Meningitis important stuff

Question 1

Classic signs and symptoms of acute bacterial meningitis include what? (classic triad)

Answer 1

1) Fever
2) Nuchal rigidity
3) Altered mental status OR headache

Question 2

True or false: The first dose of antibiotics should not be withheld, even when lumbar puncture is delayed or neuroimaging is being performed.

“will be on exam”

Answer 2

True

Question 3

1) What happens if you give abx before you get samples?
2) Should you still give abx if unable to get samples within an hour?

Answer 3

1) Sensitivity and specificity decrease
2) Yes

Question 4

It is strongly recommended that the time from suspected diagnosis to initiation of antibiotic treatment should not exceed how long?

Answer 4

1 hour

“will be on exam”

Question 5

Antibiotics having _____ molecular weights are passed more easily through biologic barriers, as do more __________ soluble abx and those that are unbound

Answer 5

low; lipid

Question 6

What are the 3 most likely organisms if a meningitis pts is <1mo old?

“important”

Answer 6

1) S. agalactiae
2) Gram negative enterics
3) L. monocytogenes

[tx w. ampicillin + cefotaxime + aminoglycoside]

Question 7

What 4 bacteria should you suspect in a meningitis pt between 1 and 23 months old?
“important”

Answer 7

1) S. pneumoniae
2) N. meningitidis
3) H. influenzae
4) S. agalactiae

[tx w. Vanc. + cefotaxime or ceftriaxone (3rd gen ceph.)]

Question 8

What 2 bacteria should you suspect in a meningitis pt between 2 and 50 years old?

“important”

Answer 8

1) N. meningitidis
2) S. pneumoniae

[tx w. Vanc. + cefotaxime or ceftriaxone (3rd gen ceph.)]

Question 9

What are the 4 most likely organisms if a meningitis pt is >50yrs old?

“important”

Answer 9

1) S. pneumoniae
2) N. meningitidis
3) Gram-negative enterics
4) L. monocytogenes

[tx w. Vanc. + ampicillin + cefotaxime or ceftriaxone (3rd gen ceph.)]

Question 10

What are the empiric therapies for the following age groups for meningitis?:
1) <1mo
2) 1-23 months
3) 2-50 years
4) >50 years

“important”

Answer 10

1) Ampicillin + cefotaxime + aminoglycoside
2) Vanc. + cefotaxime or ceftriaxone (3rd gen ceph.)
3) Vanc. + cefotaxime or ceftriaxone (3rd gen ceph.)
4) Vanc. + ampicillin + cefotaxime or ceftriaxone (3rd gen ceph.)

Question 11

What should you NOT use to Tx neonates? Why?

Answer 11

Ceftriaxone; can cause Kernicterus

Question 12

1) If a pt has a penicillin-susceptible G+ form, what should you give?
2) What abt if G+ and ceftriaxone resistant?

starred slide

Answer 12

1) Penicillin G or ampicillin
2) Moxifloxacin

Question 13

1) What do you give if a pt has a methicillin-susceptible G+ strain?
2) What abt is the alt. abx if G+ and methicillin resistant?

starred slide

Answer 13

1) Naficillin or oxacillin
2) TMP-SMX or Linezolid (B-III)

Question 14

1) What should you give a pt with group B strep meningitis?
2) What if S. epidermidis?

starred slide

Answer 14

1) Penicillin G or ampicillin +/- gentamicin
2) Vancomycin

Question 15

1) What is the drug of choice for L. monocytogenes meningitis?
2) What are other options?
3) How long should Tx be?

starred slide

Answer 15

1) Ampicillin
2) Gentamicin or penicillin
3) 21 days

Question 16

Generally meningitis should be treated for about 2-3 weeks, but what are the exceptions?

starred slide

Answer 16

If G negative or Listeria (listeria like 21+ days; G- can be 7-10 days)

Question 17

1) How long should you Tx N. meningiditis or H. influenzae meningitis?
2) How should you Tx G negative penicillin resistant organisms?

starred slide

Answer 17

1) 7-10 days
2) Meropenem or moxifloxican

Question 18

How do you Tx a pt with P. aeruginosa meningitis?

starred slide

Answer 18

Cefepime or Ceftazidime and/or Tobramycin

Question 19

What can you NOT give pregnant pts?

