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Subject: Meningitis, Bacterial
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A potentially life-threatening bacterial infection of the meninges
System affected: nervous
Predominant age: neonates, infants, and elderly
Predominant sex: male = female
<2 months: 80/100,000
2 to 23 months: 7/100,000
2 to 10 years: 0.5/100,000
11 to 17 years: 0.4/100,000
18 to 34 years: 0.66/100,000
35 to 49 years: 0.95/100,000
50 to 64 years: 1.73/100,000
≥65 years: 1.92/100,000
Varies with pathogen
Streptococcus pneumoniae: 0.81/100,000
Group B Streptococcus: 0.25/100,000
Neisseria meningitidis: 0.19/100,000
Haemophilus influenzae: 0.08/100,000
Listeria monocytogenes: 0.05/100,000
Newborns (<2 months)
Group B Streptococcus
Infants and children
Adolescents and young adults
S. pneumoniae, L. monocytogenes, gram-negative bacilli such as Pseudomonas aeruginosa
Mixed bacterial infection in <1% of cases
S. pneumoniae 50%
N. meningitidis 30%
L. monocytogenes 5%
10% gram-negatives bacilli: E. coli, Klebsiella, Enterobacter, P. aeruginosa
Alcoholism, diabetes, chronic disease
Neurosurgical procedure/head injury
Neonates: prematurity, low birth weight, premature rupture of membranes, maternal peripartum infection, and urinary tract abnormalities
Abnormal communication between nasopharynx and subarachnoid space (congenital, trauma), dural fistula
Parameningeal source of infection: otitis, sinusitis, mastoiditis
Trauma: skull fracture
Treat infections appropriately.
Strict aseptic techniques for patients with head wounds or skull fractures
Consider CSF fistula in patients with recurrent meningitis.
Meningitis caused by H. influenzae type B has decreased 55% with routine vaccination.
Conjugate vaccines against S. pneumoniae may reduce the burden of disease in childhood.
Close contacts of meningococcal meningitis patients should receive chemoprophylaxis (2)[A].
Alcoholism, old age, infancy
Diabetes mellitus, multiple myeloma
Head trauma, seizures
Coma, bacteremia, sepsis
Bacteremia, sepsis, sinusitis
Antecedent upper respiratory infection
Fever, headache, vomiting, photophobia
Seizures, confusion, nausea, rigors
Profuse sweats, weakness
Elderly: subtle findings including confusion
Infants: irritability, lethargy, poor feeding
Altered mental status
Focal neurologic deficits
Meningococcal rash: macular and erythematous at first, then petechial or purpuric
Purpura fulminans: more common with meningococcus
Brudzinski sign: Passive flexion of neck elicits involuntary flexing of knees in supine position.
Kernig sign: resistance or pain with passive knee extension following 90-degree hip flexion in supine position
Late signs and symptoms: hemiparesis, stroke, cognitive impairment, coma, epilepsy, hearing loss, permanent visual impairment
Bacteremia, sepsis, brain abscess
Seizures, other nonbacterial meningitides
Drug-induced: NSAIDs, cotrimoxazole, amoxicillin, cephalosporin, isoniazid
Inflammatory noninfectious: Behçet disease, systemic lupus erythematosus (SLE), sarcoidosis
Prompt lumbar puncture (1)[A]
Head CT first if focal neuro findings, papilledema, or altered mentation
Typical CSF analysis: turbid
>500 cells/mL WBCs
Glucose <40 mg/dL
<2/3 blood-to-glucose ratio
CSF protein >200 mg/dL
CSF opening pressure >30 cm
Suspect ruptured brain abscess when WBC count is unusually high (>100,000).
CSF Gram stain and cultures
Polymerase chain reaction (PCR) of CSF (particularly in suspected viral meningitis)
Bacterial antigen tests should be reserved for cases in which the initial CSF Gram stain is negative and CSF culture is negative at 48 hours of incubation.
Serum blood cultures, serum electrolytes
Evaluate clotting function when petechiae or purpura are present.
Chest radiograph may reveal pneumonitis or abscess.
