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Preceptors: Prof. Rita Sood Prof. Padma M.V. Dr. Rohit Bhatia Speaker: Swastik Agrawal
Preceptors: Prof. Rita Sood Prof. Padma M.V. Dr. Rohit Bhatia Speaker: Swastik Agrawal
Rita Sood
Prof. Padma M.V.
Dr. Rohit Bhatia
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In developed world MC organism in both children and
adults is S. pneumoniae ≈ 50%
N. meningitidis ≈ 25%
pregnancy, immunodeficiency.
H. influenzae: unvaccinated children and adults.
Production of i nfl ammat ory cytoki nes like TNFα , IL-1β , and IL -6
Obstruc ve and
ti cytotox c edema stroke
commun cating hydrocepha us
vasogenic edema Interstitia
i l edema l i i zures ,
se
↑ CP
DEA I
DEATTHH
Coma
Symptoms
Fever (75-95o/o)
Headache (80-95%)
Photophobia (30-50%)
Vomiting (90% of 10% of adults)
children;
Signs
Neck stiffness (50-90%)
Confusio (75-85%)
nKernig' sign*
s (5%)signst
Brudzinski'
s
Focal (5%) deficit {20-30%)
neurological
Fits (15-30%)
Rash (10-
Common signs and symptoms of acute bacterial meningitis
15%)
Lancet Neurol 2008; 7: 637–48
Right 3rd nerve palsy and severe herpes labialis in a patient of
acute bacterial meningitis
Classic triad of fever, neck stiffness, and altered
sensorium seen in only 2/3rd of adults.
Petechial skin rash that accompanies Fine petechial rash in disseminated infection and
meningitis due to Neisseria meningitidis. meningitis due to Staphylococcus aureus
Kernig’s and Brudzinski’s sign have poor sensitivity
(5%) with high specificity (95%)
N Engl
J Med 2004;351:1849-59.
↑ TLC (mean 10,600/cc vs 8900/cc).
↓Platelet counts- systemic infection, sepsis.
**Hyponatremia (serum Na < 135mEq/l) seen in 30%
cases.
- Severe (Na <130) in 6%. (resolves spontaneously)
- More common with L. monocytogenes and in
patients with symptoms > 24 hours.
Blood culture- should be taken immediately, before
starting antibiotics. Positive in 74% cases.
**QJ Med 2007;100:37-
Acute inflammatory markers - ESR, CRP and
Procalcitonin elevated : distinguish acute bacterial from
non bacterial meningitis.
CSF ANC>1000/cc 1 0
4. Advanced age
5. Predisposing conditions like immunocompromised
state, pneumonia, otitis, sinusitis.
90
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1910 1920 19)0 9~0
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Pn-eumoco«.,;1 ~tallin Thl,d·genet.1tl
M1'1$erum ~emiurty on
S.pneum0tiioe • mt.rathec;;.,lly ceph,tosporin
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H. influ1n10. Sutfona.mid
es
Figure. MortaUty Rates Associated with Community.Acquired Bacterial Meningitis over the Past 90 Years.
Initial empirical antibiotics
Predisposing Common bacterial Antimicrobial
factor pathogens therapy
Age
<1 Streptococcus agalactiae, Escherichiacoli, Ampicillin plus cefotaxime or ampicillin
month Listeria plus an
monocytogenes, Klebsiel/a species aminoglycosidea third-generation
1-23 Vancomycin
months Streptococcus
S. aga/actiae,pneumoniae,
HaemophilusNeisseria
E plus ceohalosporn':"
2-50 influenzae,
meningitidis, coli Vancomycin a third-generation
years N . S.meningitidis,S.
pneumoniae, N.pneumoniae
L. plus cephalospom'"
>50 years meningitidis, monocytogenes, Vancomycin arnpicillin plus a third-
aerobic gram-negative plus generation
Head trauma
bacilli cephelosoori
Basilar skull S. pneumoniae, H. influenzae, group A p- Vancomycin
n':" plus a third-generation
fracture hemolytic cephalosporin"
Penetrating streptococci Vancomycin plus cefepime, vancomycin plus
trauma Staphylococcus aureus. coaqulase-neqetive ceftazi•
staphylo- cocci (especially Staphylococcus dime. or vancomycin plus meropenem
epidennidis}.aer• obic gram-negative bacilli
Postneurosurg (including Pseudomonas aeruginosa} Vancomycin plus cefepime, vancomycin plus
ery Aerobic gram-negative bacilli {including P ceftazi•
aeruginosa}, S . aureus, coagulase-negative dime, or vancomycin plus meropenem
CSF staphylococci (es• pecially S. epidermidis} Vancomycin plus cetepime," vancomycin plus