Answer 19

Rifampin or fluroquinolones

Question 20

Haemophilus influenzae type b meningitis:
1) What is beneficial for treatment of infants and children with Hib meningitis to diminish the risk of hearing loss, if given before or concurrently with the first dose of antimicrobial agent(s)?
3) For prophylaxis, ______________ should be administered orally, once a day for ___ days (20 mg/kg/dose; maximum, 600 mg).

(not bolded just seems odd/ important)

Answer 20

1) Dexamethasone
2) rifampin; 4

Question 21

When you hear strep B, you should be thinking of what?

Answer 21

Babies

Question 22

“Transmission usually involves *colonization of the patient’s GI tract** with the organism, which then penetrate the gut lumen.”

This describes what bacterial form pf meningitis?

Answer 22

Listeria monocytogenes

Question 23

Listeria monocytogenes: What is a good empiric therapy to opt for?

Answer 23

Ampicillin monotherapy

Question 24

Listeria monocytogenes:
1) High failure rates with ____________.
2) What lack in vitro activity against L. monocytogenes?

(highlighted in different color)

Answer 24

1) vancomycin
2) Third-generation cephalosporins

Question 25

Recommendations by the IDSA call for the use of adjunctive dexamethasone in infants and children, and you may see recommendations as early as 2 months old+ with ____________ meningitis

Answer 25

H. influenzae

Question 26

Out of all abx, which has the worst increased risk of oral contraceptive failure via CYP450 enzyme induction?

Answer 26

Rifampin

Question 27

When to give dexamethosone:

Answer 27

1) **H. influenzae meningitis:** recommendations by the IDSA call for the use of adjunctive dexamethasone in infants and children (6 weeks old+) -0.15 mg/kg every 6 hours for 2 to 4 days, initiated 10 to 20 minutes **prior to or concomitant with the first dose of antibiotics** 2) **Pneumococcal meningitis** -Pediatrics: consider risk vs. benefit -Adults (suspected or proven): 0.15 mg/kg (up to 10 mg) every 6 hours for 2 to 4 days with the first dose administered 10 to 20 minutes prior to first dose of antibiotics 3) **Pros/ Cons:** -Associated with lower rates of hearing loss and short-term neurological sequelae in adults and children -Potential concern is that adj. therapy may reduce the penetration of antibiotics

Question 28

What age group would you expect to see H. influenzae meningitis in?

Answer 28

1-23 months

Question 29

H. influenzae: 1) Prevention? 2) Prophylaxis?

Answer 29

1) Vaccines 2) Rifampin PO QDay for 4 days (20 mg/kg/dose; maximum, 600 mg).

Question 30

N. meningitidis 1) Prevention? 2) Prophylaxis?

Answer 30

1) Vaccines 2) Antimicrobial chemoprophylaxis of close contacts should be started as soon as possible (ideally <24 hours after identification of the index patient). In general, rifampin, ceftriaxone, and ciprofloxacin are recommended for prophylaxis, however

Question 31

Streptococcus agalactiae (Streptococcus Group B) 1) Prevention? 2) Prophylaxis?

Answer 31

1) None 2) Intrapartum options are: **penicillin**, ampicillin, cefazolin (if penicillin allergy and not at high risk for anaphylaxis), or vancomycin (if penicillin allergy and at high risk for anaphylaxis) -**Penicillin G:** 5 million units IV initially (started at time of labor or rupture of membranes), then 3 million units IV every 4 hours until delivery (guideline dosage)

Question 32

What are the 2 reasons you'd opt for dexamethasone?

Answer 32

1) Empiric therapy 2) If you know pt has H. influenzae or pneumococcal meningitis