Later in course: head CT if hydrocephalus, brain abscess, subdural effusions, and subdural empyema are suspected or if no clinical response after 48 hours of appropriate antibiotics
C-reactive protein (CRP): Normal CRP has high negative predictive value (3)[A].
Lactate concentration not recommended for suspected community-acquired bacterial meningitis
IDSA head CT recommendations (prior to lumbar puncture): immunocompromised, history of central nervous system disease (stroke, mass lesion, focal infection), papilledema, focal neurologic defect including fixed dilated pupil, gaze palsy, weakness of extremity, visual field cut, new-onset seizure <12 weeks prior to presentation, abnormal level of consciousness (3)[A]
Contraindications to lumbar puncture: signs of increased intracranial pressure (decerebrate posturing, papilledema), skin infection at site of lumbar puncture, CT or MRI evidence of obstructive hydrocephalus, cerebral edema, herniation
Initiate empiric antibiotic therapy immediately after lumbar puncture (LP > Abx), or if head CT scan is needed, then immediately after blood cultures (Abx > CT > LP).
Vigorous supportive care to ensure prompt recognition of seizures and prevention of aspiration
Consider local patterns of bacterial sensitivity.
Ampicillin: 150 mg/kg/day divided q8h AND
Cefotaxime 150 mg/kg/day divided q8h
Infants >4 weeks of age (3,4)[A]
Ceftriaxone: 100 mg/kg/day divided q12–24h or cefotaxime 225 to 300 mg/kg/day divided q6–8h AND
Vancomycin: 60 mg/kg/day divided q6h
Vancomycin: loading dose 25 to 30 mg/kg IV then 15 to 20 mg/kg q8–12h with goal trough of 15 to 20 AND
Ceftriaxone: 2 g IV q12h OR
Cefotaxime: 2 g IV q4–6h
>50 years, add ampicillin: 2 g IV q4h for Listeria
Immunocompromised use vancomycin, ampicillin, ceftazidime, and acyclovir.
Precaution: aminoglycoside ototoxicity
Penicillin-allergic patients (3,4)[A]
Chloramphenicol: 1 g IV q6h AND
Vancomycin: loading dose 25 to 30 mg/kg IV then 15 to 20 mg/kg q8–12h (goal trough of 15 to 20)
S. pneumoniae: 10 to 14 days
N. meningitidis, H. influenzae: 7 to 10 days
Group B Streptococcus organisms, E. coli, L. monocytogenes: 14 to 21 days
Neonates: 12 to 21 days or at least 14 days after a repeated culture is sterile
No reliable evidence to support the use pre-admission antibiotics for suspected cases of non-severe meningococcal disease (5)[A]
Early treatment with dexamethasone (0.15 mg/kg IV q6h for 2 to 4 days) decreases mortality and morbidity for patients >1 month of age with acute bacterial meningitis with no increased risk of GI bleeding.
Corticosteroids are associated with lower rates of hearing loss and neurologic sequelae.
Initiate in adults and continue only if CSF Gram stain is gram-positive diplococcus or if blood or CSF positive for S. pneumoniae.
Nonsignificant reduction in mortality (RR) 0.90, 95% CI 0.53–1.05; p value = .009
Lower rates of severe hearing loss (RR 0.67, 95% CI 0.51–0.88), any hearing loss (RR 0.74, 95% CI 0.63–0.87), and neurologic sequelae (RR 0.83, 95% CI 0.69–1.00)
Decreased mortality in Streptococcus pneumonia (RR 0.8, 95% CI 0.20–0.59) but not in H. influenza or N. meningitidis
Associated with increased recurrent fever (RR 1.27, 95% CI 1.09–1.47)
Dexamethasone: 0.15 mg/kg IV q6h (start 15 to 20 minutes before or with antibiotic) for 4 days
Dexamethasone should only be continued if the CSF Gram stain and/or CSF or blood culture reveal Streptococcus pneumonia.
Quinolones (e.g., ciprofloxacin)
Bacterial meningitis requires hospitalization.
ICU monitoring may be needed.
