitis.
Seizures (13%).
This has been reported in up to 5% of infants, 9% of children, and 2% of adolescents with
meningococcal meningitis.
Cognitive impairment (9%).
Motor deficits (12%).
Visual impairment (6%).
Physical complications include:
Amputations — these have been reported in up to 8% of children, and 3% of
adults/adolescents with meningococcal meningitis.
Young age is the most significant risk factor.
Although bacterial meningitis can affect all ages, incidence of bacterial meningitis and
meningococcal disease is highest in children aged under 2 years and declines during
childhood.
There is also an increased risk in adolescence and early adulthood.
Other risk factors include:
Winter season — bacterial meningitis is more prevalent during the winter.
An absent or non-functioning spleen.
Older age (more than 65 years).
Immunocompromised state (for example, HIV infection or chemotherapy).
Incomplete immunization — for more information, see the CKS topics on Immunizations -
childhood and Immunizations - pneumococcal.
Cancer – people with leukaemia and lymphoma are more susceptible to bacterial meningitis.
Organ dysfunction — for example liver or kidney disease.
Smoking.
Living in overcrowded households, college dormitories, or military barracks.
Contact with someone with Hib disease or meningococcal disease, or recently been to an
area with an outbreak of meningococcal disease.
Family history of meningococcal disease.
Previous episode of bacterial meningitis or meningococcal disease.
Cranial anatomical defects — congenital or acquired.
Cochlear implants.
Cerebrospinal leak.
Contiguous infection — for example, otitis media, sinusitis, pneumonia, mastoiditis.
Sickle cell disease.
EBL
10am: Amartya a 5 year old boy is brought to the pharmacist led open clinic at a GP surgery in Bolton. His mother is concerned that he has been vomiting and had a headache since approximately 5.30am this morning. On the way to the GP surgery Amartya was complaining his headache was worse when “his eyes were open”.
HPC: Complaining of being tired with headache and general malaise over the past 48 hours. Headache has been gradually getting worse. Started complaining of shivering and vomiting early this morning. Mother gave Calpol at 8am this morning.
No known recent illnesses or injuries. No significant past medical history or family history. No recent travel. NKDA. Up to date with all childhood vaccinations including BCG.
Observations:
BP 108/62 mmHg
Temp 39.7 °C
RR 18 bpm
HR133 bpm
O2 sats98%
Cap Refill>2seconds
PEARL
Cold hands and feet, looks visibly unwell, somewhat lethargic and unresponsive. No rash on skin noted. Neurological examination reveals neck stiffness and a positive Kernig sign.
Given the presenting symptoms and history the pharmacist makes a tentative diagnosis of meningitis. She calls the local paediatric emergency department who prepare for Amartya’s immediate transfer.
The pharmacist arranges for 600mg benzylpenicillin to be administered after the examination and before transfer to hospital.
Question 7
As a group decide on a treatment plan for Amartya for the next five days, this should cover the following points:
Comments on the examination, history taking and treatment Amartya received at the GP surgery.
Tests and investigations which need to be undertaken in order to confirm the diagnosis and to aid prognosis and treatment choice.
Initial empirical therapy, with specific treatment durations.
Any supportive treatment.
Monitoring and what you would expect to happen to the values if Amartya was responding to treatment.
Discharge Planning.
Model
Examination history taking and treatment
These generally followed NICE/MFT/GMMG guidance.
The patient is presenting with the red flag combination of symptoms (NICE): fever,
headache, neck stiffness and altered consciousness. The history and examination
identified this. The examination also identified/ruled out some non-specific signs of
meningitis such as: bradycardia (HR<60) Cap refill > 3 secs, lethargy, fever.
Useful information which appears to have been missed:
Travel history (affects treatment choice at hospital)
Family hx of meningococcal disease
Contact with a case of meningitis
Previous history of meningitis
Recent history of cold sore, chickenpox (potential viral causes)
Facilitators may want to press students on what is the difference between meningitis and
meningococcal disease.
