Acute bacterial meningitis
•Download as PPTX, PDF•
17 likes•2,704 views
This document discusses meningitis, including risk factors, causes, symptoms, physical exam findings, complications, and diagnosis. The main points are: - Meningitis is an infection of the meninges that can be caused by bacteria, viruses, fungi or other organisms. Common bacterial causes include pneumococcus, meningococcus, and H. influenzae. - Risk factors include extremes of age, immunocompromise, head injuries, co-existing infections like sinusitis. Symptoms include headache, fever, neck stiffness but presentation can vary, especially in young, old, or immunocompromised patients. - Diagnosis involves lumbar puncture of CSF for analysis of white cells, glucose, proteins
More Related Content
What's hot
What's hot (20)
Similar to Acute bacterial meningitis
Similar to Acute bacterial meningitis (20)
More from Tarek Sallam
Recently uploaded
Recently uploaded (20)
Acute bacterial meningitis
- 1. Meningitis Armed Forces Fever Hospital Col. Dr. Tarek Abd-Elkader Aboulmagd
- 2. Background Primarily involving the meninges (meningitis) Primarily confined to the parenchyma (encephalitis). Infections of the CNS can
- 3. Risk factors for meningitis Extremes of age (< 5 or >60 years) Diabetes mellitus, renal or adrenal insufficiency, hypoparathyroidism, or cystic fibrosis Immunosuppression, HIV infection
- 4. Risk factors for meningitis Crowding Splenectomy and sickle cell disease, Alcoholism and cirrhosis Recent exposure to others with meningitis, with or without prophylaxis
- 5. Risk factors for meningitis Adjacent infection (eg, sinusitis) Dural defect (eg, traumatic, surgical, or congenital) Thalassemia major Intravenous (IV) drug abuse
- 6. Risk factors for meningitis Bacterial endocarditis Ventriculoperitoneal shunt Malignancy (increased risk of Listeria infection) Some cranial congenital deformities
- 8. Haemophilus influenzae meningitis H. influenzaOtitis media Paranasal sinusitis Functional or anatomic asplenia CSF leak after head trauma Hypogammaglobulinemia
- 9. Pneumococcal meningitis Hyposplenism Hypogammaglobulinemia Multiple myeloma Glucocorticoid treatment Defective complement (C1-C4)
- 10. Pneumococcal meningitis Diabetes mellitus Renal insufficiency Alcoholism Malnutrition Chronic liver disease
- 11. Group B streptococcus meningitis Diabetes mellitus Pregnancy Alcoholism Hepatic failure Renal failure Corticosteroid treatment
- 12. Meningococcal meningitis Deficiencies in terminal complement (eg, C5-C9). Properdin defects that increase the risk of invasive disease Antecedent viral infection, chronic medical illness, corticosteroid use, and active or passive smoking Crowded living.
