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Meningitis Otorrhea

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Meningitis Otorrhea Powered By Docstoc
					 Tugs, Bugs, and Drugs
 of Bacterial Meningitis

    RUBEN SALINAS, JR., MD
              MAJ, MC, USA
FAMILY MEDICINE RESIDENCY
            FORT HOOD, TX
                 Objectives

 Case Studies
 Epidemiology
 Clinical Presentation
 Diagnosis
 Treatment
 Prognosis
                       Background

 1.2 million cases worldwide
 135,000 deaths per year worldwide
 3-10 cases per 100,000 population
 Top 10 most common infections




Tunkel, Allan R. Clinical features and diagnosis of acute bacterial meningitis in
  adults. UpToDate. 16 June 2009.
                  Case #1

 2 day old with poor feeding and rectal fever
  of 102.5 during routine vital sign checks in
  the hospital.
 Birth Hx:
 Labs:
 Differential:
 Treatments:
       Signs & Symptoms in Infants

 Fever or hypothermia
 Poor Feeding
 Irritability or lethargy
 Seizures
 Rash
 Tachypnea or apnea
 Jaundice
 Bulging fontanelle (late)
 Vomiting or diarrhea
 Altered Sleep Pattern
Norris, Cecilia M.R. et al. AAFP. 15 May 1999; 59.
                       Epidemiology
 Affects all age groups
 Male=Female
 Newborns (0-4 weeks)
  Group   b strep (50%)
  E. coli (25%)
  Other gram-negative rods (8%)
  Listeria monocytogenes (6%)
  S. pneumoniae (5%)




 Edwards, Morven S. et al. Clinical features and diagnosis of bacterial
   meningitis in the neonate. UpToDate. 16 December 2008.
                      Epidemiology
 Infants (> 1 month - <3 months)
  Group  b streptococcus (39%)
  Gram-negative bacilli (32%)
  S. pneumoniae (14%)
  N. meningitidis (12%)




 Kaplan, Sheldon L. Epidemiology, clinical features and diagnosis of acute
   meningitis in children. UpToDate. 27 May 2009.
                      Epidemiology
 Children (> 3 months and <3 years)
  S.  pneumoniae (45%)
   N. meningitidis (34%)
   Group b streptococcus (11%)
 Children (> 3 years and <10 years)
   S. pneumoniae (47%)
   N. meningitidis (32%)




 Kaplan, Sheldon L. Epidemiology, clinical features and diagnosis of acute
   meningitis in children. UpToDate. 27 May 2009.
               Definition

 Meninges
  Pia

  Arachnoid

  Dura  Maters
 Infection of Arachnoid Mater and CSF
   Subarachnoid Space

   Cerebral ventricles
Meninges
Meninges
Meninges
 Treatment-Gram Stain Negative

 <1 month old
  Ampicillin  + aminoglycoside
   Ampicillin + 3rd generation cephalosporin
 No Ceftriaxone in above = Kernicterus
 1 – 23 months old
   Vancomycin + 3rd generation cephalosporin




 Tunkel, Allan R. Practice guidelines for the management of bacterial
   meningitis. Clinical Infectious Disease. 1 November 2004.
                  Case #2
 15 y/o freshman in Academy School
 1 day fever, headache, stiff neck, sleepy
 CSF shows
  1200  WBC (99% PMN’s)
   Glucose 15 mg/dL
 Cause?
 Treatment?
Case #2 (cont)
                      Epidemiology
 > 10 years and < 19 years
  N. meningitidis (55%)
  S. pneumoniae
  H. influenzae




 Kaplan, Sheldon L. Epidemiology, clinical features and diagnosis of acute
   meningitis in children. UpToDate. 27 May 2009.
            Predisposing Factors

   Colonization of Nasopharynx
   Bacteremia secondary to focal source
   Direct entry into the CNS
   Host Factors
     Asplenia
     Complement deficiency
     Corticosteroid excess
     HIV Infection


    Kaplan, Sheldon L. Epidemiology, clinical features and diagnosis of
      acute meningitis in children. UpToDate. 27 May 2009.
                Predisposing Factors

 Recent exposure
 Recent respiratory or otic infection
 Recent travel to endemic areas
 Injection drug use
 Recent head trauma
 Otorrhea or rhinorrhea

