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Chapter 30. Meningitis

Allana J. Sucher

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    AMA Citation
    Sucher AJ. Sucher A.J. Sucher, Allana J.Chapter 30. Meningitis. In: Attridge RL, Miller ML, Moote R, Ryan L. Attridge R.L., Miller M.L., Moote R, Ryan L Eds. Rebecca L. Attridge, et al.eds. Internal Medicine: A Guide to Clinical Therapeutics New York, NY: McGraw-Hill; 2013. http://accesspharmacy.mhmedical.com/content.aspx?bookid=565&sectionid=42003744. Accessed November 17, 2019.
    MLA Citation
    Sucher AJ. Sucher A.J. Sucher, Allana J.. "Chapter 30. Meningitis." Internal Medicine: A Guide to Clinical Therapeutics Attridge RL, Miller ML, Moote R, Ryan L. Attridge R.L., Miller M.L., Moote R, Ryan L Eds. Rebecca L. Attridge, et al. New York, NY: McGraw-Hill, 2013, http://accesspharmacy.mhmedical.com/content.aspx?bookid=565&sectionid=42003744.

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  • Bacterial etiology of meningitis varies by patient age, immune status, & history of neurosurgical procedure or head trauma
  • Aseptic meningitis: all nonbacterial causes (viruses, fungi, parasites, medications, cochlear implants, malignancies)
  • Nasopharyngeal (bacteria) or mucosal surface (viral) colonization → bacteremia or viremia → invasion into CNS → replication → meningeal inflammation → neurological sequelae

Table 30-1 Etiology of Bacterial Meningitis by Age & Predisposing Factors (Clin Infect Dis 2004;39:1267)
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Table 30-1 Etiology of Bacterial Meningitis by Age & Predisposing Factors (Clin Infect Dis 2004;39:1267)

Predisposing Condition

Organism

Age*

   2–50y

   >50y

Streptococcus pneumoniae, Neisseria meningitidis

S. pneumoniae, N. meningitidis, Listeria monocytogenes, enteric gram-negatives (Escherichia coli)

Head trauma

   Basilar skull fracture

   Penetrating trauma

S. pneumoniae, Streptococcus pyogenes, Haemophilus influenzae

Staphylococcus aureus, Staphylococcus epidermidis, aerobic gram-negatives (including Pseudomonas aeruginosa)

Postneurosurgery

S. aureus, S. epidermidis, aerobic gram-negatives (including P. aeruginosa)

*Any age that is immunocompromised is at risk for infection by L. monocytogenes.

Pertinent Positive Labs

  • Lumbar puncture for cerebrospinal fluid (CSF) analysis
  • CSF laboratory values & Gram stain help determine cause of meningitis
  • Further work-up of aseptic meningitis: PCR for HSV/enteroviruses; CSF cryptococcal antigen for cryptococcal meningitis in immunosuppressed patients (in HIV, CD4+ <50cells/mm3)

Table 30-2 CSF Laboratory Interpretation (Lee M. Basic Skills in Interpreting Laboratory Data, 4th ed., 2009)
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Table 30-2 CSF Laboratory Interpretation (Lee M. Basic Skills in Interpreting Laboratory Data, 4th ed., 2009)

Normal

Bacterial Meningitis

Aseptic Meningitis

WBC (mm3)

<5

>1000

5–500

Differential

No predominance

>80% PMNs

>50% lymphocytes

Protein (mg/dL)

<50

>100

30–150

Glucose (mg/dL)

2/3 serum

<1/2 serum

<30–70

Gram stain (Table 30-3)

Negative

60–90% sensitive

Negative

CSF: cerebrospinal fluid; PMNs: polymorphonuclear neutrophils (segmented neutrophils).

Table 30-3 Gram Staining Characteristics of Bacteria (Levinson W. Review of Medical Microbiology & Immunology, 2010)
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Table 30-3 Gram Staining Characteristics of Bacteria (Levinson W. Review of Medical Microbiology & Immunology, 2010)

S. pneumoniae

Gram-positive diplococci (α-hemolytic)

N. meningitidis

Gram-negative cocci

L. monocytogenes

Gram-positive rods

E. coli

Gram-negative rods (lactose positive)

S. pyogenes

Gram-positive cocci (β-hemolytic)

H. influenzae

Gram-negative rods

S. aureus

Gram-positive cocci in clusters (coagulase positive)

S. epidermidis

Gram-positive cocci in clusters (coagulase negative)

P. aeruginosa

Gram-negative rods (lactose negative, oxidase positive)

*All microorganisms in this table are aerobic.

Treatment goals: ameliorate signs & symptoms, eradicate infection, prevent development of neurological sequelae

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Clinical Pearl 30-1

Start empiric ABX as soon as possible in all patients with suspected meningitis

Principles of treatment: high-dose parenteral therapy; agent must penetrate blood-brain barrier, be bactericidal in the CSF, & have antimicrobial activity against infecting pathogen

Pharmacological Treatment ...

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