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Patient Care Process for CNS Infections



  • Patient characteristics (e.g., age, sex, weight, height, pregnancy status, allergies)

  • Patient medical history (personal and family)

  • Social history (e.g., ethanol/IV drug use, recent travel, home residence, exposure to animals) and dietary habits including intake of unpasteurized dairy products

  • Current medication use including anti-infective and immunomodulating agents.

  • Vaccination history (e.g., PCV13, PPV23, Hib, MenACWY, MenB)

  • Objective data

    • Temperature, blood pressure, respiratory rate, white blood cell count, lactate, procalcitonin, serum creatinine, blood urea nitrogen

    • Blood/CSF examination, cultures, Gram stain, PCR, 16s rRNA, smear, AFB, serology

    • Radiologic imaging (MRI, CT)


  • Presence of risk factors (e.g., vaccination history, immunocompromised status, asplenia, recent dental procedure, endocarditis, consumption of unpasteurized dairy products, central venous catheter, CSF shunt)

  • Signs and symptoms (e.g., temperature >100.4 F, nuchal rigidity, headache, Kernig and Bruzinski signs [Figs. 106-4 and 106-5], CSF characteristics [Table 106-1], radiographic evidence, pathogen identification)

  • Local susceptibilities of suspected/proven pathogen(s)

  • Source control of focal infection (e.g., minimally invasive aspiration of brain abscess)

  • Barriers for successful completion of therapeutic regimen

  • Candidates for chemoprophylaxis


  • Evidence-based empiric drug therapy regimen including anti-infective agent(s) with good CNS penetration (Table 106-3), dose, route, frequency, and duration (see Tables 106-2 and 106-5, sections Health-Care Associated Ventriculitis and Meningitis, Bacterial Abscess, Viral Encephalitis, and CNS Infections in Special Populations)

  • Definitive anti-infective therapy if specific pathogen identified (Tables 106-4 and 106-5, sections as above)

  • Corticosteroid use when indicated

  • Monitoring parameters including efficacy (e.g., fever, mental status, meningismus, white blood cell count, radiologic resolution of focal infection, drug monitoring) and safety (e.g., renal function, drug-drug interactions); frequency and timing of follow-up

  • Patient education (e.g., purpose of treatment, invasive procedures, drug-specific information)

  • Referrals to other providers when appropriate (e.g., infectious diseases, neurologist, interventional radiologist)


  • Provide patient education regarding all elements of treatment plan

  • Ensure effective transitions of care

  • Schedule follow-up if treatment continues outpatient (e.g., SCr, adherence assessment, radiographic imaging)

Follow-up: Monitor and Evaluate

  • Resolution of CNS infection symptoms (e.g., fever, nuchal rigidity, headache, altered mental status)

  • Presence of adverse effects (e.g., acute renal injury, electrolyte abnormalities, QT interval prolongation)

  • Patient adherence to treatment plan using multiple sources of information

  • Duration of therapy based on evidence-based guidelines, clinical and radiologic progress

*Collaborate with patient, caregivers, and other health professionals


For the chapter in the Wells Handbook, please go to Chapter 36. Central Nervous System Infections.



  • image The four most common pathogens of acute bacterial meningitis in the United States are Streptococcus pneumoniae, group B Streptococcus, Neisseria meningitidis, and Haemophilus influenzae type b, although routine vaccinations are having a dramatic effect on the incidence and distribution of these pathogens.

  • image In cases of bacterial meningitis, initial findings can include (a) presenting signs and symptoms: fever, headache, nuchal rigidity ...

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