shunt Coagulase--negative staphylococci {especially ceftazi•
S. epi- dennidis}, S. aureus. aerobic gram- dime," or vancomycin plus meropenern?
negative bacilli (including P aeruginosa},
Propionibacteriumacnes Clinical Infectious Diseases 2004; 39:1267–84
Dosage
Total daily (dosing interval in hours)
dose
Neonates, age in days
Corticosteroids act by
– inhibiting synthesis of IL-1 and TNF at m-RNA level
– decreasing CSF outflow resistance and
– stabilizing the BBB.
No. of No. of
Outcome title studies participants Statistical method Effect size
No. of No. of
Outcome title studies participants Statistical method Effect size
01 Mortality 15 2074 Relacive Risk (Fixed) 95% CI 0.99 [0.81, 1.20)
02 Severe hearing loss 13 1383 Relacive Risk (Fixed) 95% CI 0.61 [0.44, 0.86)
1o. of No. of
Outcome title studies participants Statistical method Effect size
Unfavorable
outcome 23/157 (15) 36/144 (25) 0.59 (0.37-0.94) 0.03
Srnprocouus
All patients p11e111111111iae 15/58 (26) 26/50 (52) 0.50 (0.30-0.83)
0.006
Ntisuria mmi11Bitidis 4/50 (8) 5/47 ( 0.75 (0.21-2.63) 0.74
Other bacteria 2/12 ( 1/17 11) 2.83 (0.29-27.8) 0.55
Negauve bacterial culture; 2/37 17) 4/30 (6) 0.41 (0.08- 0.40
Death (S) (13) 2.06)
All 11/157(7 21/144 0.48 (0.24-0.96) 0.04
S. pnmmo11ine
patients ) 8/58 (14) (15)
17/50 (34) 0.41 (0.19-0.86)
N.
0.02 2/50 (4) 1/47 (2) 1.88(0.76-20.1) 1.00
mmi119itidis
Other bacteria 1/12 (8) 1/17 (6) 1.42(0.10-20.5) 1.00
Negative bacterial culture 0/37 2/30 (7) 0.20
Focal neurologic
abnormalities 18/143 (13) 24/119 (20) 0.62 (0.36- 0.13
All patients 11/49 (22) 11/33 (33) 1.09) 0.32
S. pnmmoniae 3/46 (7) 5/44 (11) 0.67 (0.33-1.37) 0.48
N. mmingitidis 3/11 (27) 3/16 (19) 0.57 (0.15- 0.66
Other bacteria 1/37 (3) 5/26 (19) 2.26) 0.07
Negative bacterial culture 1.45 (0.36-5.92)
Hearing loss 13/143 (9) 14/119(12) 0.77
0.14 (0.38-1.58)
(0.02- 0.54
All patients 7/49 (14) 7/33 (21) 0.67
1.13) (0.25-1.69) 0.55
S. pnmnumiae 3/46 (7) 5/44 (11) 0.57 (0.15- 0.48
N. mmingitidis 2/11 (18) 1/16 (6) 2.26) 0.55
Ocher bacteria 1/37 (3) 1/26 (4) 2.91 (0.30-28.3) 1.00
Negative bacterial culture 0.70 (0.05-10.7)
Immunocompromised, H/O CNS disease, new onset seizures, focal deficits, papilledema, altered sensorium ,
delay in performing lumbar puncture.
No Yes
No CT scan head
Consider alternate
diagnosis CSF c/w pyogenic meningitis?
No C/I to
t lumbar puncture
Yes
Perform lumbar puncture
CSF gram stain positive?
Yes
No
0- . . . .
Cause of death
Meningo-
coccal
vaccine
introduced
Pneumococcal vaccine - 23 valent polysaccharide
vaccine.
Indications- asplenia, immunodeficiency, DM, CRF,
nephrotic syndrome, CLD, malignancies etc.
2 doses 1-2 months apart after age of 2 years
One time revaccination after 5 years if age < 65 years.