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lecture on bacterial meningitis for all medical personnel …

lecture on bacterial meningitis for all medical personnel
by Dr. khalid Al-Harby , consultant family physician , Al- madinah , KSA

Published in Health & Medicine
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  • 1. 1
    BACTERIAL MENINGITIS
    INTRODUCTION
    EPIDEMIOLOGICAL TRENDS
    DIAGNOSTIC EVALUATION
    INITIAL APPROACH TO MANAGEMENT
    PATHOGEN-SPECIFIC THERAPY
    DURATION OF ANTIMICROBIAL Rx
    ADJUVANT THERAPY
  • 2. 2
    Bacterial meningitis
    Dr / Khalid Al-Harby
  • 3. 3
    INTODUCTION
    High morbidity and mortality
    60% of infant who survive G-ve bacillary meningitis have developmental disabilities and/or neurological sequelae
    25% was the case-fatality rate in a review of 493 episodes of bact.meningitis in adults.
    It is a life-threatening medical emergency
    cases of meningitis are a leading cause of malpractice suits against emergency doctors
  • 4. 4
    Cont. introduction
    Meningitis is characterized by inflammation of the pia-arachnoid and surrounding CSF.
    Nasopharyngeal mucosal colonization by potentially pathogenic bacteria is the usual first step, although the organism may be included by trauma or at the time of a neurosurgical or diagnostic procedure.
    Individuals who are especially susceptible include: -
  • 5. 5
    Cont.introduction
    Those who are asplenic ( sicklers, or splenectomized)
    who congenitally lack terminal complement components.
    Who have poor anti-body response to bacterial polysaccharides ( young children or persons with multiple myeloma ).
  • 6. 6
    Epidemiological trends
    The frequency of meningitis due to H. influenzae in children has declined dramatically because of widespread use of H. influenzae type b vaccines ( 95% reduction in incidence in the past decade).
    Lasker Award in 1996.
    H. influenzae meningitis has almost disappeared from U.S.A.
  • 7. 7
    Diagnostic evaluation
    It should be considered as a medical emergency and promptly evaluated.
    Typical CSF finding but -ve gram stain: -
    latex agglutination test: -specific
    c-reactive protein in CSF : sensitive
    petechial scraping :- diagnostic in 70% of cases.
    A CT scan is rarely needed (? Delay diagn.)
  • 8. 8
    Diagnostic evaluation
    Prior oral antibiotics can decrease the positive yield of CSF culturs by 4-33% and of Gram’s stain 7-41%.
    Cell count, glucose, and protein usually are not affected.
    C&S obtained 24h after initial antibiotic administration are +ve only in 20% of cases
    lymphocyte predominance in a patient who otherwise appears to have bact.meningitis.
  • 9. 9
    Empirical treatment
    When lumpar puncture is delayed or Gram’s stain of the CSF is nondiagnostic.
    Ceftriaxone is avoided in neonate because of concerns regarding protein binding and displacement of bilirubin.
    Many antibiotics penetrate BBB poorly under normal circumstances (penetration improves if meninges are inflamed).
    Patients with bacterial meningitis must
  • 10. 10
    cont
    always be admitted to a hospital ward for I.V antibiotics, observation, and supportive care (no role for oral or I.M. treatment)
  • 11. 11
    Adjuvant therapy
    Inflammatory potential of G+ve cell wall and G-ve lipopolysaccharide.
    Dexamethasone 0.15mg per kg every 6 h. for 2-4 days is recommended in children over 2m of age suspected to have bact.meningitis.
    It should be initiated I.V. with or slightly before the antibiotics
    if delayed 3-4h after 1st dose of antibiotics
  • 12. 12
    Cont.
    Do not give
    sever sepsis, suspected or documented is a contra-indication.
  • 13. 13
    Meningococcal meningitis
    Sudden onset of fever, intense headache, nausea, and often vomiting, stiff neck and, a petechial rash with pink macules.
    Case fatality rate (10-50%)
    in fulminant meningococcemia, the death rate remains high despite prompt antibacterial treatment.
    Neisseria meningitidis groups(A,B,C,X,Y,W135,Z)
  • 14. 14
    cont
    It occurs in winter and springs mainly
    preliminarily a disease of very small children*(m>f).
    Irregular epidemics
    man is the only reservoir.
    Transmitted by direct contact, including respiratory droplets
    during epidemics, over half of the men in
  • 15. 15
    cont
    In a military unit may be healthy carriers of pathogenic meningococci.
    I.P = 2-10 days
    C.P = Until eradicated from the nose and mouth.
    Susceptibility decrease with age
    group-specific immunity of unknown duration follows even subclinical infections
  • 16. 16
    Preventive measures
    Health education
    reduce overcrowding
    quadrivalent vaccine (A,C.Y.W135) is effective in adults and is only used vaccine in U.S.A. since 1971.
    Duration of protection is limited in children 1-3 y. of age.(poor immunogenicity especially C)
    no vaccine against B
  • 17. 17
    Control
    Report to local health authority.
    Respiratory isolation for 24h. After starting antibiotics
    concurrent disinfection of discharge
    close contacts (share utensils) need obsevat-
    Ion for early signs of the disease.
    Rifampicine 600mg BID for 2 d. (10mg/kg for children , 5mg/kg for neonate)
    ceftriaxone 250mg IM stat, 125mg if under 15 y. of age.
    Ciprofloxacin 500mg
  • 18. 18
    Cont.
    P.o stat for adults
    health care personnel :- only intimate exposure to nasopharyngeal secretions (e.g.mouth to mouth resuscitation) warrant prophylaxis.??
    Vaccination of close
    Contact is of no practical use.
    The pt. should be given rifampicine prior to discharge from the hospital*
    the goal of prophylaxis is to eliminate the carrier state from naso-pharynx