The document discusses a noon conference presentation on bacterial meningitis. It includes a review of CSF findings in bacterial meningitis versus viral meningitis. It also reviews the classic triad of bacterial meningitis and other notable signs and symptoms. Empiric antibiotic coverage for various pathogens is discussed. Guidelines on when to perform lumbar puncture versus CT are provided. Multiple choice questions from MKSAP and NEJM Knowledge+ are reviewed covering topics like adjuvant dexamethasone use, antibiotic coverage for different populations, and nosocomial meningitis.

1. Noon Conference
Jackie Lemon, MD
4/11/2019

2. © 2016 Virginia Mason Medical Center
MRI w/w/o Contrast
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IMPRESSION:
1. Findings compatible with meningitis and possibly a
very thin subdural empyema around the left cerebral
hemisphere, likely secondary to the left-sided
mastoiditis.
2. Mild signal abnormalities in the anterolateral left
temporal lobe in the region of the gas bubble visible
on the prior CT, suspected to be cerebritis/early
brain abscess, although it is difficult to be confident
that the small hypointense structure is within the
brain rather than adjacent to it in the extra-axial
space.
3. Findings of ventriculitis without hydrocephalus.
4. No evidence of venous sinus thrombosis.

3. © 2016 Virginia Mason Medical Center
Kohoot.it
https://create.kahoot.it/share/noon-
conference-april-2019/18e17f28-6c53-
4c97-a556-60522285dc8d
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Objectives
Review Bacterial Meningitis
- Kahoot Quiz & Take home points
- Useful UpToDate and MKSAP tables
- Review Questions

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Review
CSF Findings of Bacterial Meningitis vs Viral
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Review
Classic Triad of Bacterial Meningitis + other
notable signs
• Frequency: 36-51%, more common in elderly
• Pneumococcal meningitis vs. Meningococcal meningitis
(58% vs. 27%, p < 0.001)
• PE Signs:
– Fever, HA, Lethargy, N/V, Confusion, AMS
– Seizures, Obtundation, Focal Neurologic Symptoms
– Paralysis, Cognitive Impairment, Coma
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Review
Empiric Coverage
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Review
Empiric Coverage
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Review
When to LP vs CT?
- Concern for elevated ICP or CNS mass lesion.
- Ie, LP can lead to rapid decompression and subsequent
herniation
- FAILS
- Focal neuro deficits
- AMS
- Immunosuppressed
- Lesion (hx of mass, stroke, focal infection)
- Seizures
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MKSAP Questions
Q62
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MKSAP Questions
Q62 – Answer A
- Adjuvant Dexamethasone will improve outcomes in
patients with presumptive diagnosis of bacterial
meningitis due to Strep Pneumo
- Improvement in mortality from 34% to 14%
- Fewer short term neuro deficits and long term
hearing loss
- Give 15min before Abx
- Note: Treating increased ICP is most beneficial in
stuporous or comatose patients
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Take Home
Strep Pneumo & Steroids
– 1st dose: before or at 1st ABx dose
– Per Cochrane Review: Decrease in hearing loss
– May reduce: cerebral edema, increased ICP,
altered cerebral blood flow, cerebral vasculitis,
and neuronal injury by decreasing inflammatory
response, but does not reverse pretreatment
damage
– Addition of rifampin may be reasonable when
steroids given as vancomycin may not
adequately penetrate the central nervous
system when steroids are given to reduce
inflammation
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MKSAP Questions
Q25
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MKSAP Questions
Q25 – Answer A
- Apparently >50 is considered advanced age, so
you need Listeria coverage.
- 3rd gen Cephalosporin and Vanc will give you
coverage of Strep Pneumo and Neisseria
mengitides (80% of cases)
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MKSAP Questions
Q71
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MKSAP Questions
Q71 – Answer B
- Nosocomial Meningitis: Cover Gram Negatives
(Pseudomonas aeruginosa, Acinetobacter species,
and Enterobacteriaceae), Staph Aureus (aka
MRSA)
NSGY Related Meningitis
- Imaging: CT and MRI to assess for abscess or
mass affect
- Broader Abx coverage
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NEJM Knowledge+ Q
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A. EEG
B. CT Head Non-Contrast
C. Pneumococcal Urinary Antigen
D. MRI Brain
E. Lumbar Puncture

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NEJM Knowledge+ Q
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A. EEG
B. CT Head Non-Contrast
C. Pneumococcal Urinary Antigen
D. MRI Brain
E. Lumbar Puncture

19. © 2016 Virginia Mason Medical Center
Sources
• MKSAP 17 Text and ID Questions
• MKSAP 18 Text
• NEJM Knowledge + Question Bank
• Dr. Shiels Noon Conference Slide Set
• Bacterial meningitis in adults, Dynamed. Updated 2019 Apr 04.
• Infectious Diseases Society of America (IDSA) guideline for
management of bacterial meningitis 2004.
• Clinical features and diagnosis of acute bacterial meningitis in
adults. UpToDate. Updated Aug 30 2018.
• Lancet Infect Dis 2016 Mar;16(3):339
• N Engl J Med 2004 Oct 28;351(18):1849
• Clin Infect Dis 2002 Jul 1;35(1):46
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Review
Duration of Treatment depends on pathogen
- H. influenzae - 7 days
- N. meningitidis - 7 days
- S. pneumoniae - 10-14 days
- S. agalactiae - 14-21 days
- aerobic gram-negative bacilli - 21 days
- L. monocytogenes - at least 21 days
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Kahoot Questions
1. Correct spelling of:
2. CSF: Opening Pressure
3. CSF: High WBC, Neutrophil
4. CSF: Gluc Low, Protein
5. Classic Triad
1. How often do you actually see this?
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22. © 2016 Virginia Mason Medical Center
Kahoot Questions
1. Nuchal Rigidity
1. Sen:
2. Spe:
3. Signs:
2. Petechia & palpable purpura: N.
men
3. Sz, Abscesses, FND: Listeria
4. Classic Triad: Strep Pneumo
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Kahoot Questions
1. Vaston Island: H Flu
1. Note: can still get the others in the
vaccinated population
2. Empiric: Immunocompetent, Strep
pneumo: CTX+Vanc+ Steroid
3. When Cefepime?
4. Empiric when need Listeria
Coverage: Add Ampicillin
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