- 13. Listeria monocytogenes meningitis Pregnant women Infants and children Elderly individuals (>60 years) Alcoholism
- 14. Listeria monocytogenes meningitis Immunosuppressed Chronic liver and renal disease Diabetes Iron-overload conditions (eg, hemochromatosis or transfusion-induced iron overload)
- 15. Meningitis caused by gram-negative bacilli Escherichia coli Klebsiella pneumoniae Serratia marcescens P aeruginosa Salmonella species
- 16. Meningitis caused by gram-negative bacilli Neurosurgical procedures or intracranial manipulation Old age Immunosuppression High-grade gram-negative bacillary bacteremia Disseminated strongyloidiasis
- 17. Staphylococcal meningitis Neurosurgery Head trauma Presence of CSF shunts Infective endocarditis and paraspinal infection
- 18. Changing Epidemiology of Acute Bacterial Meningitis in United States Bacteria 1978-1981 1986 1995 1998-2007 Haemophilus influenzae 48% 45% 7% 6.7% Listeria monocytogenes 2% 3% 8% 3.4% Neisseria meningitidis 20% 14% 25% 13.9% Streptococcus agalactiae (group B streptococcus) 3% 6% 12% 18.1% Streptococcus pneumoniae 13% 18% 47% 58%
- 19. Most Common Bacterial Pathogens on Basis of Age and Predisposing Risks Risk or Predisposing Factor Bacterial Pathogen Age 0-4 weeks Streptococcus agalactiae (GBS) Escherichia coli K1 Listeria monocytogenes Age 4-12 weeks S agalactiae E coli Haemophilus influenzae Streptococcus pneumoniae Neisseria meningitidis Age 3 months to 18 years N meningitidis S pneumoniae H influenzae
- 20. Most Common Bacterial Pathogens on Basis of Age and Predisposing Risks Risk or Predisposing Factor Bacterial Pathogen Age 18-50 years S pneumoniae N meningitidis H influenzae Age >50 years S pneumoniae N meningitidis L monocytogenes Aerobic gram-negative bacilli Immunocompromised state S pneumoniae N meningitidis L monocytogenes Aerobic gram-negative bacilli
- 21. Most Common Bacterial Pathogens on Basis of Age and Predisposing Risks Risk or Predisposing Factor Bacterial Pathogen Intracranial manipulation, including neurosurgery Staphylococcus aureus Coagulase-negative staphylococci Aerobic gram-negative bacilli, including Pseudomonas aeruginosa Basilar skull fracture S pneumoniae H influenzae Group A streptococci CSF shunts Coagulase-negative staphylococci S aureus Aerobic gram-negative bacilli Propionibacterium acnes
- 23. History 25% ----- present acutely, within 24 hours. if taking antibiotics --- ---- longer to develop + less intense.
- 24. History Seizures (30% of adults and children; 40% of newborns and infants). If previously been treated with oral antibiotics, seizures may be the sole presenting symptom.
- 25. History • Atypical presentation Elderly + comorbidities • lethargy • absence of meningeal symptoms Neutropenia • slight symptoms of meningeal irritation.
- 27. History Exposures similar or epidemic Sexual (HSV) Animal unpasteurized milk-------Brucellosis and L monocytogenes
- 28. History Previous medical treatment and existing conditions Location and travel Season and temperature
- 29. Physical Examination The classic triad (but not all patients have all 3) : nuchal rigidity, fever altered mental status can range from irritability to somnolence, delirium, and coma. no focal neurologic deficits.
- 31. Kernig's Sign
- 32. Physical Examination coinfection Pulmonary otitis media Endotoxic shock N meningitidis (meningococcal)
- 33. Physical Examination Some cases • Increased BP + • bradycardia Vomiting • in 35% of patients Nonblanching petechiae • N.meningitidis (50%) • H influenzae, S pneumoniae, or S aureus Arthritis • Meningococcal and with M pneumoniae infection.
- 35. Physical Examination • Cranial nerves III, IV, VI, and VII • Papilledema is a rare finding (< 1% of patients)
- 36. Cranial nerve III palsy
- 37. Cranial nerve IV palsy
- 38. Cranial nerve VI palsy
- 39. Cranial nerve 7 palsy
- 40. Systemic and extracranial findings • Epstein-Barr virus [EBV], cytomegalovirus [CMV], adenovirus, or HIV Morbilliform rash with pharyngitis and adenopathy • meningococcemia (with or without meningitis) Macules and petechiae that rapidly evolve into purpura • VZVVesicular lesions in a dermatomal distribution • HSV-2 meningitis. Genital vesicles
- 41. Systemic and extracranial findings • usually with S pneumoniae or, less often, H influenzae. Sinusitis or otitis • S pneumoniaeRhinorrhea or otorrhea --- ---(CSF) leak • mononucleosislike syndrome in EBV, CMV, and HIV and fungal Hepatosplenomegaly and lymphadenopathy • infective endocarditis with secondary bacterial seeding of the meninges. The presence of a heart murmur
- 42. Chronic meningitis general, systemic, and neurologic examinations Lymphadenopathy Papilledema and tuberculomas during funduscopy Meningismus Cranial nerve palsies
- 43. Tuberculous meningitis •acute may be, •subacute •spans weeks classic presentation. •fever of varying degrees, malaise, and intermittent headaches prodrome. •(III, IV, V, VI, and VII) Cranial nerve palsies
- 44. Syphilitic meningitis The median incubation period :21 days (range, 3-90 days occurs during the primary or secondary stage of syphilis, headache, nausea, vomiting, and meningismus. focal neurologic symptoms spans weeks to months.
