Kembara Xtra - Medicine - Bacterial Meningitis

Kembara Xtra - Medicine - Bacterial Meningitis 
Meningeal bacterial infection that causes systemic sickness, discomfort, and inflammation

Predominant ages are newborns, infants, and the elderly; males outnumber females.
Incidence
dependent on pathogen and age
Ages 18 to 34: 0.66 per 100,000. Ages 35 to 49: 0.95 per 100,000. 65 years and older: 1.92/100,000. 50 to 64 years: 1.73/100,000.
0.25 per 100,000 for group B streptococcus. Haemophilus influenzae type B: 0.08/100,000. Neisseria meningitidis: 0.19/100,00. 0.05/100,000 Listeria monocytogenes
Prevalence
In the US, 15,000 to 25,000 instances happen every year.


Pathophysiology and Etiology 

Streptococcus pneumoniae (50%) and N. meningitidis (30%) are the most common causes of community-acquired bacterial meningitis. Nosocomial or postsurgical meningitis develops when the central nervous system (CNS) space is altered, allowing infections to enter. Group B Streptococcus, Escherichia coli, and L. monocytogenes in newborns (2 months). S. pneumoniae, N. meningitidis, and H. influenzae in infants and young children. S. pneumoniae and N. meningitidis in adolescents and young adults. Adults with impaired immune systems are vulnerable to gram-negative bacteria like Pseudomonas aeruginosa and S. pneumoniae. 1% of cases involve mixed bacterial infection. Senior citizens: 50% S. pneumoniae, 30% N. meningitidis, and 5% L. monocytogenes. 10% gram-negative bacteria, including P. aeruginosa, E. coli, Klebsiella, and Enterobacter.
Genetics
There seems to be a hereditary or acquired predisposition to invasive illness in some Native American tribes.

Risk factors Members of the patient's immediate family or household.
impaired immune system, alcoholism, diabetes, and chronic illness. head injury, neurosurgical surgery, and cramped housing. Neonatal conditions include prematurity, low birth weight, early membrane rupture, peripartum infection in the mother, and anomalies of the urinary system. Dural fistula, abnormal communication between the nasopharynx and the subarachnoid area (congenital, trauma). Otitis, sinusitis, and mastoiditis are parameningeal sources; skull fracture is the trauma.
Risk factors for listeriosis include immunosuppressed individuals, pregnant women, adults over 65, complement component deficits C3, C5 to C9, properdin, factor H, and factor D, as well as HIV infection. either anatomic or functional asplenia. Military recruits, young college students living in congested residence halls, and anyone who regularly come into contact with isolates of N. meningitidis in microbiologists' work are all at elevated risk for meningococcal disease.

In cases of recurrent meningitis, consider using a CSF fistula; for head injuries or skull fractures, use aseptic procedures.
With routine vaccination, the risk of H. influenzae type B-related meningitis was dropped by 55%. Conjugate vaccines against S. pneumoniae and chemoprophylaxis for close contacts of meningococcal meningitis patients may lessen the burden of disease in children.


Accompanying Conditions 
Alcoholism, advanced age, infancy, diabetes mellitus, multiple myeloma, head injury, seizures, immunocompromised, coma, sepsis, and sinusitis are risk factors linked to a worse prognosis.

History: Previous upper respiratory infection; fever, headache, photophobia, vomiting; seizures; and confusion.
 Weakness, sweating, rigors, and nausea. Elderly: delicate observations, such as bewilderment
Infants exhibit agitation, sluggishness, and poor eating. altered mental state; exposure to L. monocytogenes in diet

clinical assessment 
Fever, stiff neck, and changed mental status are indicators with low sensitivity (44%).
The following symptoms are present in 95% of patients: headache, fever, stiff neck, and impaired mental status.
- Meningismus; localized impairments in neurologic function. Meningococcal rash: petechial or purpuric at first, then initially macular and erythematous. Meningococcal purpura fulminans is suspected. Papilledema. Brudzinski sign: In a supine position, passive neck flexion causes involuntary knee flexion. In a supine position, the Kernig sign is resistance or pain with passive knee extension following 90-degree hip flexion. Late indications and symptoms include hearing loss, lifelong vision damage, hemiparesis, stroke, cognitive decline, coma, and epilepsy.

Differential diagnosis: sepsis, brain abscess, and bacteremia. convulsions, aseptic meningitis, and other nonbacterial meningitides
 Noninfectious inflammatory conditions include migraine, sarcoidosis, systemic lupus erythematosus (SLE), and Behçet illness.
The stroke. Leptospirosis, Lyme disease, and viral meningitis.
Central nervous system vasculitides and subarachnoid hemorrhage

