Meningitis

Definition

Meningitis is inflammation of the thin tissue that surrounds the brain and spinal cord,
called the meninges. There are several types of meningitis. The most common is viral
meningitis, which you get when a virus enters the body through the nose or mouth and
travels to the brain. Bacterial meningitis is rare, but can be deadly. It usually starts with
bacteria that cause a cold-like infection. It can block blood vessels in the brain and lead
to stroke and brain damage. It can also harm other organs.

Etiology

Etiology of neonatal meningitis: Staphylococcus epidermidis and Candida species are

uncommon butt greater frequency in neonates. L monocytogenes. Etiology of meningitis
in infants and children: In children older than 4 weeks, S pneumoniae and N meningitidis
are the most common etiologic agents. H influenzae type b has essentially disappeared
in countries where the conjugate vaccine is routinely used.

Causes

Staphylococcus epidermidis and Candida, L monocytogenes, Serratia marcescens,

Pseudomonas aeruginosa, and Proteus species, Staphylococcus epidermidis and
Pseudomonas, Citrobacter, and Bacteroides species.

S pneumoniae colonizes the upper respiratory tract of healthy individuals; however,

disease often is caused by a recently acquired isolate. Transmission is person-to-person,
usually by direct contact, and secondary cases are rare. The incubation period varies
from 1-7 days, and infections are more prevalent during the winter when viral
respiratory disease is prevalent. The disease often results in sensorineural hearing
loss, hydrocephalus, and other CNS sequelae. Prolonged fever despite adequate
therapy is common in patients with meningitis caused by this organism.

N meningitidis are gram-negative, kidney bean–shaped organisms and frequently are

found intracellularly. The upper respiratory tract frequently is colonized with
meningococci, and transmission is person-to-person by direct contact through infected
droplets of respiratory secretions, often from asymptomatic carriers. The incubation
period is generally less than 4 days, with a range of 1-7 days.
 H influenzae type b meningitis Mode of transmission is person-to-person by direct
contact through infected droplets of respiratory secretions. The incubation period
generally is less than 10 days.

L monocytogenes meningitis: L monocytogenes causes meningitis in newborns,

immunocompromised children, and pregnant women. The disease also has been
associated with the consumption of contaminated foods (eg, milk, cheese). Most cases
are caused by serotypes Ia, Ib, and IVb. Signs and symptoms in patients with listerial
meningitis tend to be subtle, and diagnosis often is delayed. In the laboratory, this
pathogen can be misidentified as a diphtheroid or as hemolytic streptococci.

S epidermidis and other coagulase-negative staphylococci frequently cause meningitis

and CSF shunt infection in patients with hydrocephalus or following neurosurgical
procedures.

Immunocompromised children can develop meningitis caused by species of

Pseudomonas, Serratia, Proteus, and diphtheroids.

Signs and Symptom

Signs and Symptoms found in textbook S/sx manifested by patient

Headache
Alterations of the sensorium
Irritability
Lethargy
Nuchal rigidity
Opisthotonos
Anorexia
Nausea
Vomiting
Coma
Fever (generally present, although some
severely ill children present with hypothermia)
Headache
Photophobia
Bulging fontanelle
Convulsions
MEDICAL MANAGEMENT

Management of the patient includes:

 Crystalloid infusion. If the patient is in shock or hypotensive, crystalloid should be

infused until euvolemia is achieved.
 Seizure precautions. If the patient’s mental status is altered, seizure precautions
should be considered, seizures should be treated according to the usual protocol,
and airway protection should be considered.
 IVT and oxygen administration. If the patient is alert and in stable condition with
normal vital signs, oxygen should be administered, intravenous (IV) access
established, and rapid transport to the emergency department (ED) initiated.

Pharmacologic Management

Begin empiric antibiotic coverage according to age and presence of overriding physical
conditions.

 Sulfonamides. Trimethoprim and sulfamethoxazole work together to inhibit bacterial