Patients with suspected meningococcal infection require respiratory isolation for 24 hours.
Consider home therapy to complete IV antibiotics once clinically stable and culture/sensitivity results are known.
Brainstem auditory—evoked response hearing test for infants before hospital discharge
4 doses Hib conjugate vaccine recommended during infancy
Meningococcal conjugate vaccine quadrivalent (MCV4) is given to children aged 11 to 12 years with a booster at 16 years.
Immunizing infants <3 months old with MCV4 does not reduce morbidity or mortality, and vaccinating pregnant women does not reduce infant infections.
Administer 2 doses MCV4 at least 2 months apart to adults with the following:
HIV, functional asplenia
Persistent complement deficiencies
Administer 1 dose of meningococcal vaccine to:
Microbiologists routinely exposed to isolates of N. meningitidis
Those who travel to or live in countries where meningitis is hyperendemic or epidemic
1st-year college students up through age 21 years who live in residence halls if they have not received a dose on or after their 16th birthday
MCV4 is preferred for adults with any of the preceding indications who are ≤55 years of age; meningococcal polysaccharide vaccine (MPSV4) is preferred for adults aged ≥56 years.
Revaccination with MCV4 every 5 years is recommended for adults previously vaccinated with MCV4 or MPSV4 who are at increased risk.
Only for close contacts of patients
Rifampin is effective in eradicating N. meningitidis up to 4 weeks after treatment but may lead to resistance.
Rifampin: 600 mg PO BID for 2 days
Ciprofloxacin and ceftriaxone are effective up to 2 weeks after treatment without leading to resistance.
Ciprofloxacin: 500 mg PO for 1 dose
Ceftriaxone: 250 mg IM for 1 dose
Bacterial meningitis is fatal in 5– 40% of children and 20–50% of adults despite treatment with adequate antibiotics.
The mortality rate of untreated disease approaches 100%.
Seizures: 20–30%; focal neurologic deficit
Cranial nerve palsies (III, VI, VII, VIII)
Comprises 10–20% of the cases
Usually disappear within a few weeks
Sensorineural hearing loss: 10% in children
Neurodevelopmental sequelae: 30% have subtle learning deficits.
Obstructive hydrocephalus, subdural effusion
Syndrome of inappropriate secretion of antidiuretic hormone
Elevated intracranial pressure: herniation, brain swelling
Tunkel A, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America’s clinical practice guidelines for healthcare-associated ventriculitis and meningitis [published online ahead of print February 14, 2017]. Clin Infect Dis. doi:10.1093/cid/ciw861.
van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016;22(Suppl 3):S37–S62. [View Abstract]
G00.9 Bacterial meningitis, unspecified
G00.2 Streptococcal meningitis
G00.8 Other bacterial meningitis
G00.1 Pneumococcal meningitis
G00.3 Staphylococcal meningitis
G00.0 Hemophilus meningitis
320.9 Meningitis due to unspecified bacterium
320.2 Streptococcal meningitis
320.82 Meningitis due to gram-negative bacteria, not elsewhere classified
320.1 Pneumococcal meningitis
320.89 Meningitis due to other specified bacteria
320.7 Meningitis in other bacterial diseases classified elsewhere
320.3 Staphylococcal meningitis
320.0 Hemophilus meningitis
320.81 Anaerobic meningitis
95883001 Bacterial meningitis (disorder)
4510004 Streptococcal meningitis (disorder)
425887005 Bacterial meningitis due to Gram-negative bacteria
51169003 pneumococcal meningitis (disorder)
12166008 Staphylococcal meningitis
192643004 Haemophilus meningitis
192655005 Escherichia coli meningitis (disorder)
Classic triad of fever, neck stiffness, and altered mental status has low sensitivity for bacterial meningitis.
Adjunctive dexamethasone should not be given to adults who have already received antimicrobial therapy because it is unlikely to improve patient outcomes.
A potential problem with rifampin therapy is the induction of hepatic CYP isoenzymes, thereby increasing the metabolism of a variety of drugs.
Careful management of fluid and electrolyte balance is important because both over- and underhydration are associated with adverse outcomes.