Kaplan, Sheldon L. Epidemiology, clinical features and diagnosis of acute
    meningitis in children. UpToDate. 27 May 2009.
                    Clinical Features
 Classic Triad
  Fever  (77%-95%)
   Nuchal Rigidity (83%-88%)
   Change in Mental Status (69-78%)
 Headache (87%)
   Severe and generalized




 Van de Beek D et al. Clinical features and prognostic features in adults with
   bacterial meningitis. NEJM. 28 October 2004.
             Other Clinical Features
 Symptoms lasting < 24 hours (48%)
 Focal Neurologic Deficit (33%)
 Rash (26%)
   Petechiae
   Palpable purpura
 Coma (14%)
 Seizure (5%)



Van de Beek D et al. Clinical features and prognostic features in adults with
    bacterial meningitis. NEJM. 28 October 2004.
                  Examination

 Exam for signs of infection
 Kernig’s Sign
 Brudzinski’s sign
 Glasgow Coma Scale




Kaplan, Sheldon L. Epidemiology, clinical features and diagnosis of acute
    meningitis in children. UpToDate. 27 May 2009.
                  Examination
 Kernig’s Sign
                Examination

 Brudzinski’s Sign
                                   Labs
 Leukocytosis or leukopenia
 Possible thrombocytopenia
 Normal renal function
 +Blood cultures (40-75%)
 CSF studies




Kaplan, Sheldon L. Epidemiology, clinical features and diagnosis of acute
    meningitis in children. UpToDate. 27 May 2009.
Meningitis Diagnostic Score (Nigrovic)

 For children >2 months
 100% negative predictive value
    Negative gram stain
   CSF protein < 80mg/dl
   Peripheral ANC < 10,000 cells/mm3
   No seizure at or before presentation
   CSF ANC < 1000 cells/mm3
 Specificity 66%

 Nigrovic LE et al. Clinical prediction rule for identifying children with
   cerebrospinal fluid pleocytosis at very low risk of bacterial
   meningitis. JAMA. 2007.
Meningitis Diagnostic Score

 2 options if all Negative
  Admission     for observation
   If adequate f/u, outpatient management*
 Abx pre-treated children (Don’t use if)
   If difficulty making Aseptic Meningitis Dx
   If pre-treatment affects CSF profiles




  Nigrovic LE et al. Clinical prediction rule for identifying children with
    cerebrospinal fluid pleocytosis at very low risk of bacterial
    meningitis. JAMA. 2007.
                                    *Strongly consider Parenteral Antibiotic
Oostenbrink Rule (1mo-15 yrs)
 Duration of main problem in patient hx           1.0/d max 10d
   Hx of vomiting                                 2.0
   Physical examination findings                  6.5
   Cyanosis                                       8.0
   Meningeal Irritation                           7.5
   Petechiae                                      4.0
   Serum C-reactive protein level,mg/dl (mg per L)
    <5.0 (50)                                        0
    5.0 to 9.9 (50-99)                             0.5
    10.0 to 14.9 (100 to 149)                      1.0
    15.0 to 19.9 (150 to 199)                      1.5
     > 20.0 (200)                                  2.0
   Looking for a score less than 8.5
OostenBrink, Rianne et al. A Diagnostic decision rule for management of children with
  meningeal signs. European Journal of Epidemiology. February 2004.
Possible Complications-Children
Neurological
 Impaired mental status (most irritable/lethargic 15%
  comatose at admission)
 Cerebral edema and increased intracranial pressure
 Seizures (20-30%) Seizure D/O (4%)
 Focal Deficits
     Hearing loss (11%)
     CN VI-most commonly affected
 Cerebrovascular abnormalities
 Neuropsychological impairment (4%)
 Subdural effusion (10-33%)
 Hydrocephalus                Kaplan, Sheldon. UpToDate. 27 May 09
                            Treatment
 2-50 years of age-Empiric
  Vancomycin   + 3rd generation cephalosporin
 For Gram Stain +
   N. meningitidis/ H. influenzae: 3rd generation
    cephalosporin
   S. pneumoniae: Vancomycin + 3rd generation
    cephalosporin


