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PATIENT CARE PROCESS

Patient Care Process for CNS Infections

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Collect

  • 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)

Assess

  • 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

Plan*

  • 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)

Implement*

  • 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

CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK

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

KEY CONCEPTS

KEY CONCEPTS

  • Image not available. 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 not available. In cases of bacterial meningitis, initial findings can include (a) presenting signs and symptoms: fever, headache, nuchal rigidity (the classic triad), ...

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