- 45. Lyme meningitis (mostly chronic) • concurrent appearance of erythema migrans at the site of the tick bite 2-10 weeks before meningitis.
- 46. Lyme meningitis • the most common symptom Headache • less frequent photophobia, nausea, and neck stiffness • may occur Somnolence, emotional lability, and impaired memory and concentration • most common cranial nerve deficit. Facial nerve palsy • fluctuate and may last for months if left untreated. symptoms of meningitis
- 47. Fungal meningitis defective cell-mediated immunity (HIV) gradual onset of symptoms, the most common of which is headache. most serious form of disseminated coccidioidomycosis fatal if left untreated
- 48. Fungal meningitis headache vomiting altered mental pleocytosiselevated protein decreased glucose Eosinophils
- 49. Fungal meningitis Blastomyces dermatitidis: may present with an abscess or fulminant meningitis. Histoplasma capsulatum: may present with headache, cranial nerve deficits, or changes in mental status months before diagnosis.
- 51. Complications Delayed Decreased hearing or deafness cranial nerve dysfunctions Multiple seizures Focal paralysis Subdural effusions Hydrocephalus Intellectual deficits Ataxia Blindness Waterhouse- Friderichsen syndrome Peripheral gangrene
- 52. Diagnosis challenges Acute: Early identification and treatment Identifying the causative organism
- 53. Diagnosis patients with headache, neck stiffness, fever, and altered mental Acute bacterial meningitis medical emergency
- 54. Diagnosis whenever • meningitis is strongly considered, Lumbar Puncture • should be promptly performed Examination of the (CSF) • cell count • Chemistry • microbiology
- 55. Diagnosis • A screening (CT) scan of the head may be performed before LP to determine the risk of herniation. CT abnormalities are found in: Age ≥60 years Immunocompromise A history of CNS disease A history of seizure within 1 week before presentation Any abnormality on neurologic examination
- 56. Diagnosis Chest X-ray Pneumonia 50% with pneumococcal - 10% H influenzae or N meningitidis and 20% other
- 57. Blood Studies • polymorphonuclear leukocytosis CBC • dehydration Serum electrolytes • compared with the CSF glucose Serum glucose • assess organ function • adjust antibiotic dosing (BUN) or creatinine and liver profile • chronic alcohol use, chronic liver disease, or suspected (DIC)……… (Fresh Frozen Plasma) before LP.coagulation profile
- 58. Cultures and Bacterial Antigen Testing Cultures Blood Nasopharynx Respiratory secretions Urine Skin lesions Latex agglutination or CIE blood, urine, and CSF S pneumoniae antigen 99%-100% sensitivity and specificity PCR HSV Enteroviruses
- 59. Syphilis Testing Screening by nontreponemal tests: rapid plasma reagent (RPR) or Venereal Disease Research Laboratory (VDRL). Confirmed: FTA-Abs, TPHA, MHA-TP and ICE Syphilis Progress indicators: nontreponemal titres
- 60. Serum Procalcitonin Testing (PCT) S.(PCT) distinguish between bacterial and aseptic meningitis in children. Elevated predict bacterial threshold of 0.5 ng/mL sensitivity = 99% specificity = 83%
- 61. Lumbar Puncture and CSF Analysis
