Bacterial meningitis: Causes, diagnosis, treatment, and prognosis Mortality: 25% in community acquired acute bacterial meningitis o Associated

d with: >60 years old, obtunded mental status on admission, onset of seizures within 24 hours of admission Complications: cognitive impairment, hearing loss, seizures, hydrocephalus, visual deficits Classic triad of fever, nuchal rigidity, altered mental status: in less than half of patients 95% of patients had at least 2 of: headache, fever, nuchal rigidity, altered mental status Headache is most common Other symptoms: nausea, vomiting, photophobia, rash (meningococcal) Kernigs sign and Brudzinskis sign not considered useful diagnostically (5% sensitive, 95% specific) Nuchal rigidity: 30% sensitive, 68% specific Clinical features not consistent Causes 4.0 mmol/L or more is consistent with bacterial meningitis instead of aseptic postsurgical meningitis Latex agglutination: detects capsular polysaccharides of bacterial pathogens. For patients with negative CSF Gram stain from previous antibiotic use. High false positive rates. PCR: 100% sensitive, 98.2% specific. Expensive, not widely available Other studies: CSF VDRL, CSF PCR for enteroviruses and herpesvirus, CSF fungal stain, CSF mycobacterial stain Treatment If negative CSF Gram stains and cultures + high clinical suspicion chose treatment based on host presentation o

Diagnosis CSF: Gram stain and culture, cell count, glucose, protein o CT in patients with: immunocompromise, papilledema, focal neurological deficits, CSF shunts, history of hydrocephalus, and/or trauma to prevent brain herniation (secondary to intracranial masses) Two sets of blood cultures before initiation of antibiotics Blood lactic acid if recent neurosurgical procedure

Penicillin minimum inhibitory concentration (MIC) <0.1 mg/mL penicillin G, ampicillin Penicillin MIC 0.1-1 mg/mL third generation cephalosporin (ceftriaxone), cefepime, meropenem Penicillin MIC >2.0 mg/mL vancomycin + third generation cephalosporin Ceftriaxone MIC > 2mg/mL add rifampin Pneumococcal meningitis: dexamethasome (0.15 mg/kg every 6 hours) for the first 2-4 days. Only before and during first antibiotic dose. Decreases risk of adverse outcomes. Meningococcal meningitis: respiratory isolation first 24 hours, prophylaxis for close contacts. If patient does not improve in 48 hours, repeat LP. However, neck stiffness may persist up to 7 days. Length of antiobiotic regimen: 7 days for N meningitides and H influenzae, 10-14 days for S pneumonia, 14-21 days for S agalactiae, 21 days for L monocytogenes or aerobic Gram negative bacilli