Meningitis

Question 1

clinical classic 3 presentation of acute bacterial meningitis

Answer 1

high fever, neck stiffness and AMS

Question 2

Common organism for bacterial meningitis in ages 2-50 yrs

Answer 2

Streptococcus pneumoniae and Neisseria meningitidis

Question 3

Empiric abx for patients from 2-50 yrs with acute bacterial meningitis

Answer 3

vancomycin and 3rd gen cephalosporin

cover cephalosporin resistant strep and reg Strep

Question 4

Common organisms that cause bacterial meningitis >50 yrs

Answer 4

Strep pneumoniae, N meningitidis, Listeria

Question 5

Empiric abx for patients from >50 yrs with acute bacterial meningitis

Answer 5

Vancomycin, ampicillin and 3rd generation cephalosporin

Question 6

Common organisms that cause bacterial meningitis in immunocompromised pts

Answer 6

Strep pneumoniae, N meningitidis, Listeria and GRAM NEGATIVE RODS

Question 7

Empiric abx for immunocompromised pts with acute bacterial meningitis

Answer 7

vancomycin + ampicillin + cefepime

Question 8

Common organisms that cause acute bacterial meningitis in patients who recently had neurosurgery/ penetrating skull trauma

Answer 8

gram negative rods, MRSA,

coagulase negative Staph

Question 9

Empiric abx for patients who have suspected bacterial meningitis and had recen neurosurgery or skull penetrating injury

Answer 9

vancomycin and cefepime

Question 10

Who needs a CT scan prior to lumbar puncture in the rule out of meningitis?

Answer 10

AMS, new seizure, focal deficit, immunocompromise, CNS dx or papilledema

Also give abx prior to LP or CT scan.

Question 11

What drug is given before first dose of abx for patients with suspected bacterial meningitis?

Answer 11

dexamethasone 10 mg

(reduces neurological sequelae and lowers risk for hearing loss) and mortality in those with pneumococcal meningitis.

STOP steroids if CSF gram stain or culture or blood culture) indicates infection with a non penumoccocal organism.

Question 12

herpes encephalitis presentation

Answer 12

high fever, AMS, seizure, and/or focal neurological deficits and rarely associated w/ neck stiffness or nuchal rigidity.

85% of cases of HSV will have gential lesions

Question 13

Medication used to treat herpes encephalitis

Answer 13

acyclovir.

Question 14

In patients who have suspected meningitis or HSV encephalitis what can you give?

Answer 14

can give vancomycin + rocephin and acyclovir as empiric if strong enough suspicion but never give acyclovir alone.

Question 15

cause of meningococcal meningitis

Answer 15

neisseria meningitidis

Question 16

presentation of meningococcal meningitis

Answer 16

nonspecific fever, headache, vomiting, myalgias, sore throat, and within 12-24 hrs see petechiae, purpura, meningeal signs and AMS

Question 17

treatment of meningococcal meningitis

Answer 17

ceftriaxone

Question 18

complications of meningococcal meningitis

Answer 18

shock,
DIC,
adrenal hemorrhage

Question 19

precautions and prevention of spread of meningococcal meningitis

Answer 19

droplet precautions (wear surgical mask within 6 feet) and chemoprophylaxis for close contacts

house hold members
roommates of intimate contacts
child care center workers
persons directly exposed to respiratory or oral secretions

person seated next to affected person for >8 hrs (airline traveler)

Question 20

What is chemoprophylaxis for close contacts with meningococcal meningitis?

Answer 20

rifampin, ciprofloxacin, and ceftriaxone

Question 21

how to treat protein C deficiency and purpura fulminans related to Neisseria meningitidis?

Answer 21

protein c concentrate

Question 22

how often to vaccinate asplenic patients?

Answer 22

vaccinate asplenic patients 14 days prior to and post splenectomy and revaccinate every 5 years

Question 23

Gram positive bacilli seen on CSF and immunocompromised pt with meningitis. What abx do you use to treat?

Answer 23

ampicillin only

it’s going to be Listeria. Affects neonates, adults>50 yrs and immunocompromised pts.

Can give penicillin G too. Sometimes can have aminoglycoside added for synergy.

Question 24

who is at greater risk for meningococcal dx?

Answer 24

apslenic pts

need booster vaccine for meningococcus every 5 years for boster.

Question 25

if suspecting meningitis first thing you should do for management

Answer 25

IV antibiotics and adjuvant dexamethasone. CT scan can take up to 6 hrs and LP also takes a while. Can still have pathogens culture after 4-10 hrs of antibiotic initiation.

Question 26

Does a pt with suspected meninigitis need a CT scan prior to LP?

Answer 26

no they don't.