- 62. Lumbar Puncture and CSF Analysis Agent WBC count (cells/µL) Glucose (mg/dL) Protein (mg/dL) Microbiology Bacterial meningitis 100-5000; >80% PMNs < 40 >100 Specific pathogen demonstrated in 60% of Gram stains and 80% of cultures Viral meningitis 10-300; lymphocytes Normal, reduced in lymphocytic choriomeningitis and mumps Normal but may be slightly elevated Viral isolation, PCR assays Tuberculous meningitis 100-500; lymphocytes Reduced, < 40 Elevated, >100 Acid-fast bacillus stain, culture, PCR Cryptococcal meningitis 10-200; lymphocytes Reduced 50-200 India ink, cryptococcal antigen, culture Aseptic meningitis 10-300; lymphocytes Normal Normal but may be slightly elevated Negative findings on workup Normal values 0-5; lymphocytes 50-75 15-40 Negative findings on workup
- 63. Lumbar Puncture and CSF Analysis Normal Finding Bacterial Meningitis Viral Meningitis Fungal Meningitis Pressure (mm H2 O) 50-150 Increased Normal or mildly increased 1. Normal or mildly increased in tuberculous meningitis; 2. May be increased in fungal; AIDS patients with cryptococcal meningitis have increased risk of blindness and death unless kept below 300 mm H2 O
- 64. Lumbar Puncture and CSF Analysis Normal Finding Bacterial Meningitis Viral Meningitis Fungal Meningitis Cell count (mononuclear cells/µL) Preterm: 0-25 Term: 0-22 >6 months: 0-5 Not exclude bacterial meningitis; PMN count typically in 1000s less or even normal (in very early meningococcal meningitis and in extremely ill neonates); lymphocytosis +normal chemistries seen in 15-25%, especially when cell counts < 1000 or with partial treatment; Cell count usually < 500, nearly 100% mononuclear; up to 48 hours, significant PMN pleocytosis may be indistinguishable from early bacterial meningitis; presence of nontraumatic RBCs in 80% of HSV meningoencephalitis, though 10% have normal CSF results Hundreds of mononuclear cells
- 65. Lumbar Puncture and CSF Analysis Normal Finding Bacterial Meningitis Viral Meningitis Fungal Meningitis Microscopy No organisms Gram stain 80% sensitive; No organism India ink is 50% sensitive for fungi; cryptococcal antigen is 95% sensitive; AFB stain is 40% sensitive for tuberculosis
- 66. Lumbar Puncture and CSF Analysis Normal Finding Bacterial Meningitis Viral Meningitis Fungal Meningitis Glucose Euglycemia: >50% serum Hyperglycemia: >30% serum Wait 4 hr after glucose load Decreased Normal Sometimes decreased; lowest levels of CSF glucose are seen in tuberculous meningitis, primary amebic meningoencephalitis, and neurocysticercosis
- 67. Lumbar Puncture and CSF Analysis Normal Finding Bacterial Meningitis Viral Meningitis Fungal Meningitis Protein (mg/dL) Preterm: 65-150 Term: 20-170 >6 months: 15-45 Usually >150, may be >1000 Mildly increased Increased; >1000
- 68. CFS sample handling After drawing the CSF sample Tube 1 – Send to the chemistry laboratory for glucose and protein Tube 2 – Send to the hematology laboratory for a cell count with differential Tube 3 – Send to the microbiology and immunology laboratory
- 69. CFS sample handling tube 3 Gram stain Bacterial culture AFB stain and tuberculosis cultures India ink stain Cryptococcal antigen Fungal cultures, (CIE), VDRL, and cryptococcal antigen Microbiology and immunology
- 70. CSF characteristics of acute bacterial meningitis Normal Bacterial Viral Tubercular Fungal Glucose (mg/dL): 40–85 Normal - <40 <40 (Low) <40 Normal Protein (mg/dL) 15–45 > 250 25 -500 50 -500 <100 (moderate increase) WBCs (cells/µL) 0–5 (adults / children); up to 30 (newborns). >500 (usually > 1000). Early: May be < 100. Variable (10 - 1000) <500 Variable (10 - 1000) <500 < 100 Cell differential: 60–70% lymphocytes; up to 30% monocytes and macrophages; other cells 2% or less. Neutrophils Lymphocytes Lymphocytes Early: neutrophils. Late: lymphocytes. Culture: sterile Positive Positive (fungal) (+) AFB Negative Opening Pressure 50–180 mmH2O Elevated Elevated Variable Usually normal