Meningitis is inflammation of the two inner meninges (the pia and arachnoid mater) of the
brain and spinal cord.
This is different from encephalitis, which is inflammation of the brain tissue itself.
Causes of meningitis can be infective (bacterial, viral, and fungal) and non-infective (certain
cancers, autoimmune disorders, and drugs).
Bacterial meningitis is a life-threatening condition that affects all ages, but is most common
in babies and children.
Meningococcal disease is infection with Neisseria meningitidis.
It can result in meningococcal meningitis (15% of cases) or meningococcal septicaemia
(25% of cases), or a combination of both (60% of cases). Other bacteria can also cause
meningitis.
Pneumococcal disease is infection with Streptococcus pneumoniae (also called
pneumococcal).
Bacterial meningitis and meningococcal disease are notifiable diseases. (NICE CKS)
Meningococcal disease usually presents with non-blanching rash.
Haemorrhagic, non-blanching, >2mm spots
Check for petechiae in conjunctivae
DO NOT rule out meningococcal disease if rash not present.
If meningococcal disease is suspected benzylpenicillin is recommended to be given ASAP
(GMMG). The route of administration of benzylpenicillin has not been specified, according to
GMMG IM can be used if a vein cannot be found.
NICE recommends that transfer to hospital MUST NOT BE DELAYED by administration of
antibiotics.
It is important that the primary care provider rings through to the hospital to ensure a senior
decision maker is aware of the childs’ arrival.
Tests and Investigations
Paediatric Early warning score (PEWS)
WCC
CRP
These three are routinely used to aid
decision making and monitor disease
progression. PEWS includes RR (and
respiratory distress, SpO2, HR, SBP, AVPU
and temperature. If patient not alert check
pupillary response. (MFT)
Lumbar puncture
Aids initial assessment of CSF (e.g. is it
purulent). Will be tested for red and white
cell count, total protein, glucose and
microscopy (for bacteria). Sample will also
be sent for bacterial and viral cultures and
sensitivities. (up to 48 hours). (From
MFT/NICE)
Blood Culture
Test for septicaemia (up to 48 hours for full
results)
Lactate
Sepsis screen
Whole blood PCR screen
Allows for quicker identification of
meningococcal or pneumococcal infection
than blood culture.
Initial Empirical therapy
Ceftrixaone i/v (as per MFT microguide) for ten days
Dose: If less than 50kg 80-100mg/kg once daily (max dose 4g) give high dose as meningitis
is severe infection.
If viral meningitis is suspected cover with aciclovir i/v 500mg/m2 every 8 hours (until ruled
out).
N.B the aciclovir indication in the BNF is encephalitis rather than meningitis. Remind
students that they should be aware of similar diagnoses and the relationship between them.
Supportive treatment:
Pain relief: paracetamol (i/v or oral – ask students their thoughts). Possibly ibuprofen if temp
problematic. Avoid opioids due to reducing CNS responses.
Steroids if lumbar puncture reveals certain criteria (see below from MFT guidance) - this is
an off-label recommendation (NICE).
For bacterial meningitis in children > 3 months of age: Dexamethasone 0.15mg/Kg (max 10mg) 4 times daily for 4 days if lumbar puncture reveals any of:
• Frankly purulent CSF
• CSF WCC > 1000/microlitre
• Raised CS WCC with protein conc > 1g/L
• Bacteria on Gram stain
Start Dexamethasone with the first dose of antibiotic. Do not start Dexamethasone more than 12 hours after starting antibiotics.
NOTE: if TB meningitis suspected steroids must not be initiated before anti-tuberculosis therapy.
Monitoring
It would be expected that Amartya would have elevated CRP, WCC, and PEWS scores on
admission. Potenitally the CSF would also have increased white cells and bacteria present.
We would expect these values to return to normal (reduce) if the patient was responding to
treatment.
Ideally lactate would be <2 which means the patient is unlikely to have sepsis. in general
amartya should become more lively and responsive as the treatment works.
After 48 hours we would expect cultures and sensitivities to identfy the causative agent. The
table below identies any changes which should be made. Bear in mind 95% of meningitis
infections will be Neiserria meningitidis or Strep pneumoniae.