 Tunkel, Allan R. et al. Practice guidelines for the management of bacterial
   meningitis. Clin Infect Dis. 1 November 2004
                   IV Steroid Therapy
 Not indicated:
   Under 6 weeks old
   Children with CNS abnormalities
   Prior antibiotic use
 Indicated:
   Children with H. influenzae type B meningitis (A-1)
          Decreases risk of hearing loss
          Must give before or at time of antibiotics
 Controversial in S. pneumo meningitis (C-II)
Kaplan, Sheldon N. Dexamethasone and other measures to prevent neurologic complications of
  bacterial meningitis in children. UpToDate. 16 July 2009. 2004 Practice Guidelines, Clinical
  Infectious Disease.
  Duration of Treatment for CSF Culture Proven
                   Organism


 S. pneumoniae: 10-14 days
 H. influenzae: 7 days
 N. meningitidis: 7 days




Tunkel, Allan R. et al. Practice guidelines for the management of bacterial meningitis.
    Clin Infect Dis. 1 November 2004
          Chemoprophylaxis
 N. meningitidis/H. Influenzae
  Rifampin   x 2 days or 4 days
   Ciprofloxacin x 1 dose
   Ceftriaxone x 1 dose
 If patient <15 years old and N. meningitidis
   Add 7 day course phenoxymethyl PCN or
    Amp to above


 Chaudhuri A. et al. EFNS guideline on the management of community-
   acquired bacterial meningitis: report of an EFNS Task Force on acute
   bacterial meningitis in older children and adults. Eur J Neurology.
   July 2008.
                 Case #3

 42 y/o Homeless male presents to ED with
  mental status changes and fever.
 What next?
 Studies?
 TX?
Case #3 (Cont)
                       Epidemiology
 Adult to age 60
  S. pneumoniae (51%-60%)
  N meningitidis (20-37%)
  L. monocytogenes (4-6%)
  H. influenzae, Streptococci, S.
   aureus, and gram-neg
   bacilli


 Quagliarello, Vincent. Epidemiology of bacterial meningitis in adults. Uptodate. 26
   May 2009.
                  Examination

 Exam for signs of infection
 Kernig’s sign
 Brudzinski’s sign (Nape of Neck)
 Brudzinski’s sign (Contralateral leg
  signs)
 Jolt accentuation of headache
 Glasgow Coma Scale
Tunkel, Allan R. Clinical Features and diagnosis of acute bacterial
  meningitis in adults. UpToDate. 16 June 2009.
                        CT Scan
 2004 IDS Guidelines (II B)
   Immunocompromised                    state
   History of CNS disease
   New onset seizure
   Papilledema
   Abnormal level of consciousness
   Focal neurological deficit
 Get Treatment with abx’s/steroids

Tunkel, Allan R. et al. Practice guidelines for the management of
   bacterial meningitis. Clin Infect Dis. 1 November 2004
           CSF Findings in Meningitis

Normal                   Bacterial            Viral
Pressure (mmH20)
100-150                  Elevated, >200       Normal to sl ↑
Protein (mg/dl)
30-45                    >150                 >100
CSF/serum glucose
0.6 (infants 0.81)       <0.4 (low CSF glu)   0.6
Cell Count (cells/mm3)
<3 (mononuclear)         >500 (PMNs)          <100 (monos)
Gram Stain
No organisms             Positive 70-90%      No organisms
Appearance
Clear                    Turbid               Opalescent
            Diagnostic Tests

 Gram Stain: A-III
 Latex Agglutination: D-II
 Limulus Lysate Assay: D-II
 PCR: B-II
 Differentiating bacterial from viral
  LactateConc: D-III
  CRP: B-II
  Procalcitonin: C-II; PCR: B-II

 Tunkel, Allan R. et al. Practice guidelines for the management of
   bacterial meningitis. Clin Infect Dis. 1 November 2004
                            Treatment
 Inpatient (often ICU)
 Appropriate Antibiotic Therapy
   No interval how soon to receive abx
   But Neuro Emergency (C-III)
 Supportive Care
 Treat coexisting conditions
 Prevent hypothermia and dehydration
Tunkel, Allan R. et al. Practice guidelines for the management of bacterial
   meningitis. Clin Infect Dis. 1 November 2004
        Gram Stain Negative