- 71. Initial Antibiotics for Acute Bacterial Meningitis Patient Group Suspected Bacteria Provisional Antibiotics 3 mo–18 yr Neisseria meningitidis S. pneumoniae S. aureus* Haemophilus influenzae‡ Cefotaxime,or ceftriaxone plus Vancomycin 18–50 yr S. pneumoniae N. meningitidis S. aureus* Ceftriaxone or cefotaxime plus Vancomycin > 50 yr S. pneumoniae L. monocytogenes S. aureus Gram-negative bacteria N. meningitidis(unusual in this age group) Ceftriaxone or cefotaxime plus Ampicillin plus Vancomycin
- 72. Initial Antibiotics for Acute Bacterial Meningitis Patient Group Suspected Bacteria Provisional Antibiotics Sinusitis, otitis, CSF leaks S. pneumoniae† H. influenzae Gram-negative bacteria includingPseudomonas aeruginosa Anaerobic or microaerophilic streptococci Bacteroides fragilis S. aureus* Vancomycin plus Ceftazidime or meropenem plus Metronidazole Penetrating head wounds, neurosurgical procedures, shunt infections S. aureus S. epidermidis Gram-negative bacteria includingP. aeruginosa S. pneumoniae Vancomycin plus Ceftazidime
- 73. Initial Antibiotics for Acute Bacterial Meningitis Patient Group Suspected Bacteria Provisional Antibiotics AIDS, other conditions that impair cell-mediated immunity S. pneumoniae L. monocytogenes Gram-negative bacteria including P. aeruginosa S. aureus* Ampicillin plus Ceftazidime plus Vancomycin
- 74. Specific Antibiotics for Acute Bacterial Meningitis Bacteria Age Group Antibiotics* Comments Gram-positive bacteria (unidentified) Children and adults Vancomycin plus Ceftriaxone (cefotaxime) and ampicillin† — Gram-negative bacilli (unidentified) Children and adults Cefotaxime (or ceftriaxone, meropenem,or ceftazidime) plus Gentamicin, tobramycin, or amikacin ‡ if systemic infection is suspected — Haemophilus influenzae type b Children and adults Ceftriaxone (cefotaxime) — Neisseria meningitidis Children and adults Ceftriaxone (cefotaxime) Penicillin G is used for susceptible strains after sensitivities are known.
- 75. Specific Antibiotics for Acute Bacterial Meningitis Bacteria Age Group Antibiotics* Comments Streptococcus pneumoniae Children and adults Vancomycin and ceftriax one (cefotaxime) Penicillin G may be used for susceptible strains after sensitivities are known. Staphylococcus aureus and S. epidermidis Children and adults Vancomycin with or without rifampin Vancomycin is used for methicillin-resistant strains, or nafcillin or oxacillin may be used after sensitivities are known. Rifampin is added if no improvement occurs with vancomycin or nafcillin
- 76. Specific Antibiotics for Acute Bacterial Meningitis Bacteria Age Group Antibiotics* Comments Listeria sp Children and adults Ampicillin (penicillin G) or Trimethoprim/sulfamethoxaz ole‡ Penicillin G is used for susceptible strains after sensitivities are known. Trimethoprim/sulfamethoxaz ole is used in patients who are allergic to penicillin. Enteric gram-negative bacteria (eg,Escherichia coli, Klebsiellasp, Proteus s p) Children and adults Ceftriaxone (cefotaxime) plus Gentamicin, tobramycin, or amikacin ‡ if systemic infection is suspected — Pseudomonas sp Children and adults Meropenem (ceftazidime or cefepime), usually alone but sometimes with an aminoglycoside or Aztreonam —
