Meningitis

MeningitisBy:

Sahar BannaniID Intern

Practical Guidelines for the Management of Bacterial

Meningitis• Developed By:

Infectious Diseases Society of America

• Date Released:November 2004

• Date Modified:March 2008

Guideline Category:

• Diagnosis• Evaluation• Management• Treatment

Rating Scheme

• Strength of Evidence:I, II, III

• Strength of the Recommendations:A, B, C, D, E

Diagnosis

Diagnosis

• LP:–WBCs, RBCs,

Bacteria, Proteins, Glucose

– Lactate– CRP– Gram Stain– Latex

Agglutination Test– Limulus Lysate

Assay– PCR / RT-PCR

• Hx and P/Ex• Blood Cultures• LP• Serum

Procalcitonin• CT

Which Patients with Suspected Bacterial Meningitis Should

Undergo CT before LP?

B-II

• Immunocompromised State• Hx of CNS Disease• New Onset Seizure• Papilledema• Abnormal Level of Consciousness• Focal Neurological Deficit

What Specific CSF Diagnostic Tests Should Be Used to Determine

the Bacterial Etiology of Meningitis?

• Gram Stain (A-III)

• Latex Agglutination (D-II)– G-Stain –ve (C-II)– Pretreated (B-III)

• Limulus Lysate Assay (D-II)

• PCR (B-II)

What Lab Tests Helps in Distinguishing Bacterial from Viral Meningitis?

Bacterial vs. Viral

• Lactate Concerntration (D-III)– Post-op NeuroSurg (B-II)

• CRP (B-II)

• Procalcitonin (C-II)

• PCR (B-II)

Treatment

How Quickly Should Antimicrobial Therapy

be Administered in Suspected Bacterial

Meningitis?

C-III

Empirical Antimicrobial

Therapy (A-111)Ampi + CefotaximeOR Ampi + Aminoglycoside

< 1 month

Vanco + 3G Cephalo± Rifampin (with Dexa)

1-23 months

Vanco + 3G Cephalo± Rifampin (with Dexa)

2-50 years

Vanco + 3G Cephalo + Ampi± Rifampin (with Dexa)

> 50 years

Specific Antimicrobial Therapy (A-111)

• Child + suspected L. Monocytogenes: Ampi + 3G Ceph + Vanco• Child + Suspected G-ve enteric bacteria: Ampi +

Aminoglycoside

Duration of Antimicrobial

Therapy(A-III)

• N. meningitidis, H. influenza 7 days

• S. pneumoniae 10 – 14 days

• S. agalactiae 14 – 21 days

• Aerobic G-ve Bacilli, L. monocytogenes 21 days

Role of Dexa

• Neonates (C-I)• Infants and Children:– H. influenza b (A-I)– Post Antimicrobial Rx (A-I)– Pneumococcal (C-I)

• Adults:– Pneumococcal (A-I)– Post Antimicrobial Rx (A-I)– All (B-III)

• Pneumococcal Meningitis (B-III)– Rifampin + Vanco + 3G Ceph + Dexa (B-

III)

Specific Antimicrobial

Therapy

• Cephalosporins• Vancomycin• Rifampin• Carbapenems• Flouroquinolones

Bacterial Meningitis postCSF-Shunting

• Do we administer Antimicrobial Therapy by Intraventricular Route?

(A-III) vs. (B-III)

Bacterial Meningitis fromPre-Existing CSF-Shunt

• Do we remove the shunt? And when a new one can be implanted?

(A-II)(B-II)(C-III)

Indications for Repeated LP

(A-III)

Criteria for Out-Patient Rx(A-III)

• In-patient Rx ≥ 6 days• Afebrile 24-48 hrs• No neuro dysfunction• Stable• PO intake• Access to home nursing for Rx• Reliable IVL and infusion device (if needed)• Daily availability of a physician• Plan• Compliance• Safe environment

Management Algorithm for Children with Suspected Bacterial Meningitis

Management Algorithm for Adults with Suspected Bacterial Meningitis

Questions ?!

Comments ?!

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