Transcript ANTIBIOTIC THERAPY IN 2000 PROBLEMS AND SOLUTIONS

Bacterial Meningitis A Medical Emergency
Swartz MN
N Engl J Med
2004;351:1826-1828
Mortality Rates Associated with
Community-Acquired Bacterial Meningitis
over the Past 90 Years
Swartz MN
N Engl J Med
2004;351:1826-1828
Bacterial Meningitis A Medical Emergency
 Fever and neurologic
symptoms
 Bacterial meningitis
 Aseptic meningitis
Neurologic Symptoms
With Fever
Bacterial meningitis
Aseptic meningitis
Encephalitis
Brain abscess
Epidural Abscess
Subdural empyema
Sinus septic
thrombosis
Collagen diseases
Typical CSF Changes
etiology
protein glucose leukocytes
bacterial meningitis
viral meningitis
TB meningitis
fungal meningitis
brain abscess
100-500
50-200
100-10000, P
N
<1000, MN
100-500
10-500, MN
25-500
25-500, MN
75-500
N
0-200, MN
Bacterial Meningitis
Etiology
Neonates
> 3 months
Gram (-) rods
Strep group B
Listeria
monocytogenes
Haemophilus
influenzae b
Haemophilus
influenzae b
Strep pneumoniae
N. meningitidis
Bacterial Meningitis
Clinical Presentation
1.
2.
3.
4.
5.
6.
7.
8.
"Looks Bad”
Fever
Headache, nausea, vomiting
Irritability, restlessness
Sleepy
Confusion, mental signs
Back pain
Bulging fontanel / nuchal rigidity
Bacterial Meningitis
Diagnosis
1. LP – mandatory (protein, glucose,
cells, culture, Gram stain, antigen
detection by latex, ELISA, CIE)
2. Blood culture – always
3. CT? (search for focus)
Bacterial Meningitis
Treatment
1.
2.
3.
4.
5.
Antibiotic regimen
Steroids
Fluid restriction?
Anticonvulsant medications?
Monitoring
CSF Penetration
of Antibiotics
adequate
chloramphenicol
sulfa
TMP/SMX
metronidazole
rifampin
good with minimal with
inflammation inflammation
ampicillin
cefotaxime
amikacin
vancomycin
gentamicin
tobramycin
erythromycin
ketoconazole
nil
clindamycin
benza pen
ampho B
polymyxin
Bacterial Meningitis
Treatment
1.
2.
3.
4.
5.
Antibiotic regimen
Steroids
Fluid restriction?
Anticonvulsant medications?
Monitoring
Bacterial Meningitis
Sequelae
1. Mortality: 1-5%
2. Hearing loss: 10-40%
3. Language disorders 15%
4. Impaired vision: 2-4%
5. Mental retardation: 10%
(Sell et al)
6. Motor abnormalities
7. Seizures: 2-8%
8. Hydrocephalus
9. Cranial N palsy
10. Ataxia…
Bacterial Meningitis
factors affecting prognosis
1.
2.
3.
4.
5.
6.
Age
Specific cause
Underlying disorders
Delay in therapy
Focal neurologic findings
Bacterial load (animals)
Aseptic Meningitis
Bacterial – partially treated, mycobacteria,
T. pallidum, borrelia, leptospira
Viral
Rickettsia
Fungal
Protozoa
Parameningeal foci (abscess, mastoiditis,
sinus septic thrombosis)
Viral Meningitis - USA
Enteroviruses - 85%
Arboviruses 5%
Mumps 2%
Herpes simplex 2-5%
Others: adeno, VZV, CMV, measles,
rubella, influenza, parainfluenza, RSV
Herpes simplex
Encephalitis
Presentation (Kohl, Ped C N Am 1998)
 Fever
90-100%
 Altered consciousness
80-100%
 Headache
76-80%
 Seizures
40-85%
 Hemiparesis
33-40%
 Cranial N palsy
30-35%
 Behavioral changes
47-85%
Herpes simplex
Encephalitis
Laboratory findings
 Abnormal CSF
 CSF pleocytosis
 CSF RBCs
 CSF protein
 CSF glucose
 Culture
 PCR (type 1, 2)
(Kohl, Ped C N Am 1998)
90-97%
50-1000, lymph
75-85%
increased
normal
negative
positive
Herpes simplex
Encephalitis – Outcome
Acyclovir Vidarabine placebo
Mortality (1m)
16%
Severe sequelae
34
Moderate sequelae
10
Minor or no impairment 46%
36%
72%
15%
13%
70%
Recurrent Meningitis
Communication of SAS with:
Skin - dermal sinus, meningomyelocele
Paranasal sinuses, middle ear, nasopharynx –
due to fractures, cong malformations
Parameningeal focus – epidural, brain, mastoid
Immune deficiency
Unknown
Thank You
for the
attention
Shai Ashkenazi