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CNS infections occurs with a wide variety of clinical conditions, what are the major examples?
- brain and meningeal abcesses
- shunt infections
- wide variety of bacteria, fungi, viruses, and parasites
What are the top four organisms causing meningitis morality?
- 1) S. pneumonia (PCN-R)
- 2) S. pneumonia (PCN-S)
- 3) N. meningitides
- 4) H. flu
What can cause aseptic meningitis?
- Chemical irritants (INCLUDING DRUGS), viral, fungal, parasitic, tubercular, sarcoid, neoplastic, and syphilitic processes in the CNS
- NSAIDs are a common drug etiology
What is a normal CSF Glucose result?
50-66% of plasma
What is an abnormal CSF Glucose result?
< 50 mg/dl
What is a normal CSF Protein result?
< 50 mg/dl
What is an abnormal CSF Protein result?
> 150 mg/dl
What is a normal CSF WBC result?
< 10/mm3 (monos
What is an abnormal CSF WBC result?
What is a normal CSF Lactic Acid result?
< 14 mg/dl
What is an abnormal CSF Lactic Acid result?
> 35 mg/dl
What is a normal CSF pH?
What is an Abnormal CSF pH?
Bacteria which cause meningitis possess a ___________________which resists neutrophil phagocytosis.
Bacteria which lack ______________________ are incapable of producing meningitis
How does meningitis present?
- Fever, stiff neck or back
- Nuchal rigidity (don’t want to move head)
- + Brudzinski sign
- + Kernig sign
- All lead to seizures and or hydrocephalus
What is a + Kernig sign?
MD flexes hip 90 degrees to the trunk and attempts to extend the knees. This will produce contracture or extensor spasm at the knee
What is a + Brudzinski sign?
Flexion of the neck by the MD will produce hip and knee flexion
What characteristics of a drug allow it to transfer into the CNS?
- Small molecular weight
- Antibiotics which are un-ionized
- Highly lipid soluble
- Low protein binding
- Relationship between MBC and concentration in the CSF
What groups of patients are most likely to get N. meningitides (Meningococcus)?
Children and young adults
What specific symptom/sign indicates N. meningitides (Meningococcus)?
What is the treatment for N. meningitides (Meningococcus)?
- Pen G Q4H
- Cefotaxime 2 grams IV Q4H
- Ceftriaxone 2 grams IV Q12H
How do you prophylax for N. meningitides (Meningococcus)?
- Ceftriaxone when Rifampin is CI (like pregnant adults)
What patients are more likely to get Streptococcus pneumonia (Pneumococcus)?
- Very young (1-4 months)
- Very old
- Patients with a primary infection of the ear, paranasal or sinuses
What are the risk factors for Streptococcus pneumonia (Pneumonococcus)?
- CSF leak secondary to head trauma
- sickle cell disease
- bone marrow transplantation
How do you treat Streptococcus pneumonia (Pneumonococcus)?
- Pen G, Cefotaxime or Ceftriaxone
- Relatively resistant = Ceftriaxone
- Highly resistant = Vancomycin
What patients are most likely to get H. flu meningitis?
- Previously 6 months to 3 years
- Primary infection of middle ear, paranasal sinuses or lungs
H. flu is often resistant to what drug?
What are the drugs used to treat H. flu meningitides?
3rd gen cephalosporins (Cefotaxime or Ceftriaxone)
Why are cefotaxime or ceftriaxone preferred for H. flu meningitis?
DOC for Beta-lactamase producers
How do you prophylax for H. flu meningitis?
What concomitant drug should be given along with antibiotics for bacterial meningitis?
Dexamethasone before or at the time of the initiation of antibiotics
What benefits does Dexamethasone given before or at the time of antibiotic initiation have for meningitis?
Lower fatality, lower rates of severe hearing loss, neurological sequelae
What is the TREATMENT OF CHOICE for N. meningitides meningitis?
PCN G 200-300,000 U/kg/d
What is the TREATMENT OF CHOICE for S. pneumonia?
- Ceftriaxone 2 Gm IV Q12H + Vancomycin 15 mg/kg/dose
- (children 100mg/kg/day IV Q 12hrs)
What is the TREATMENT OF CHOICE for H. influenza?
Ceftriaxone 2 Gm IV Q12 H (children 50-100mg/kg IM/IV Q 12 hrs)
What groups are most susceptible to Listeria monocytogenes?
- Neonates (genital or subclinical infection in mother)
What is the treatment of choice for Listeria monocytogenes?
- Ampicillin (DOC) +/- aminoglycoside
- 100 mg/kg IV q 8 hrs in neonates
- 200 mg/kg IV Q 4 hours in adults
- Trimethoprim-sulfamethoxazole has been used with success
- Length of therapy - 3 weeks or longer
What is the most common etiology of viral meningitis?
- Enteroviruses including polio, Coxsackie, and echoviruses
- (RNA viruses present in the GI tract)
- Fecal oral
What group usually gets viral meningitis?
- Children < 14 years (children and young adults)
- Summer and early fall
What are the Symptoms of Meningitis?
Headache, low grade fever, nuchal rigidity, malaise, drowsiness, nausea, vomiting, and photophobia
How long does it take to recover from Viral meningitis?
Are you more likely to see PMNs or Lymphocytes with Aseptic meningitis?
Are you more likely to see PMNs or Lymphocytes with Septic meningitis?
What is the treatment for Aseptic meningitis?
What group of patients is most likely to get Herpes?
Neonates and sexually active adults
How does Herpes Meningitis present?
- Suddenly after a brief influenza like prodrome
- Fever, HA, behavioral disorders, speech difficulties, focal seizures
What is the treatment for Herpes meningitis?
- Acyclovir resistant viruses = Vidarabine or Foscarnet
What is the primary cuase of shunt infections?
- S. epidermidis for VA and VP shunts
- S. aureus (2nd leading cause)
- Usually G+
How do you treat shunt meningitis where MRSA or MRSE is suspected?
- Vancomycin and Gentimicin or rifampin
- Remove shunt
S. aureus shunt infection with PCN-resistant MSSA is:
Nafcillin 2 Gm IV Q4H
S. aureus shunt infection with MCN-resistant MRSA?
Vancomycin 30-40 mg/kg/d
PCN-resistant S. epidermidis shunt infection should be treated with what?
Vancomycin 30-40 mg/kg/d
MCN-resistant epidermidis shunt infection should be treated with what?
Vancomycin 30-40 mg/kg/d