synthesis of tetrahydrofolic acid.
 Tetracyclines. Tetracyclines inhibit protein synthesis and, therefore, bacterial growth
by binding with 30S and possibly 50S ribosomal subunits of susceptible bacteria.
 Carbapenems. Carbapenems inhibit bacterial cell wall synthesis by binding
to penicillin-binding proteins; carbapenems, including meropenem, can be used for
the treatment of meningitis.
 Fluoroquinolones. Fluoroquinolones inhibit bacterial DNA synthesis and,
consequently, growth by inhibiting DNA gyrase and topoisomerases, which are
required for replication, transcription, and translation of genetic material.
 Glycopeptides. Vancomycin inhibits bacterial cell wall synthesis by blocking
glycopeptide polymerization; it is indicated for many infections caused by gram-
positive bacteria.
 Aminoglycosides. Aminoglycosides primarily act by binding to 16S ribosomal RNA
within the 30S ribosomal subunit; they have mainly bactericidal activity against
susceptible aerobic gram-negative bacilli.
  Cephalosporins, 3rd generation. Third-generation cephalosporins are less active
against gram-positive organisms than first-generation cephalosporins are; they are
highly active against Enterobacteriaceae, Neisseria, and H influenzae.
 Antivirals. Antiviral agents interfere with viral replication; they weaken or abolish
viral activity; they can be used in viral meningitis.
 Systematic antifungals. Antifungal agents are used in the management of infectious
diseases caused by fungi.
 Vaccines, inactivated. Inactivated bacterial vaccines are used to induce active
immunity against pathogens responsible for meningitis.
 Corticosteroids. The use of steroids has been shown to improve overall outcome for
patients with certain types of bacterial meningitis, such as H influenzae, tuberculous,
and pneumococcal meningitis.
 Osmotic diuretics. Mannitol may reduce subarachnoid-space pressure by creating an
osmotic gradient between CSF in the arachnoid space and plasma.
 Loop diuretics. Furosemide is a loop diuretic that increases the excretion of water by
interfering with the chloride-binding cotransport system, which, in turn,
inhibits sodiumand chloride reabsorption in the ascending loop of Henle and
distal renal tubule.
 Anticonvulsants. Anticonvulsants are used to help aggressively control seizures (if
present) in acute meningitis, because seizure activity increases ICP.

Nursing Management

Nursing management of the patient with meningitis include the following:

Nursing Assessment

Assessment of the patient with bacterial meningitis include.

 Neurologic status. Neurologic status and vital signs are continually assessed.
 Pulse oximetry and arterial blood gas values. These values are used to quickly
identify the need for respiratory support.
Nursing Interventions

Important components of nursing care include the following measures:

 Assess neurologic status and vital signs constantly. Determine oxygenation from
arterial blood gas values and pulse oximetry.
 Insert cuffed endotracheal tube (or tracheostomy), and position patient
on mechanical ventilation as prescribed.
 Assess blood pressure. (usually monitored using an arterial line) for incipient shock,
which precedes cardiac or respiratory failure.
 Rapid IV fluid replacement may be prescribed, but take care not to overhydrate
patient because of risk of cerebral edema.
 Reduce high fever to decrease load on heart and brain from oxygen demands.
 Protect the patient from injury secondary to seizure activity or altered level of
consciousness (LOC).
 Monitor daily body weight; serum electrolytes; and urine volume, specific gravity,
and osmolality, especially if syndrome of inappropriate antidiuretic hormone (SIADH)
is suspected.
 Prevent complications associated with immobility, such as pressure
and pneumonia.
 Institute infection control precautions until 24 hours after initiation
of antibiotictherapy (oral and nasal discharge is considered infectious).
 Inform family about patient’s condition and permit family to see patient at
appropriate intervals.

Evaluation

Expected patient outcomes include:

 Avoidance of injury.
 Avoidance of infection.
 Restoration of normal cognitive functions.
 Prevention of complications.
Discharge and Home Care Guidelines

After hospitalization, the patient at home should:

 Activities. Alternate rest and activity to conserve energy.

 Diet. Consume safe, clean, and healthy foods.
 Asepsis. Promote simple infection control procedures at home.
 Infectious process. Identify signs and symptoms of an infectious process and report
to the physician promptly.

Documentation Guidelines

The focus of documentation in patients with bacterial meningitis are:

 Client’s description of response to pain.

 Acceptable level of pain.
 Prior medication use.
 Current physical findings.
 Client’s understanding of individual risks and safety concerns.
 Availability and use of resources.
 Current and previous level of function.
 Effect on independence and lifestyle.
 Results of laboratory and diagnostic tests.
 Mental status pr cognitive evaluation results.
 Plan of care.
 Teaching plan.
 Response to interventions, teaching, and actions performed.
 Attainment or progress towards desired outcomes.
 Modifications to plan of care.
 Pathophysiology of Meningitis

Infectious Agents like parasite, virus,

bacteria, and fungus.

Initially, the infectious agent colonizes or

establishes a localized infection in the host.

Through infecting

Skin, nasopharynx,
respiratory tract,
gastrointestinal tract, or
genitourinary tract.