bacterial meningitis slideshare

1. BACTERIAL MENINGITIS
BY PANYIN ATAKORA
1

2. OUTLINE
• DEFINITION
• EPIDEMIOLOGY
• ETIOLOGY
• CLINICAL FEATURES
• TREATMENT
• PREVENTION
• REFERENCES
2

3. DEFINITION
• Bacterial meningitis is an acute purulent infection within the
subarachnoid space (SAS).
• It is associated with a CNS inflammatory reaction that may result in
decreased consciousness, seizures, raised intracranial pressure (ICP),
and stroke.
• The meninges, SAS, and brain parenchyma are all frequently involved
in the inflammatory reaction (meningoencephalitis).
3

4. THE MENINGITIS
4

5. EPIDEMIOLOGY
• Bacterial meningitis is the most common form of suppurative CNS
infection, with an annual incidence in the United States of >2.5
cases/100,000 population.
• The organisms most often responsible for community-acquired
bacterial meningitis are Streptococcus pneumonia (~50%), Neisseria
meningitidis (~25%), group B streptococci (~15%), and Listeria
monocytogenes (~10%).
• Haemophilus influenzae type b accounts for <10% of cases of
bacterial meningitis in most series.
• N. meningitidis is the causative organism of recurring epidemics of
meningitis every 8–12 years.
5

6. EPIDEMIOLOGY & ETIOLOGY
AGE/ PEOPLE GROUP PATHOGENS
LESS THAN 3 MONTHS Group B Streptococcus
Escherichia coli
Klebsiella pneumoniae
Listeria monocytogenes
3 MONTHS TO LESS THAN 18 YEARS Streptococcus pneumoniae
Neisseria meningitidis
18 YEARS TO LESS THAN 60 YEARS S. pneumoniae
N. meningitidis
60 YEARS OR OLDER S. pneumoniae
Gram-negative bacilli
L. monocytogenes
IMMUNOCOMPROMISED S. pneumoniae
N. meningitidis
L. monocytogenes
Gram-negative bacilli
(including Pseudomonas aeruginosa)
6

7. EPIDEMIOLOGY & ETIOLOGY
PREDISPOSING FACTOR PATHOGEN
POSTNEUROSURGICAL INFECTION S. aureus (including MRSA)
Coagulase-negative Staphylococcus (including MRSE)
Gram-negative bacilli (including P. aeruginosa)
PENETRATING HEAD TRAUMA S. aureus (including MRSA) coagulase-negative
Staphylococcus
Gram-negative bacilli (including P. aeruginosa)
CSF SHUNT Coagulase-negative Staphylococcus (including MRSE)
S. aureus (including MRSA)
Gram-negative bacilli (including P. aeruginosa)
7

8. PATHOPHYSIOLOGY
8

9. 9

10. CLINICAL FEATURES
• Fever
• Headache
• Nuchal rigidity
• Photophobia
• Kernig’s sign
• Brudzinski’s sign
• Altered mental
status
• Stupor
• Seizures
10
• Excessive irritability
• Crying
• Vomiting
• Diarrhea
• Tachypnea
• Altered sleep pattern
• Poor eating

11. 11

12. CSF FINDINGS
PARAMETER FINDING
WBC (× 10*3/mm*3 or × 10*9/L) 1.0–greater than 5.0
WBC differential (% or fraction in brackets,
predominant cell type)
At least 80% (0.80) PMNs
Protein (mg/dL, mg/L) > 100 (> 1000)
Glucose (mg/dL, mmol/L) 5–40 (0.3–2.2)
CSF: serum glucose ratio < 0.4 serum glucose
CSF stain Positive Gram stain (60%–90%)
Opening pressure > 20 mm Hg
12

13. TREATMENT
EMPIRIC THERAPY; PATHOGEN- DIRECTED THERAPY; ADJUNCTIVE THERAPY; ICP
THERAPY
13

14. THE BLOOD BRAIN BARRIER
14

15. ANTIBIOTIC PENETRATION OF BBB
• Sulfonamides, trimethoprim, chloramphenicol, rifampin, and most
antitubercular drugs achieve therapeutic CSF levels even without
meningeal inflammation.
• Most beta-lactams and related antibiotics (ie, carbapenems and
monobactams), vancomycin, quinolones, acyclovir, linezolid,
daptomycin, and colistin achieve therapeutic CSF levels in the
presence of meningeal inflammation.
• Aminoglycosides, first-generation cephalosporins, second- generation
cephalosporins (except cefuroxime), clindamycin, and amphotericin
do not achieve therapeutic CSF levels, even with inflammation, but
clindamycin does achieve therapeutic brain tissue levels.
15

