Meningitis

Question 1

What are the signs of neurological sequelae?

Answer 1

Seizures
Hearing loss
Hydrocephalus

Question 2

What are the meninges?

Answer 2

Membranes that surround the brain and spinal cord

Question 3

What are the 3 layers of the meninges?

Answer 3

Dura mater - attached to the skull.
Arachnoid - middle.
Pia mater - covering the brain tissue.

Question 4

What is the CSF?

Answer 4

Fluid within the CNS that suspends the brain and other CNS structures.

Question 5

Where is the CSF produced?

Answer 5

In choroids plexus

Question 6

What are the normal contents of the CSF?

Answer 6

WBC < 5 cells/m3
Protein < 50 mg/dL
Glucose 50-66% simultaneous serum value

Question 7

BBB

Answer 7

Natural barrier.
Exchange of drugs and endogenous compounds among the blood, brain and CSF.
Consists of tightly joined endothelial cells.

Question 8

What is the definition of meningitis?

Answer 8

Inflammation of the subarachnoid space or spinal fluid

Question 9

What are the types of Meningitis?

Answer 9

Bacterial

Aseptic

Question 10

What are the causes of aseptic meningitis?

Answer 10

NSAIDs
Bactrim
OKT3-anti-rejection monoclonal antibody
Azathioprine

Question 11

What is the definition of encephalitis?

Answer 11

Inflammation of the brain

Question 12

What type of bacteria are able to gain entry into the subarachnoid space?

Answer 12

Bacteria that have a polysaccharide capsule ad other cell surface structures are able to evade host defenses and gain entry

Question 13

What are the steps for bacterial meningitis infection?

Answer 13

Hematogenous spread of organisms.
Contiguous spread from parameningeal focus.
Direct bacterial inoculation.

Question 14

What are predisposing risk factors for meningitis?

Answer 14

Immunosuppression
Head trauma
Neurosurgical patients 
Local infection
Exposure to someone with meningitis
Anatomicial or functional asplenia
Complement deficiency
Recent travel to area with endemic meningococcal disease

Question 15

What are the 3 classical triad s/sx for meningitis?

Answer 15

Fever
Nuchal rigidity
Altered mental status

Question 16

What are the classic s/sx for meningitis?

Answer 16

Fever
Nuchal rigidity
Altered mental status
Severe HA
Photophobia
Petechial rash (N. meningitidis only)
Kernig sign (+)
Brudzinski sign (+)

Question 17

What are the ways to diagnose meningitis?

Answer 17

History and physical exam
Lumbar puncture
CSF gram stain and culture
Rapid-identification latex agglutination
PCR
CT scan

Question 18

What does a rapid identification agglutination detect?

Answer 18

H. influenzae
S. pneumonia
N. meingitides
E. coli
group B streptococci

Question 19

What is different in the lumbar puncture in the differential?

Answer 19

> 80 PMNs

Question 20

How many serotypes are there of N. meningitides?

Answer 20

5: A, B, C, Y, W135

Question 21

What symptoms occur in ~50% of the population in N. meiningitides infections?

Answer 21

Petechiae

Purpuric lesions

Question 22

What are the post infection immunologic reactions for patients with N. meningitides?

Answer 22

~10-14 days after onset of disease.
Fever, arthritis, pericarditis.
Even with successful treatment.

Question 23

Which bacteria is the leading cause of mengintis?

Answer 23

S. pneumoniae

Question 24

What are the risk factors of meningitis caused by S. pneumoniae?

Answer 24

Repeated episodes of otitis media, CSF leaks, fracture of sinuses, COPD

Question 25

What kinds of complications are common in S. pneumonia meningitis?

Answer 25

Neurologic (coma, seizures)

Question 26

What are the risk factors for meningitis caused by H. influenzae?

Answer 26

Otitis media Paranasal sinus infections CSF leak

Question 27

What vaccination has decreased the incidence of H. influenzae pneumoniae?

Answer 27

Hib vaccine

Question 28

What populations are primarily affected by Listeria monocytogenes meningitis?

Answer 28

Neonates Alcholics Immunocompromised adults The elderly

Question 29

What people are at risk for G- meningitis?

Answer 29

People with CNS trauma

Question 30

What are the treatment goals for bacterial meningitis?

