Professional Documents
Culture Documents
Case Example: Presents For Evaluation When He Starts To Notice Faint Rash On Trunk, Back and Arms No Known Sick Contacts
Case Example: Presents For Evaluation When He Starts To Notice Faint Rash On Trunk, Back and Arms No Known Sick Contacts
Case Example: Presents For Evaluation When He Starts To Notice Faint Rash On Trunk, Back and Arms No Known Sick Contacts
Questions to address:
Meningitis or encephalitis?
Bacterial or “aseptic”
Likelypathogen?
Clues?
Appropriate isolation?
Appropriate immediate management?
Treatment?
Prognosis?
EPIDEMIOLOGY
Risk Factors
Head trauma
Neurosurgery
CSF leak
VP shunt, hardware
Underlying illness (DM, luekemia, AIDS, cirrhosis)
Pathogens
Staph aureus (MSSA and MRSA)
Enteric GNRs (E coli, Klebsiella)
Polymicrobial gram negative meningitis: think
Strongyloides hyperinfection syndrome
Mortality
Up to 35%
CLINICAL FINDINGS IN COMMUNITY-
ACQUIRED BACTERIAL MENINGITIS
Symptom US, MGH Netherlands
1962-88 (296) 1998-92 (N=696)
Fever, neck stiffness & MS 67% 44%
1 sign present: 99% (fever, neck 99% (fever, HA, neck
stiffness, MS) stiffness, MS)
2 signs present NA 95% (as above)
Fever 95% 77%
Neck stiffness 88% 83%
Headache NA 87%
Rash 11%* 26%
22/30 N. menigitidis, rash also present with S. pneumoniae, H. influenzae, negative culture
CSF FINDINGS IN COMMUNITY-ACQUIRED
ACUTE BACTERIAL MENINGITIS, MGH
Systemic Neurologic
Septic shock Impaired mental status
ARDS Increased ICP, herniation
DIC Seizures (25%)
Septic or reactive arthritis CN palsies, focal neurologic
Death (25%) deficits
Older age Sensorineural hearing loss
Obtundation at presentation Neurocognitive/intellectual
Seizures within 24 hours impairment
Strep pneumonia
TREATMENT:
GENERAL GUIDELINES
Age 18-50
S. pneumoniae, N. meningitidis; much less likely H. influenzae,
L. monocytogenes, Grp B streptococcus
Ceftriaxone 2 mg IV Q12 hr plus vancomycin 1 gm IV Q12 hr*
Consider adding doxycycline 100 mg IV Q12 hr (RMSF season)
Acyclovir if HSV or VZV suspected
Age >50
S. pneumoniae, N. meningitidis, L. monocytogenes; less often
Grp B streptococcus, H. influenzae, GNR
Above plus ampicillin 2 gm IV Q4 hr
Consider adding doxycycline 100 mg IV Q12 hr (RMSF season)
Acyclovir if HSV or VZV suspected
30-45 mg/kg per day divided every 8-12 hours
TREATMENT:
EMPIRIC THERAPY
Nosocomial meningitis
Coagulase negative staphylococcus, S. aureus, Gram-negative
bacilli, streptococci
Ceftazidime* 2 g IV Q8 hr plus vancomycin 1 gm IV Q12 hr
* Use ceftazidime instead of ceftriaxone for improved coverage of P. aeruginosa
TREATMENT:
PENICILLIN-ALLERGIC PATIENT
Options
Replace ceftriaxone or ceftazidime with meropenem (carbapenem
approved for meningitis) – small risk of cross reactivity
Coverage: MSSA, streptococci, penicillin-susceptible pneumococci,
meningococcus, GNRs, P. aeruginosa
Replace ceftriaxone or ceftazidime with aztreonam (monobactam) –
low risk of cross reactivity (no coverage for pneumococcus)
Coverage: Meningococcus, GNRs, P. aeruginosa
Replace ceftriaxone with chloramphicol (or moxifloxacin)
Coverage chloramphenicol: Streptococci, pneumococci, RMSF,
meningococcus, H. influenzae
DURATION OF THERAPY
Clinical presentation
Meningitis: Viral, bacterial, fungal, mycobacterial
Encephalitis (abnl brain function—motor/sensory, change in
MS, personality, speech/movement): Arboviruses, HSV
Onset
Acute: S. pneumoniae, N. meningitidis
Chronic: Fungal, mycobacterial
Recurrent: S. pneumoniae
Host
Normal
Immunocompromised: HIV, organ transplant, steroids
Aseptic Meningitis
9.00%
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2007 2008
ISOLATION FOR
AIRBORNE/DROPLET DISEASES
Regimen options:
Ciprofloxacin 500 mg PO x 1
Ceftriaxone 250 mg IM x 1 (children, pregnant women)
Rifampin 600 mg PO 2x/day for 2 days (resistance described)
Definition of exposure
Droplet spread disease
Close contact with respiratory secretions (mouth-to-mouth
resuscitation, intubation, nasotracheal suctioning)
IMPACT OF
DELAYED ANTIBIOTIC THERAPY