 Older age and adults <50
  Vancomycin  plus a 3rd generation
   cephalosporin




 Tunkel, Allan R. et al. Practice guidelines for the management of
   bacterial meningitis. Clin Infect Dis. 1 November 2004
          Gram Stain Positive
 Gram + Diplococci (S. pneumo)
   Vanc + 3rd generation cephalosporin

 Gram – Diplococci (N. meningiditis)
   Penicillin G or
   3rd generation cephalosporin

 Gram + Bacilli (Listeria)
   Amp + aminogycoside

 Gram – bacilli
   3rd generation cephalosporin + aminoglycoside

 Tunkel, Allan R. et al. Practice guidelines for the management of
   bacterial meningitis. Clin Infect Dis. 1 November 2004
             CSF Culture Positive
 S. pneumoniae
   Vanc + 3rd gen ceph x 10-14 d
 N. meningitidis
   Pen G x 7 days
 H. influenzae
   3rd generation cephalosporin x 7 days
 L. monocytogenes
   Amp or PCN + aminoglycoside x 2-8 weeks
    (immunity?)


 Tunkel, Allan R. et al. Practice guidelines for the management of
   bacterial meningitis. Clin Infect Dis. 1 November 2004

 .
                 IV Steroid Therapy

 Glucocorticoids (Dexamethasone)
   Strong  evidence for bacterial meningitis
   Give 20 minutes prior or with 1st Abx use
 Dev world with suspected pneumo meningitis (B-1)
 High HIV Prevalence: do not give (B-1)
 Developing world with low HIV prevalence
   Give if +gram stain
   +Rapid dx test (B-II)
 Add Rifampin to regimen
Sexton, Daniel J. et al. Dexamethasone to prevent neurologic complications of
  bacterial meningitis in adults. UpToDate. 17 June 2009.
                  Case #4

 65 y/o farmer with DM, HTN, HLD, OA
  presents with 2 days of fever, headache, and
  stiff neck.
 PE:
 Studies:
 CSF:
 TX:
Case #4 (cont)
                    Epidemiology

 Adults over age 60
  S. pneumoniae (70%)
  L. monocytogenes (20%)

  N. meningitidis (3-4%)

  Group b strep (3-4%)

  H. influenzae (3-4%)

 Quaglierello, Vincent . Epidemiology of bacterial meningitis in adults.
   Uptodate. 26 May 2009.
 Possible Complications-Adults
Neurological                            Systemic
 Seizures (15-30%)                      Septic shock
 Focal neurologic deficit               DIC
  (20-50%)                               ARDS
 CN Palsies (III, VI, VII,              Septic or reactive
  VIII) 5-11%                             arthritis
 Sensorineural hearing
  loss (12-14%)
 Hemiparesis (4-13%)
 CVA complications
 Intellectual impairment
Tunkel, Allan R. Clinical Features and diagnosis of acute bacterial
meningitis in adults. UpToDate. 16 June 2009.
        Gram Stain Negative

 Adults >50 years old
  Vancomycin   plus ampicillin plus a 3rd
   generation cephalosporin




 Tunkel, Allan R. et al. Practice guidelines for the management of
   bacterial meningitis. Clin Infect Dis. 1 November 2004
                  Mortality Rate

 Depends on Organism
   S.pneumoniae 21-25%
   Listeria monocytogenes 15%
   N. meningitidis 3-10%
 Nosocomial-35%
 Community Acquired-25%


Tunkel, Allan R. Initial therapy and prognosis of bacterial meningitis in
  adults. UpToDate. 15 October 2009.
             Assessment of Risk

 Validated Prognostic Model
 3 Baseline Clinical Features
 <BP, ∆ in Mental Status, Seizures
   Low risk (no risk factors) – 9%

   Mod risk (1 risk factor) – 33%

   High risk (> 2 risk factors) – 57%




    Tunkel, Allan R. Clinical Features and diagnosis of acute bacterial
      meningitis in adults. UpToDate. 16 June 2009.
Meningitis
                 Summary

 Case Studies
 Epidemiology
 Clinical Presentation
 Diagnosis
 Treatment
 Prognosis
Questions?

				
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