Laboratory Results 

Initial examinations (lab, imaging)
 If there are focal neurologic symptoms, papilledema, or altered mental status, perform a lumbar puncture as away. CSF is murky in appearance; adults have >500 cells/mL WBCs, glucose 40 mg/dL, a blood-to-glucose ratio of 2/3, >200 mg/dL of CSF protein, and a CSF opening pressure >30 cm. WBC count that is extremely high (>100,000); polymerase chain reaction (PCR) of CSF (especially in suspected viral meningitis); suspect ruptured brain abscess
Reserve bacterial antigen tests for situations where the CSF culture and initial Gram stain are negative after 48 hours.
 Serum electrolytes and serum blood cultures. In the case of petechiae or purpura, analyze the clotting function. A chest radiograph may show an abscess or pneumonitis. Protein C-reactive (CRP): High negative predictive value exists for normal CRP.
 If hydrocephalus, brain abscess, subdural effusions, or subdural empyema are suspected later on in the course or if there is no clinical improvement after receiving the recommended antibiotics for 48 hours. For probable bacterial meningitis obtained from the community, lactate concentration is not advised.
Hypoglycorrhachia and an elevated CSF protein concentration point to meningitis or ventriculitis.
Tests in the Future & Special Considerations
If the lumbar puncture is postponed, think about starting empiric antibiotics after the blood cultures are taken.
Lumbar puncture/Other Diagnostic Procedures
If the patient is immunocompromised, has papilledema, a history of CNS disease, focal neurologic deficit on exam, visual field cut, new-onset seizure 1 week or less prior to presentation, or has an abnormal level of consciousness, a noncontrast head CT is advised before lumbar puncture to evaluate the risk of herniation.
 Signs of elevated intracranial pressure (decerebrate posturing, papilledema), skin infection at the site of the lumbar puncture, evidence of obstructive hydrocephalus on CT or MRI, cerebral edema, and herniation are contraindications to lumbar puncture.
 Infection-related symptoms, a positive CSF culture, and CSF pleocytosis all point to ventriculitis or meningitis.
Interpretation of Tests
Opening pressure >180 mm H20, high levels of protein and glucose in the CSF, and cell counts >1 109/L are all indicators of bacterial meningitis.


Management 

After lumbar puncture, start empiric antibiotic therapy right away (lumbar puncture > Abx). Initiate antibiotic therapy right away following blood cultures (Abx > CT > lumbar puncture) (1)[A] if a head CT scan is required. Precautions for aspiration and seizure monitoring are advised.

Until culture results are available, patients with known or suspected S. pneumoniae meningitis should receive empiric antibiotic IV therapy with dexamethasone.

Initial Line
Neonatals should get 150 mg/kg/day of ampicillin and 150 mg/kg/day of cefotaxime split every eight hours.
Ceftriaxone: 100 mg/kg/day divided q12-24h or cefotaxime: 225 to 300 mg/kg/day split q6-8h and vancomycin: 60 mg/kg/day divided q6h for infants older than four weeks.
(1) Adults[A]
Cefotaxime 2 g IV q4-6h or ceftriaxone 2 g IV q12h for immunocompetent patients.
Vancomycin 15 to 20 mg/kg IV q8-12h (target level 15 to 20 g/mL), plus ampicillin 2 g IV q4h in adults over 50 - Immunocompromised: vancomycin 15 to 20 mg/kg IV q8-12h, plus ampicillin 2 g IV q4h, plus either cefepime 2 g IV q8h or meropenem 2 g IV q8h (if meropen
- If you are over 50, add ampicillin: 2 g IV q4h for Listeria along with either cefotaxime: 2 g IV q4-6h, ceftriaxone: 2 g IV q12h, or meropenem: 2 g IV q8h (ampicillin is not required).
Ampicillin or penicillin should be included to the treatment plan in addition to gentamicin if Listeria is found to be the cause of the illness.
- Patients with penicillin allergies:
Meropenem should be used in place of ceftriaxone in patients who have mild hives to a cephalosporin but do not have additional symptoms of anaphylaxis.
Vancomycin loading dose of 25 to 30 mg/kg IV, followed by 15 to 20 mg/kg every 8 to 12 hours (goal trough of 15 to 20), as well as 400 mg of moxifloxacin IV once daily, are recommended for people with severe allergies. the course of treatment 10 to 14 days for S. pneumoniae (2)[A]
- H. influenzae and N. meningitidis: 7 to 10 days. E. coli, L. monocytogenes, and Group B Streptococcus organisms: 14 to 21 days. Neonates: a repeated culture is sterile 12 to 21 days after birth, or at least 14 days afterwards.
- For suspected instances of non-severe meningococcal disease, there is no solid evidence to justify the administration of antibiotics prior to admission. Pediatric corticosteroids: Corticosteroids are linked to a lower incidence of hearing loss and neurologic complications.
Dexamethasone, given early in the course of acute bacterial meningitis in individuals older than one month, reduces mortality and morbidity while posing no increased risk of gastrointestinal bleeding (0.15 mg/kg IV every six hours for two to four days).
Adults: Start with adults and only continue if a CSF Gram stain reveals gram-positive diplococcus or if blood or CSF tests positive for S. pneumoniae.
 Associated with decreased mortality in S. pneumoniae (RR 0.8, 95% CI 0.20-0.59) but not in H. influenzae or N. meningitidis (2); increased recurrence of fever (RR 1.27, 95% CI 1.09-1.47); and decreased mortality in S. pneumoniae (3).[A]
 Lower incidence of neurologic sequelae (RR 0.83, 95% CI 0.69- 1.00), severe hearing loss (RR 0.67, 95% CI 0.51-0.88), and any hearing loss. Mortality decrease that was not statistically significant (RR 0.90, 95% CI 0.53-1.05); p =.009
- Dexamethasone: 0.15 mg/kg IV every six hours for two to four days (start 15 to 20 minutes before or with an antibiotic).
Only if S. pneumoniae is detected by the CSF Gram stain, CSF or blood culture, or both, should dexamethasone be continued.
Next Line
Antipseudomonal penicillins should be administered alongside other suitable medications.
Aztreonam 2 g IV every 6–8 hours. Meropenem IV 2 g q8h with fluoroquinolones (such as ciprofloxacin) IV 400 mg q8-12h