Question 27

presentation of West Nile Virus

Answer 27

asymptomatic but 20-40% with symptoms see encephalitis, meningitis or mixed. maculopapular rash (20-50% in chest arms, back acute asymmetric flaccid paralysis extrapyramidal symptoms (upper>lower extremity) Parkinsonian symptoms (with rigidity) Sometimes described as a poliomyelitis like syndrome- see unilateral weakness to quadriplegia and respiratory failure

Question 28

labs of WNV

Answer 28

CSF pleocytosis with lymphocytic predominance CT head is normal and MRI may show nonspecific FLAIR enhanced abnormalities EEG -show frontal and temporal generalized slowing MRI- shows bilateal enhancement of thalamus and basal ganglia IgM is detectable in CSF in greater than 90% of pts with WNV neuroinvasive dx at the time of presentation.

Question 29

Diagnosis of WNV

Answer 29

positive serum IgM antibody (pts with fever only) CSF positive IgM antibody (pts with CNS dx)

Question 30

highest incidence of WNV is

Answer 30

summer months due to vector of the mosquito

Question 31

asymmetrical flaccid paralhysis and extrapyramidal symptoms with fever and sometimes a maculopapular rash and AMS

Answer 31

West Nile infection

Question 32

where does the west nile virus attack

Answer 32

anterior horn cell (poliomyelitis) rather than transverse leukomyelitis thus will have sparing of ascending (pain and temperature and vibration or proprioception) and descending (pyramidal and extrapyramidal motor system and autonomics)

Question 33

Treatment of WNV

Answer 33

supportive and prevention of mosquito control

Question 34

enterovirus causing viral meningitis presentation

Answer 34

happens in summer and early fall and present with severe headache, neck stiffness and photophobia and low grade fever and no mental status changes. NO flaccid paralysis

Question 35

who gets airborne precautions

Answer 35

TB | varicella and SARS and measles

Question 36

who gets contact precautions

Answer 36

MRSA, VRE C diff, E coli O157:H7 parasitic scabies viral RSV

Question 37

who gets droplet precautions

Answer 37

H influenzae type B, neisseria meningitidis mycoplasma pneumoniae influenzae and adenovirus

Question 38

Does a partner need Neisseria meningitis prophylaxis if they have been exposed to someone who has it and already had vaccination for Neisseria

Answer 38

yes. doesn't matter if they had been vaccinated for Neisseria. Anyone with 3-6 feet for more than 8 hours need repeat prophylaxis with rifampin, ciprofloxacin, and ceftriaxone.

Question 39

age 2-50 yrs: most common organisms for meningitis empiric antibiotics:

Answer 39

strep pneumo neisseria meningitis tx with vancomycin and 3rd gen cephalosporin

Question 40

Age >50 yrs most common organisms for meningitis empiric antibiotics:

Answer 40

strep pneumoniae Neisseria meningitis listeria Start vancomycin + ampicillin + 3rd gen cephalosporin

Question 41

Immunocompromised pt most common organisms for meningitis empiric antibiotics:

Answer 41

strep pneumoniae Neisseria meningitis listeria AND gram neg rods Vancomycin + ampicillin + cefepime

Question 42

Neurosurgery and penetrating skull trauma most common organisms for meningitis empiric antibiotics:

Answer 42

Gram neg rods, MRSA coagulase neg staph vancomycin and cefepime

Question 43

if you can't use cefepime to treat meningitis what alternate antibiotics can you use?

Answer 43

ceftazidime or meropenum

Question 44

if you can't use ampicillin to treat listeria meningitis what can you use instead?

Answer 44

bactrim for listeria.

Question 45

Why do we not like pipercillin/tazobactam for pseudomonal coverage in meningiditis?

Answer 45

it has poor CNS penetration unlike cefepime which is excellent.

Question 46

lab findings concerning for HSV encephalitis:

Answer 46

CSF with HSV PCR positive or show lymphocytic pleocytosis CT or MRI brain shows temporal lobe abnormalities EEG shows high amplitude slow waves >80% of pts

Question 47

signs of HSV encephalitis

Answer 47

rapid onset <1 week and fever and headache see focal neurological deficits (cranial nerve palsies, hemiparesis, ataxis) see mental status changes and seizures

Question 48

will giving empiric acyclovir skew results for CSF?

Answer 48

no it won't it doesn't affect PCR results even if acyclovir has been given for 7 days

Question 49

When treating someone with viral meningitis or HSV meningitis and they are on acyclovir what should you also do to their regimen?

Answer 49

need to give IVF fluids of at least 2L/day with goal UOP of 75 cc/hr to reduce renal drug concentration and prevent crystal formation. Acyclovir is a very poorly soluble medication and you can have AKI develop within 48 hrs of using this medication and so need to prevent this happening. Can give loop diuretics ot help flush crystals from renal tubules.

Question 50

consider meningitis when there's

Answer 50

sinusitis and recent head trauma