- 77. Specific Antibiotics and Duration of Therapy for Acute Bacterial Meningitis Bacteria Susceptibility Antibiotic(s) Duration (days) Streptococcus pneumoniae Penicillin sensitive Recommended: Penicillin G or ampicillin Alternatives: Cefotaxime, ceftriaxone, chloramphenicol 10-14 Penicillin resistant Cefotaxime or ceftriaxone MIC ≥0.12 μg/mL Recommended: Cefotaxime or ceftriaxone Alternatives: Cefepime, meropenem Cefotaxime or ceftriaxone resistant Recommended: Vancomycin plus cefotaxime or ceftriaxone Alternatives: Vancomycin plus moxifloxacin
- 78. Specific Antibiotics and Duration of Therapy for Acute Bacterial Meningitis Bacteria Susceptibility Antibiotic(s) Duration (days) Haemophilus influenzae Beta-lactamase−negative Recommended: Ampicillin Alternatives: Cefotaxime, ceftriaxone, cefepime, chloramphenicol, aztreonam, a fluoroquinolone 7 Beta-lactamase−positive Recommended: Cefotaxime or ceftriaxone Alternatives: Cefepime, chloramphenicol, aztreonam, a fluoroquinolone Beta-lactamase−negative, ampicillin- resistant Recommended: Meropenem Alternatives: Cefepime, chloramphenicol, aztreonam, a fluoroquinolone
- 79. Specific Antibiotics and Duration of Therapy for Acute Bacterial Meningitis Bacteria Susceptibility Antibiotic(s) Duration (days) Neisseria meningitidis Penicillin sensitive Recommended: Penicillin G or ampicillin Alternatives: Cefotaxime, ceftriaxone, chloramphenicol 7 Penicillin resistant Recommended: Cefotaxime or ceftriaxone Alternatives: Cefepime, chloramphenicol, a fluoroquinolone, meropenem
- 80. Specific Antibiotics and Duration of Therapy for Acute Bacterial Meningitis Bacteria Susceptibility Antibiotic(s) Duration (days) Listeria monocytogenes ... Recommended: Ampicillin or penicillin G Alternative: TMP-SMX 14-21 Streptococcus agalactiae ... Recommended: Ampicillin or penicillin G Alternatives: Cefotaxime, ceftriaxone, vancomycin 14-21
- 81. Specific Antibiotics and Duration of Therapy for Acute Bacterial Meningitis Bacteria Susceptibility Antibiotic(s) Duration (days) Enterobacteriaceae ... Recommended: Cefotaxime or ceftriaxone Alternatives: Aztreonam, a fluoroquinolone, TMP-SMX, meropenem, ampicillin 21 Pseudomonas aeruginosa ... Recommended: Ceftazidime or cefepime Alternatives: Aztreonam, meropenem, ciprofloxacin 21 Staphylococcus epidermidis Recommended: Vancomycin Alternative: Linezolid Consider addition of rifampin
- 82. Common IV Antibiotic Dosages for Acute Bacterial Meningitis* Antibiotic Dosage Children > 1 mo Adults Ceftriaxone (Rocephin) 50 mg/kg q 12 h 2 g q 12 h Cefotaxime (CLAFORAN) 50 mg/kg q 6 h 2 g q 4–6 h Ceftazidime 50 mg/kg q 8 h 2 g q 8 h Cefepime (MAXIPIME) 2 g q 12 h 2 g q 8–12 h
- 83. Common IV Antibiotic Dosages for Acute Bacterial Meningitis* Antibiotic Dosage Children > 1 mo Adults Ampicillin 75 mg/kg q 6 h 2–3 g q 4 h Penicillin G 4 million units q 4 h 4 million units q 4 h Nafcillin (UNIPEN) and oxacillin (BACTOCILL) 50 mg/kg q 6 h 2 g q 4 h Vancomycin (VANCOCIN) † 15 mg/kg q 6 h 10–15 mg/kg q 8 h
- 84. Common IV Antibiotic Dosages for Acute Bacterial Meningitis* Antibiotic Dosage Children > 1 mo Adults Meropenem 40 mg/kg q 8 h 2 g q 8 h Gentamicin and tobramycin† 2.5 mg/kg q 8 h 2 mg/kg q 8 h Amikacin† 10 mg/kg q 8 h 7.5 mg/kg q 12 h Rifampin 6.7 mg/kg q 8 h 600 mg q 24 h Chloramphenicol 25 mg/kg q 6 h 1 g q 6 h
- 85. Corticosteroids • Dexamethasone is used to decrease cerebral and cranial nerve inflammation and edema; Adults are given 10 mg IV; q 6 h for 4 days.