referral advice from an expert in critical care or infectious diseases

Furthermore Treated 
Close contacts that receive chemoprophylaxis include family members, roommates, intimate contacts, those at a daycare facility, young adults exposed in dorms, and military recruits exposed in training facilities. On a long journey (over eight hours), passengers who were seated close to an index patient or who came into touch with their respiratory secretions; people who came into contact with their oral secretions.


Surgical Techniques 
MRSA and aerobic gram-negative organisms including Pseudomonas spp. and Enterobacteriaceae are used as an emergency backup for postsurgical bacterial meningitis and meningitis linked to head trauma or shunts.

Admission 
Meningitis caused by bacteria need hospitalization. Perhaps an ICU monitor is required. Meningococcal infection suspicion necessitates a 24-hour respiratory isolation period for patients.
 Droplet precautions for hospitalized patients beginning with the first 24 hours of antimicrobial medication and continuing through any suspected diagnosis.

Patient Follow-Up Monitoring
Before being discharged from the hospital, babies have a brainstem auditory—evoked response hearing test.
Vaccinations - Meningococcal vaccine:
Every 11 to 12-year-old should receive the MenACWY vaccine, followed by a booster shot at age 16. Teenagers and young adults (16 to 23) may also receive the MenB vaccination. For additional kids and adults who are more likely to contract meningococcal disease, the CDC also suggests meningococcal vaccine.
The CDC advises routine MenACWY immunization for all preteens and teens at 11 to 12 years of age with a booster dose at 16 years of age, as well as for kids and adults who are at increased risk for meningococcal illness.
For those 10 years of age or older who are at a higher risk for meningococcal illness, routine MenB immunization
- Immunization against pneumococci:
Pneumococcal conjugate vaccine (PCV13) is typically given in 4 doses to infants and young children at 2, 4, 6, and 12 to 15 months of age. A youngster may occasionally only require 3 doses of PCV13 vaccine to finish. If they have not already received PCV13, anyone under the age of two who has specific medical issues is advised to obtain a dosage of PCV13. Based on conversations between the patient and the healthcare professional, this vaccination may be administered to people older than 65.
PPSV23 for all individuals 65 years, according to the CDC. Those aged 2 to 64 with specific medical issues, as well as those aged 19 to 64 who smoke cigarettes
Prophylaxis: From 2019 to 2020, 11 meningococcal isolates from American patients carried mutations that made them resistant to both ciprofloxacin and penicillin.
- The majority of American isolates are treatable with the advised drugs.
- For ciprofloxacin-resistant N. meningitidis exposure (not first agent), azithromycin 500 mg PO single dose; rifampin 600 mg PO BID for 2 days; ceftriaxone 250 mg IM for 1 dose; chemoprophylaxis for close contacts of patients with confirmed meningococcal meningitis


Regular diet, as tolerated, with the exception of the syndrome of incorrect antidiuretic hormone secretion


Mortality from meningitis caused by S. pneumoniae is 19–37%; meningococcal meningitis is 5%.
Usually, N. meningitidis-related deaths take place 12 to 24 hours after the onset of symptoms. Untreated illness has a mortality rate that is close to 100%.

Complications 
After pneumococcal meningitis, up to 50% of patients experience long-term neurologic consequences (cognitive impairment). Seizures cause a 20–30% focal neurologic loss. Subdural effusion or empyema, septic sinus thrombosis, intracraneal hypertension, cerebral edema, temporal lobe or cerebellar herniation, and hydrocephalus are among the 15-20% cerebrovascular sequelae.
 Cranial nerve palsies (III, VI, VII, VIII) occur in 10–20% of patients; they are typically temporary. 10% of kids have hearing loss due to sensorineural. impairment of vision for life.
30% of those with neurodevelopmental sequelae have mild learning difficulties.
Meningococcal-induced microvascular thrombosis and DIC; depression, subarachnoid bleed, stroke; obstructive hydrocephalus, subdural effusion; syndrome of inappropriate secretion of antidiuretic hormone (SIADH); elevated intracranial pressure: herniation, brain swelling; purpura fulminans, septic shock;

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