Answer 30

Eradicate invading organism Alleviate symptoms Prevent neurologic sequelae

Question 31

What happens once meingitis is suspected?

Answer 31

NEUROLOGIC EMERGENCY! DO NOT delay once meningitis is suspected.

Question 32

How long do we treat meningitis?

Answer 32

48-72 hours or until it is ruled out

Question 33

What are antibiotic characteristics that affect penetration of antibiotics into the CSF?

Answer 33

Low molecular weight > high Non-ionized at physiologic pH > ionic Highly lipid soluble > water soluble Non-protein bound > protein bound

Question 34

What are the common pathogens for < 1 month of age?

Answer 34

S. agalactiae E. coli L. monocytogenes Klebsiella spp.

Question 35

What is the empiric therapy for < 1 month old?

Answer 35

Cefotaxime + ampicillin OR Ampicillin + aminoglycoside

Question 36

What are the common pathogens for 1-23 month olds?

Answer 36

``` S. pneumonia N. meningitideis S. agalaciae H. influenzae E. coli ```

Question 37

What is the empiric therapy for 1-23 month olds?

Answer 37

Vancomycin + ceftriaxone (or cefotaxime)

Question 38

What are the common pathogens for 2-50 year olds?

Answer 38

S. pneumoniae | N. meningitidis

Question 39

What is the empiric therapy for 2-50 year olds?

Answer 39

Vancomcin + ceftriaxone (or cefotaxime)

Question 40

What are the common pathogens for > 50 year olds?

Answer 40

S. pneumoniae N. meningitidis L. monocytogenes Aerobic G- bacilli

Question 41

What is the empiric therapy for > 50 year olds?

Answer 41

``` Vancomycin + Ceftriaxone (or cefotaxime) + Ampicillin ```

Question 42

What is the duration of therapy for N. meningitidis?

Answer 42

7 days

Question 43

What is the duration of therapy for H. influenzae?

Answer 43

7 days

Question 44

What is the duration of therapy for S. pneumoniae?

Answer 44

10-14 days

Question 45

What is the duration of therapy for S. agalactiae

Answer 45

14-21 days

Question 46

What is the duration of therapy for aerobic G- bacilli?

Answer 46

21 days

Question 47

What is the duration of therapy for L. monocytogenes?

Answer 47

>/= 21 days

Question 48

When do you administer adjunctive dexamethasone therapy?

Answer 48

10-20 minutes before or at the same time as 1st dose of antibiotic, for 2-4 days

Question 49

What is the current thoughts on use of adjunctive dexamethasone therapy?

Answer 49

Controversial with conflicting data. Evidence of decreased neurologic sequelae in: -infants and children with H. influenzae type b meningitis. -Adults with suspected S. pneumoniae meningitis

Question 50

What are the disadvantages in the use of adjunctive dexamethasone therapy?

Answer 50

Decreased inflammation which leads to decreased amount of drug that penetrates the CNS

Question 51

How do you prevent H. influenzae type b (Hib)

Answer 51

Hib conjugate vaccin | Routine vaccination starting at 2 months of age

Question 52

How do you prevent N. meningitidis?

Answer 52

Meningococcal conjugate vaccines Hib-MenCY (infants), Menactra (MCV4-D), Menveo (MCV4-CRM) Routine vaccination: MCV4 at age 11-18yo, with a booster at age 16

Question 53

When do you prophylax for N. meningitidis?

Answer 53

Chemoprophylaxis Close contacts - persons with prolonged contact to the infected person or their secretions within 1 week before symptoms being until 24 h after antibiotics are initiated. Those who frequently sleep and ear in the same dwelling with the index case

Question 54

What is the N. meningitidis chemoprophylaxis treatment?

Answer 54

Rifampin for 2 days Adults: 600mg q12h x 4 doses Children > 1 month of age: 10mg/kg/d x 2 days

Question 55

Who should receive chemoprophylaxis?

Answer 55

Household members Day care center contacts Any person directly exposed to the patient's secretions (coughing, sneezing, kissing)

Question 56

How do you prevent S. pneumoniae?

Answer 56

PCV13 - routine vaccination series starting at 2 months | PPSV23 - routine vaccination in persons >/= 65 yo