- 86. Other measures • Patients presenting with papilledema or signs of impending brain herniation are treated for increased ICP: 1. elevation of the head of the bed to 30˚, 2. hyperventilation to a PCO2 of 27 to 30 mm Hg to cause intracranial vasoconstriction, 3. Osmotic diuresis with IV mannitol, usually, adults are given mannitol 1 g/kg IV bolus over 30 min, repeated as needed q 3 to 4 h or 0.25 g/kg q 2 to 3 h
- 87. Supportive measures • include IV fluids, anticonvulsants, treatment of concomitant infections, and treatment of specific complications (eg, corticosteroids for Waterhouse-Friderichsen syndrome, surgical drainage for subdural empyema).
- 88. Supportive measures • Furosemide (Lasix) 40 mg after osmotic agents lowering ICP by: (1) lowering cerebral sodium uptake, (2) affecting water transport into astroglial cells by inhibiting the cellular membrane cation-chloride pump, and (3) decreasing CSF production by inhibiting carbonic anhydrase.
- 89. Supportive measures • Phenytoin (Dilantin, Phenytek) Doses of 15 mg/kg have been used. Status epilepticus Load 10-15 mg/kg or 15-20 mg/kg at 25-50 mg/min, THEN Maintenance: 100 mg IV/PO q6-8hr PRN Administer IV slowly; not to exceed 50 mg/min
- 90. Herpes simplex meningitis • Acyclovir 10-15 mg/kg IV q8hr for 10 days; up to 14-21 days reported • In obese patients, use IBW (Ideal Body Weight)
- 91. Cytomegalovirus meningitis 1. Ganciclovir is given in an induction dosage of 5 mg/kg IV every 12 hours for 21 days and a maintenance dosage of 5 mg/kg every 24 hours.
- 92. Cytomegalovirus meningitis 2. Oral valganciclovir (900 mg/day) can be used for maintenance if immunosuppression continues (as, for example, in AIDS patients or transplant recipients).
- 93. Cytomegalovirus meningitis 3. Foscarnet is given in an induction dosage of 60 mg/kg IV every 8 hours for 21 days and a maintenance dosage of 90-120 mg/kg IV every 24 hours.
- 94. Treatment of Fungal Meningitis Cryptococcal meningitis • Amphotericin B (0.7-1 mg/kg/day IV) for at least 2 weeks, with or without flucytosine (100 mg/kg orally), in 4 divided doses.
- 95. Cryptococcal meningitis • Liposomal preparations of amphotericin B may be used in patients who either have or are predisposed to develop renal dysfunction (amphotericin B liposome 3-4 mg/kg/day or amphotericin B lipid complex 5 mg/kg/day).
- 96. Cryptococcal meningitis • Fluconazole is given for consolidation therapy (400 mg/day for 8 weeks); • For maintenance therapy, long-term administration of fluconazole (200 mg/day) is most effective in preventing relapse (superior to itraconazole and amphotericin B at 1 mg/kg weekly). • The risk of relapse is high in patients with AIDS.
- 97. Cryptococcal meningitis • Itraconazole 200 mg PO q8hr initially for 3-4 days, then 200-400 mg/day for at least 3 months is an alternative if fluconazole is not tolerated.
- 98. Cryptococcal meningitis 1. Complicated by increased ICP 2. Repetition of LP or insertion of a lumbar drain or a shunt. 3. Administration of mannitol, have also been used.
