Meningitis

Meningitis is an inflammation of the lining around the brain and spinal cord caused by bacteria or viruses. Septic Meningitis is caused by bacteria like Streptococcus pneumonia and Neisseria meningitis. Haemohilus influenza was once a common cause of meningitis in children, but, because of vaccination, infection with this organism is now rare in developed countries. Aseptic Meningitis is caused by virus or secondary to lymphoma, leukemia, or human immunodeficiency virus.

Pathophysiology
Meningeal infections generally originates in one of two ways: through the bloodstream as a consequence of other infections or by direct spread, such as might occur after a traumatic injury to the facial bones or secondary to invasive procedures. N. meningitides concentrates in the nasopharynx and is transmitted by secretion or aerosol contamination. Once the causative organism enters the bloodstream, it crosses the blood-brain barrier and proliferates in the cerebrospinal fluid (CSF). The host immune response stimulates the release of cell wall fragments and lipopolysaccharides, facilitating inflammation of the subarachnoid and pia mater. Because the cranial vault contains little room for expansion, the inflammation may cause increased intracranial pressure (ICP). CSF circulates through the subarachnoid space, where inflammatory cellular materials from the affected meningeal tissue enter and accumulate.

Manifestations
*Headache *Stiff and painful neck *Positive Brudzinski s sign *Rashes *Disorientation *lethargy *coma *Brain stem herniation *Fever *Positive Kernig s sign *Photophobia *Skin lesions may develop *Memory impairment *unresponsiveness *Seizures

Diagnostic Procedures
Blood Tests are preformed for markers of inflammation (e.g. C-reactive protein, CBC), as well as blood culture Lumbar Puncture (LP, Spinal tap) is done by inserting a needle into the dural sac (a sac around the spinal cord) to collect cerebrospinal fluid or CSF).

It is contraindicated to patients with mass in the brain (tumor or abscess), and increase Intracranial pressure (ICP) as it may lead to brain herniation. CSF Analysis cloudy, increased pressure, WBCs and proteins high, glucose decreased, culture and gram stain are positive.

Medical Management
1. Early administration of an antibiotic that crosses the blood-brain barrier into the subarachnoid space in sufficient concentration to halt the multiplication of bacteria. y Vancomycin hydrochloride in the combination of cefalosporins is administered intravenously 2. Dexamethasone 15-29 minutes before first dose of antibiotic 3. Dehydration and shock are treated with fluid volume expanders 4. Phenytoin (Dilantin) for seizure 5. Administer osmotic diuretics, restricting fluids, draining CSF, controlling fever, maintaining systematic blood pressure and oxygenation, and reducing cellular metabolic demands for increase ICP.

Nursing Management
1. Neurologic status and vital signs are continually assessed. 2. Insertion of a cuffed endotracheal tube (or tracheotomy) and mechanical ventilation to maintain adequate tissue oxygenation. 3. Rapid IV fluid replacement may be prescribed, but care is taken to prevent fluid overload. 4. Reduce body temperature if the patient have a fever. 5. Protect the patient from injury secondary to seizure activity or altered LOC. 6. Monitor daily body weight; serum electrolytes; and urine volume, specific gravity, and osmolality, especially if syndrome of inappropriate antidiuretic hormone (SIADH) is suspected. 7. Preventing complications associated with immobility such as pressure ulcers and pneumonia. 8. Instituting infection control and precautions until 24 hours after initiation of antibiotic therapy (oral and nasal discharge is considered infectious).

Treatment
Initial treatment Meningitis is potentially life-threatening and has a high mortality rate if untreated; delay in treatment has been associated with a poorer outcome. Thus treatment with wide-spectrum antibiotics should not be delayed while confirmatory tests are being conducted. If meningococcal disease is suspected in primary care, guidelines recommend that benzylpenicillin be administered before transfer to hospital. Intravenous fluids should be administered if hypotension (low blood pressure) or shock are present. Given that meningitis can cause a number of early severe complications, regular medical review is

recommended to identify these complications early, as well as admission to an intensive care unit if deemed necessary. Mechanical ventilation may be needed if the level of consciousness is very low, or if there is evidence of respiratory failure. If there are signs of raised intracranial pressure, measures to monitor the pressure may be taken; this would allow the optimization of the cerebral perfusion pressure and various treatments to decrease the intracranial pressure with medication (e.g. mannitol). Seizures are treated with anticonvulsants. Hydrocephalus (obstructed flow of CSF) may require insertion of a temporary or long-term drainage device, such as a cerebral shunt. Bacterial Miningitis Antibiotics Structural formula of ceftriaxone, one of the third-generation cefalosporin antibiotics recommended for the initial treatment of bacterial meningitis. Empiric antibiotics (treatment without exact diagnosis) must be started immediately, even before the results of the lumbar puncture and CSF analysis are known. The choice of initial treatment depends largely on the kind of bacteria that cause meningitis in a particular place. Empirical therapy may be chosen on the basis of the age of the patient, whether the infection was preceded by head injury, whether the patient has undergone neurosurgery and whether or not a cerebral shunt is present. Once the Gram stain results become available, and the broad type of bacterial cause is known, it may be possible to change the antibiotics to those likely to deal with the presumed group of pathogens. The results of the CSF culture generally take longer to become available (24 48 hours). Once they do, empiric therapy may be switched to specific antibiotic therapy targeted to the specific causative organism and its sensitivities to antibiotics. For an antibiotic to be effective in meningitis, it must not only be active against the pathogenic bacterium, but also reach the meninges in adequate quantities; some antibiotics have inadequate penetrance and therefore have little use in meningitis. Most of the antibiotics used in meningitis have not been tested directly on meningitis patients in clinical trials. Rather, the relevant knowledge has mostly derived from laboratory studies in rabbits. Steroids Adjuvant treatment with corticosteroids (usually dexamethasone) has been shown in some studies to reduce rates of mortality, severe hearing loss and neurological damage in adolescents and adults from high income countries which have low rates of HIV. The likely mechanism is suppression of overactive inflammation. Viral meningitis Viral meningitis typically requires supportive therapy only; most viruses responsible for causing meningitis are not amenable to specific treatment. Viral meningitis tends to run a more benign course than bacterial meningitis. Herpes simplex virus and varicella zoster virus may respond to treatment with antiviral drugs such as aciclovir, but there are no clinical trials that have specifically addressed whether this treatment is effective. Mild cases of viral meningitis can be treated at home with conservative measures such as fluid, bed rest, and analgesics