ANTIBIOTIC THERAPY IN 2000 PROBLEMS AND SOLUTIONS
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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