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This case presentation will help you managing the meningits and antibiotics choices

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  1. 1.  Up to age 60:  Age 60 and above  S. pneumoniae 60%  S. pneumoniae 70%  N. meningitidis 20%  L. monocytogenes 20%  H. influenzae 10%  group B streptococcus 4%  L. monocytogenes 6%  N. meningitidis 3%  group B streptococcus 4%
  2. 2.  Up to age 60:  GNB 33%  Streptococci 9%  Risk Factors:  Staphylococcus aureus 9%  neurosurgery  Coagulase-negative staph 9%  head trauma  S. pneumoniae, N.  neurosurgical device meningitidis, and L.  CSF leak monocytogenes 8%
  3. 3. Predisposing Organism Site of entry Age range conditions Neisseria Usually none, rarely Nasopharynx Childhood-mid 20's meningitidis complement deficiency All conditions that Nasopharynx or direct Streptococcus predispose to extension across skull All ages pneumoniae fracture pneumococcal bacteremia Listeria Defects in cell mediated GI tract, placenta All ages monocytogenes immunity Surgery and foreign Coagulase-negative Dermal or foreign body All ages body, especially staphylococcus ventricular shunt Endocarditis, surgery Staphylococcus Bacteremia, dermal, or and foreign body, All ages aureus foreign body especially ventricular shunt All ages, especially the Advanced medical Gram negative rods Various elderly illness, neurosurgery Adults now, but infants Haemophilus Diminished humoral Nasopharynx and children if not influenzae vaccinated immunity
  4. 4.  predisposing factors  Recent exposure to someone with meningitis  A recent infection (especially respiratory or otic infection)  Recent travel, particularly to endemic meningococcal areas  Injection drug use  Recent head trauma  Otorrhea or rhinorrhea  A progressive petechial or ecchymotic rash
  5. 5. Frequency of defect Host problem Organism favored actually leading to infection S. pneumoniae Common in all age groups Absence of opsonizing antibody H. influenzae Common in very young children S. pneumonia Rare Asplenia surgical / functional N. meningitidis Very rare Complement deficiency N. meningitidis Very rare L. monocytogenes Rare Corticosteroid C. neoformans Rare About five percent eventually C. neoformans get cryptococcal meningitis HIV infection S. pneumoniae Common presenting illness L. monocytogenes Rare S. aureus various gram-negative Bacteremia/Endocarditis rods Rare S. pneumoniae or other oral Basilar skull fracture flora Very rare
  6. 6.  Presenting manifestations  Fever was present in 95%  Neck stiffness was present in 88%  Mental status was altered in 78%  Headache 79%  Neurologic complications:  neurologic deficits 20%  Seizures 15%  Photophobia
  7. 7. Jolt accentuation of headache •sensitivity of 97 % •specificity of 60 % for the diagnosis of CSF pleocytosis
  8. 8. •Untreated or delayed treatment “FATAL” •Markers for bad prognosis: •Hypotension •altered mental status •seizures • In-hospital mortality 27% •Neurologic deficit on discharge 9%
  9. 9. CBC-D / BMP Blood cultures positive in 50 to 75%
  10. 10. •Immunocompromised state. •History of CNS disease. •New onset seizure (within one week) •Papilledema •Abnormal level of consciousness •Focal neurologic deficit
  11. 11. •Prior administration of antimicrobials tends to have minimal effects on the chemistry and cytology findings • can reduce the yield of Gram's stain and culture
  12. 12. Opening Pressure
  13. 13. •cell count and differential •glucose •protein concentration • Gram's stain •Culture & sensitivity
  14. 14. Normal values for CSF analysis • protein < 50 mg/dL of •CSF/serum glucose ratio >50% •WBC < 5 white cells /microL
  15. 15. Total white blood cell count Glucose (mg/dL) Protein (mg/dL) (cells/µL) 100- <10* 10-45 >250 50-250 >1000 5-100 1000 More common Early Viral bacterial meningitis Bacterial or meningitis Bacterial Bacterial Bacterial Bacterial Lyme viral Viral meningitis meningitis meningitis meningitis disease meningitis meningitis Neurosyphilis Neurosyphilis TB meningitis Less common Neurosyphilis TB meningitis Some viral Some cases Fungal infections TB meningitis Encephalitis Encephalitis of mumps meningitis (such as mumps)
  16. 16. •Antibiotic therapy should be initiated immediately after (LP) •“if CT scan indicated before LP”, ABx therapy should be initiated immediately are obtained
  17. 17. •Antibiotic therapy • Bactericidal • BBB penetration •All Abx should be given I.V.
  18. 18. •Empiric drug regimen •3rd generation cephalosporin: •Ceftriaxone •Ceftazidime •Vancomycin •Ampicillin
  19. 19. •Dexamethasone (0.15 mg/kg every six hours) be given •Glasgow coma score of 8 to 11 •Therapy for 4 days in pneumococcal meningitis •I.V.F
  20. 20. Pathogen Antibiotics •Vancomycin (500 mg Q6h) PLUS •Ceftriaxone (2 g Q12h) or, S. pneumoniae •Cefotaxime (2 g Q4-6h or Q6-8h) •14 days •Penicillin G (4 million units Q4h) for N. meningitidis seven days •Ceftriaxone (2 g Q12h) or H. influenzae •Cefotaxime (2 g Q6h) •7 days •Ampicillin (2 g Q4h) L. monocytogenes •Penicillin G (3-4 million U Q4h) • +Gentamicin (1-2 mg/kg Q8h). •Penicillin G (4 million U Q4h) Group B streptococci •2-4 weeks •Ceftriaxone (2 g Q12h) or •Cefotaxime (2 g Q6-8h) PLUS Enterobacteriaceae •Gentamicin (1-2 mg/kg Q8h) •3 weeks •Ceftazidime (2 g Q8h) Pseudomonas or Acinetobacter •21 days
  21. 21. •4% percent of invasive GBS infections involve (CNS) •1% of all cases of meningitis. •GBS meningitis has been described •following elective abortion •adult GBS meningitis has been noted recently in Southeast Asia. •equally among immunocompromised and immunocompetent hosts. •mortality rate of 27%. •>(65 years) Mortality rate 56%. •The incidence of infection has a bimodal distribution, with peaks mid-20s &mid-60s. •patients present with •Fever. •Meningismus. •neurologic deficits. •spinal fluid glucose, protein, and cell counts suggestive of bacterial meningitis •mortality rates of 15 to 38%