16. EMPIRIC THERAPY
INDICATION EMPIRIC THERAPY
Preterm infants to infants <1 month Ampicillin + cefotaxime
Infants 1–3 months Ampicillin + cefotaxime or ceftriaxone
Immunocompetent children >3 months and adults <55 Cefotaxime, ceftriaxone, or cefepime + vancomycin
Adults >55 and adults of any age with alcoholism or
other debilitating illnesses
Ampicillin + cefotaxime, ceftriaxone or cefepime +
vancomycin
Hospital-acquired meningitis, posttraumatic or
Postneurosurgery meningitis, neutropenic patients, or
patients with impaired cell-mediated immunity
Ampicillin + ceftazidime or meropenem +
vancomycin
16

17. 17

18. INTRAVENTRICULAR INJECTION
18

19. DOSES OF MEDICATIONS
19

20. SAFETY MONITORING
DRUG CLASS ADVERSE EFFECTS
PENICILLINS Hypersensitivity (rash, anaphylaxis), diarrhea
CEPHALOSPORINS Hypersensitivity (rash, anaphylaxis), LFT elevation,
cholecystitis, pseudocholelithiasis,
pseudomembranous colitis
GENTAMICIN Nephrotoxicity, ototoxicity
MEROPENEM Rash, hypersensitivity, diarrhea, decreased seizure
threshold
METRONIDAZOLE Metallic taste, dry mouth, myalgia, nausea and
vomiting.
VANCOMYCIN Rash, red man syndrome (if infused too quickly)
nephrotoxicity, thrombocytopenia
20

21. ADJUNCTIVE THERAPY
• IV Dexamethasone 4-10mg x QID for 5-7 days
• 15- 20minutes before or at time of administration of antibiotic therapy.
21

22. MANAGING INCREASED INTRACRANIAL
PRESSURE
• Elevation of the patient’s head to 30–45°
• Intubation
• Hyperventilation (Paco2, 25–30 mmHg)
• Mannitol
22

23. NON- PHARMACOLOGICAL THERAPY
• Tepid sponging
• Keep airway clear
• NG tube feeding (if applicable)
23

24. PREVENTION OF BACTERIAL
MENINGITIS
VACCINATION AND ANTIBIOTIC PROPHYLAXIS
24

25. VACCINATION
• Meningococcal vaccine- N. meningitidis
• Pneumococcal vaccine- S. pneumoniae
• Hib vaccine- H. influenzae type B
25

26. ANTIBIOTIC PROPHYLAXIS
• N. meningitides
• Rifampin 600 mg orally every 12 hours for 2 days
• Ciprofloxacin 500 mg orally for one dose
• Ceftriaxone 250 mg intramuscularly for one dose.
• Regimens for children include
• rifampin 5 mg/kg orally every 12 hours for 2 days (< 1 month of age)
• rifampin 10 mg/kg orally every 12 hours for 2 days (> 1 month of age)
• ceftriaxone 125 mg intramuscularly for one dose (< 12 years of age).
• Hib
• Rifampin- 600mg/day for 4 days- adults
• Rifampin 20mg/kg/day (max 600mg/day) for 4 days- children
• Rifampin prophylaxis is not necessary for individuals who have received the full Hib
vaccine series.
26

27. REFERENCES
• Ministry Of Health (2017). Standard Treatment Guidelines. 7th
Edition. Yamens Press Limited, Accra. Pages 494- 498
• Jameson J. L. Et Al (2018). Harrison’s Principles Of Internal Medicine.
20th Edition. Mcgraw Hill Education, New York. Pages 998- 1003.
• Dipiro J. T. Et Al (2020). Pharmacotherapy: A Pathophysiologic
Approach. 11th Edition. Mcgraw-hill Education, Usa. Pages 5152-
5198.
• Chisholm- Burns M. A. Et Al (2019). Pharmacotherapy: Principles And
Practice. 5th Edition. Mcgraw- Hill Education, Usa. Pages 1073- 1088.
27

28. 28