- 99. Coccidioides immitis 1. The preferred treatment is oral fluconazole (400 mg/day). 2. Some physicians initiate therapy with a larger dose of fluconazole (as high as 1000 mg/day) or with a combination of fluconazole and intrathecal amphotericin B. 3. Itraconazole (400-600 mg/day) has been reported to be comparably effective. 4. Lifelong treatment is usually required.
- 100. Histoplasma capsulatum • Liposomal amphotericin B (5 mg/kg/day IV for a total of 175 mg/kg given over 4-6 weeks), • Followed by oral itraconazole (200-300 mg 2 or 3 times daily for at least 1 year or until the resolution of CSF abnormalities and Histoplasma antigen levels). • Blood levels of itraconazole should be measured to ensure good absorption of the oral drug.
- 101. Candida species • The preferred initial therapy is amphotericin B (0.7 mg/kg/day). • Flucytosine (25 mg/kg every 6 hours) is usually added and adjusted to maintain serum levels of 40-60 µg/mL.
- 102. Sporothrix schenckii • Initial The lipid formulation of amphotericin B • after the patient responds, itraconazole (200 mg twice daily) for at least 12 months of therapy. • Fluconazole is less active against Sporothrix than itraconazole.
- 103. Treatment of Tuberculous Meningitis • Isoniazid 300 mg/day • Rifampin 600 mg/day • Pyrazinamide 15-30 mg/kg/day • Ethambutol 15-25 mg/kg/day • Streptomycin 7.5 mg/kg every 12 hours
- 104. Treatment of Tuberculous Meningitis • Treatment is best started with INH, RIF, and PZA. • The addition of a fourth drug is left to the choice of the local physicians and their experience, with little evidence to support the use of one over the other.
- 105. Treatment of Tuberculous Meningitis • Corticosteroid therapy is indicated with those with neurologic deficits or deterioration in mental function). • For reduction of the inflammatory effects associated with mycobacterial killing by the antimicrobial agents. • Dexamethasone; 60-80 mg/day, tapered in 6 weeks.
- 106. Treatment of Syphilitic Meningitis • The treatment of choice for neurosyphilis is aqueous crystalline penicillin G (2-4 million U/day IV every 4 hours for 10-14 days), often followed with IM penicillin G benzathine (2.4 million U).
- 107. Treatment of Syphilitic Meningitis • An alternative is procaine penicillin G (2.4 million U/day IM) plus probenecid (500 mg orally every 6 hours for 14 days), followed by IM benzathine penicillin G (2.4 million U).
- 108. Treatment of Syphilitic Meningitis • These regimens are also used for neurosyphilis in patients with HIV infection. • Because penicillin G is the treatment of choice, penicillin-allergic patients should undergo penicillin desensitization.
- 109. Treatment of Syphilitic Meningitis • After treatment, CSF examination every 6 months ------- the success of therapy. • Failure of the cell count to normalize or the serologic titers to fall may warrant retreatment.
- 110. Treatment of Parasitic Meningitis • Primary amebic meningoencephalitis (PAM), is usually fatal. • The few survivors were benefited from early diagnosis and treatment with high-dose IV and intrathecal amphotericin B or miconazole and rifampin.
- 111. Treatment of Parasitic Meningitis • Treatment of helminthic eosinophilic meningitis is largely supportive. • It includes adequate analgesia, therapeutic CSF aspiration, and the use of anti- inflammatory agents, such as corticosteroids.
- 112. Treatment of Parasitic Meningitis • Anthelmintic therapy may be contraindicated, because clinical deterioration and death may occur as a consequence of severe inflammatory reactions to the dying worms.
- 113. Treatment of Lyme Meningitis • The drug of choice is ceftriaxone (2 g/day for 14-28 days). • The alternative therapy is penicillin G (20 million U/day for 14-28 days). • Doxycycline (100 mg orally or IV every 12 hours for 14- 28 days) or chloramphenicol (1 g every 6 hours for 14- 28 days) has also been used. • Treatment for only 10 days has been associated with a high rate of residual symptoms.