Oral antibiotics NOT appropriate for suspected / confirmed meningitis
See green table
Prescribing for Patients with Penicillin Allergy
• Do not give steroids in children less than 3 months of age
• Do not give high dose steroids to patients with meningococcal septicaemia
For bacterial meningitis in children > 3 months of age: Dexamethasone 0.15mg/Kg (max 10mg) 4 times daily for 4 days if lumbar puncture reveals any of:
• Frankly purulent CSF
• CSF WCC > 1000/microlitre
• Raised CSF WCC with protein conc > 1g/L
After 5 days, stop antibiotics if the person has recovered, or get advice from an infection
specialist if they have not. (NICE, 2024)
Discharge Planning
Patient evaluated for complications: ocular, neuro, developmental etc.
Community neurodevelopmental follow up
Audiology assessment (within 4/52, but ideally before discharge)
Main point of contact after discharge
Review with paediatrics 4-6 weeks post discharge to discuss:
Results of audiological assessment
Damage to bones/joints
Skin complications (inlcuding potenital scarring from necrosis)
Psychosocial problems
Neurological/developmental problems
For babies, children and young people, community child development services should follow
up and assess the risk of long-term neurodevelopmental complications for at least 2 years
after discharge. (NICE 1.13.6)
Ours:
Examination - continue monitoring RR, HR, BP, temperature, 02 saturation, and capillary refill
° History - assess headache (type, location, duration, severity), number of vomiting episodes, temperature of hands and feet, visible wellbeing, rashes, neck stiffness
° Treatment - 600mg benzylpenicillin is the correct first-line choice for suspected bacterial meningitis by IV or IM injection in children aged 1-9 years
• Tests and investigations which need to be undertaken in order to confirm the diagnosis and to aid prognosis and treatment choice
° Clinical assessment - take history and examine for signs of fever, headache, neck stiffness, photophobia, and altered consciousness
0 Lumbar Puncture (LP) CRUCIAL! - CSF analysis for opening pressure, appearance, cell count, protein, glucose, gram stain, culture
• Blood tests - blood cultures （before antibiotics）， CBC, CRP, procalcitonin, serum glucose, HIV
•Imaging （before LP if needed） - CT/MRI brain scan
° Additional tests (if indicated) - viral PCRs, TB PCR and culture, cryptococcal antigen, autoimmune
• Initial empirical therapy with specific treatment durations
Patient Group
Vs Likely Pathogens
Vs Empirical Treatment
< 1 month (neonates)
Group B Strep, E.coli, Listeria
Ampicillin + Cefotaxime (or Gentamicin)
1 month - 50 years
S. Pneumoniae, Meningitides
Ceftriaxone or Cefotaxime +
Vancomycin
> 50 years or immunocompromised
Treatment: Ceftriaxone/Cefotaxime + Vancomycin
+ Ampicillin
Post-neurosurgery/CSF shunt
S.aureus, Pseudomonas
Vancomycin + Ceftazidime/Cefepime/Meropenem
Suspected HSV encephalitis
Herpes Simplex Virus
Add IV acyclovir
Pathogen/Type vs Duration (days)
N.meningitides
7
H.influenzae
7-10
S.pneumoniae
10-14
Listeria monocytogenes
>21
Gram-negative bacilli
21
HSV (encephalitis)
14-21
TB meningitis
>12 months
Cryptococcal meningitis (HIV+)
Induction: 2 weeks Amphotericin + Flucytosine
Consolidation: 8 weeks fluconazole
• Any supportive treatment
• Dexamethasone; start before or with first antibiotic dose in suspected S.pneumoniae meningitis (adults) or H.influenzae (children)|
• Monitoring and what you would expect to happen to the values if Amartya was responding to treatment See point 1
• Discharge planning
• Reason for admission
• Hospital course
• Condition at discharge
• Medications at discharge
• Follow-up appointments
• Patient education
• Activity restrictions
• Prognosis
