DOM Morning Report: Bacterial Meningitis

Week of February 16, 2009

Objectives
To know the most common causes of bacterial meningitis in the United States To understand cerebrospinal fluid diagnosis of bacterial meningitis To choose appropriate empiric antibiotic coverage

Background
Streptococcus pneumoniae
Most common cause in US (47%) Mortality rate = 19-26% Heptavalent conjugate vaccine
97.4% effective Recommended in all infants < 2yo

Background
Neisseria meningitidis
Second most common cause in US Mortality rate = 3-13% Quadrivalent polysaccharide vaccine
All 11-12 year olds catch-up for unvaccinated adolescents Microbiologists Travelers to hyperendemic areas Splenectomy and functionally asplenic pts

Background
Listeria monocytogenes
8% of cases in United States Mortality = 15-29%

Background
Associations
Extremes of age Alcoholism Malignancy Immunosuppression Diabetes mellitus Pregnancy Hepatic disease Renal disease Iron overload Collagen vascular disorders HIV infection

Background
Other organisms
Haemophilus influenzae type b Staphylococcus aureus Coagulase-negative staphylococci Aerobic gram-negative bacilli
Klebsiella species Escherichia coli Serratia marcescens Pseudomonas aeruginosa

Diagnosis
Classic presentation
Fever Headache Nuchal rigidity Signs of cerebral dysfunction

CSF Parameter Opening pressure

Bacterial 200-500

Viral 250

TB Crypto 180-300 > 200

Leukocyte count Differential Glucose Protein Gram stain Acid-fast smear India ink prep Crypto antigen
Culture

1000-5000 50-1000 50-300 neutrophils lymphs lymphs < 40 > 45 45 100-500 < 200 50-300 60-90% < 25% 70-85% 25-86%

20-500 lymphs < 40 > 45 60% > 85%

95%

Diagnosis
Broad-based PCR
Range of bacterial primers Promising results
Sensitivity = 100% Specificity = 98.2% PPV = 98.2% NPV = 100%

Needs to be refined

Microorganism Streptococcus pneumoniae

Antimicrobial Agent Vanco + 3rd gen ceph

Neisseria meningitidis
Listeria monocytogenes Streptococcus agalactiae

3rd gen ceph

Ampicillin or Pcn G Ampicillin or Pcn G

Haemophilus influenzae type B

3rd gen ceph

Predisposing factor
Age 2-50

Common bacterial Antimicrobial pathogens agents

Vanc + 3rd gen ceph Vanc + amp + 3rd gen ceph Vanc + ceftaz or cefepime or meropenem

S. pneumoniae, N. meningitidis Age > 50 As above + Listeria and GNR Postneurosurgery Staph and GNR or head trauma

Treatment
Dexamethasone
Attenuates inflammatory response NEJM, 2002
Adults with bacterial meningitis unfavorable outcomes or death

Resistant pneumococcal strains

Careful observation and follow-up Adverse clinical outcomes Repeat LP after 48hrs without response

Treatment
Timing is critical for maximal benefit
Concomitant with or Just prior to first antibiotic dose

Objectives Revisited
Most common causes
Streptococcus pneumoniae Neisseria meningitidis

CSF findings
Leukocyte count Differential Protein Glucose Neutrophils