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

27.  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%

28.  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%

30. 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

31.  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

32. 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

33.  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

34. Jolt accentuation of headache
•sensitivity of 97 %
•specificity of 60 % for the diagnosis of CSF
pleocytosis

35. •Untreated or delayed treatment “FATAL”
•Markers for bad prognosis:
•Hypotension
•altered mental status
•seizures
• In-hospital mortality 27%
•Neurologic deficit on discharge 9%

36. CBC-D / BMP
Blood cultures positive in 50 to 75%

37. •Immunocompromised state.
•History of CNS disease.
•New onset seizure (within one week)
•Papilledema
•Abnormal level of consciousness
•Focal neurologic deficit

39. •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

40. Opening Pressure

41. •cell count and differential
•glucose
•protein concentration
• Gram's stain
•Culture & sensitivity

42. Normal values for CSF analysis
• protein < 50 mg/dL of
•CSF/serum glucose ratio >50%
•WBC < 5 white cells /microL

43. 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)

47. •Antibiotic therapy should be initiated
immediately after (LP)
•“if CT scan indicated before LP”, ABx therapy
should be initiated immediately
are obtained

48. •Antibiotic therapy
• Bactericidal
• BBB penetration
•All Abx should be given I.V.

49. •Empiric drug regimen
•3rd generation cephalosporin:
•Ceftriaxone
•Ceftazidime
•Vancomycin
•Ampicillin

50. •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

51. 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

52. •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%