Severe disease with high mortality (50%)
Unpredictable course of the disease in first 48h
Causes
<1 month: E.coli, Listeria, Klebsiella
1-23 months: Pneumococcus, meningococcus, haemophilus, Haemophilus
2-50 years: S. pneumoniae, N.meningitidis
>50 years: S. pneumoniae, N.meningitidis, Listeria
Meningococcus (Neisseria meningitides, gram negative diplococcus)
Pneumococcus (Streptococcus pneumoniae, gram positive diplococcus)
Haemophilus (gram negative) got rare since vaccination available
Clinical presentation
- Preceded by flu-like symptoms
- Fever
- Rash (80%) (meningococcus septicaemia)
- headache
- shock
- signs of meningitis
- Nuchal rigidity
- Kernig: pain and spasm when straightening leg with hip bent
- Brudzinski: Neck flexion causes lower limb flexion
- Altered concious level > coma
- seizure (25%)
Diagnosis
- Clinical Presentation
- Blood culture
- Throat swab
- Lumbar Puncture
- clody CSF
- gram stain
- culture, PCR
- increased opening pressure (>400mm; Normal range 80-180 mm H2O)
- pleocytosis (>100 leucocytes/mm3)
- decreased glucose level
- protein >0.5g/l
Indications for CTB prior to LP
- HIV or other immunocompromised state
- Seizures
- Focal neurology
- Evidence of raised ICP (
Complicatons
- Seizure
- Stroke
- tentorial herniation
- hydrocephalus
- neurological sequelae
Management / Therapy
ABC and FASTHUG
Antibiotics
Empiric (organism not known)
Ceftriaxone 4g/day or 2g bd (Children 100mg/kg in one or two doses)
PLUS
Vancomycin 12.5mg/kg (1g/80kg) 6/24
Neisseria meningitidis
Benzylpenicillin 1.8g 4/24
OR
Ceftriaxone 4g 24/24
OR
Cefotaxime 2g 6/24
Hospital acquired meningitis
Vancomycin 12.5mg/kg (up to 500mg) iv 6/24
PLUS
Meropenem 2g 8/24
Steroids
Dexamethasone 0.15mg/kg iv with the first dose of antibiotics, then 0.15mg/kg 6/24 for 4/7
Reduction of antimicrobial agent induced inflammation
Significant reduction in mortality and neurological sequelae
In particular for pneumococcal meningitis
Neuro ICU Management
Consideration of monitoring and management of high ICPs
Repeated lumbat CSF drainage
EEG to detect seizure activity (in particular nonconvulsive state)