Viral

• HSV (leading cause of severe encephalitis in all ages)
• Enterovirus
• EBV
• Adenovirus
• Arbovirus
• HIV

Bacterial

Neonates: Group B Streptococcus, Listeria monocytogenes, Citrobacter

Others: Borrelia burgdorferi, Bartonella henselae, Rickettsia rickettsii, Mycoplasma pneumoniae

• Disturbance in brain function (psychiatric symptoms, emotional lability, altered sensorum, ataxia, movement disorders, focal neurologic deficit, paresis, stupor, coma, seizures)
• Fever
• Headache
• Personality change or irritability lasting for hours to days
• Lethargy (coma, death)

• Lumbar puncture
• Culture blood, urine, nasopharyngeal, and stool
• Metabolic Screening
• MRI
• Serum Specimen: Mycoplasma serology

• CSF cell count normaly to slightly elevated
• Protein normal to slightly elevated (high protein + polymorphonuclear pleocytosis = brain necrosis)
• Glucose normal
• Pleocytosis of mononuclear cells (elevated WBCs)

Support Measures

• Airway protection
• Cerebral perfusion
• Seizure control

Empiric Acyclovir

• Needs to be started ASAP (better safe than sorry)
• For HSV
• Insufficient data to recommend for Mycoplasma treatment

• High fever, headache, nuchal rigidity
• N/V, photophobia
• Confusion, sleepiness
• Seizures
• Children (lethargic, irritable, vomiting, feeding poorly)

Kernig's Sign

Brudzinski's Neck Sign

Both will hurt if they have meningitis

• Streptococcus pneumoniae (#1)
• Neisseria meningitides
• Haemophilus influenzae type B
• Listeria monocytogenes
• Streptococcus agalactiae (Group B Strep.)
• Escherichia coli or other G-

WBCs

< 5 (adults)

< 20 (newborns)

Diff

70% Lymphocytes

30% Monocytes

Protein

< 50

Glucose

2/3 serum

WBCs

400-100,000

Diff

80-90% Neutrophils (PMNs)

Protein

Mild to marked elevation (80-500)

Glucose

< 1/2 serum

1. Group B Strep
2. E. coli
3. Listeria

Streptococcus pneumoniae

Most Common Meningitis

Known to Affect:

• Children younger than 2 yrs old
• Adults with weakened immune systems

Causes neurologic damage (deafness to severe brain damage)

• Highly contagious through droplets
• Primarily children and young adults, those in close quarters, and travelers to foreign countries (West, Central, and East Africa, Pilgrimage to Saudi Arabia)

• Petechial rash or purpuric lesions
• Advances rapidly and can be fatal
• Becomes limb threatening with hours

Streptococcus agalactiae

• Most common cause of meningitis in neonates
• Has been found in pregnant women (asymptomatic)
• Less than half of adult cases had no underlying symptoms

• Found in very young children and older adults
• Crosses placental barrier and causes stillbirth
• Immunocompromised at risk (except HIV)
• Enters through GI tract (coleslaw, raw veggies, milk, cheese)

In Neonates

• E. coli and Klebsiella spp.

Head trauma or Neurosurgery Patients

• Pseudomonas aeruginosa and others
• MDR strains may need intraventricular doses of antibiotics

Empiric Meningitis Therapy: < 1 month

Common Bacteria and Treatment

S. agalactiae

E. coli

Listeria monocytogenes

Klebsiella

Ampicillin

+

Cefotaxime or Aminoglycoside

Empiric Meningitis Therapy: 1-23 months

Common Bacteria and Treatment

S. pneumoniae

Neisseria meningitidis

S. agalactiae

H. influenzae type B

E. coli

Vancomycin

+

Ceftriaxone or Cefotaxime

Empiric Meningitis Therapy: 2-50 yrs

Common Bacteria and Treatment

N. meningitidis

S. pneumoniae

Vancomycin

+

Ceftriaxone or Cefotaxime

Empiric Meningitis Therapy: > 50 yrs

Common Bacteria and Treatment

S. pnuemoniae

N. meningitidis

Listeria monocytogenes

Aerobic G- bacilli

Vancomycin

+

Ampicillin

+

Ceftriaxone or Cefotaxime

Empiric Meningitis Therapy: Basilar Skull Fracture

Common Bacteria and Treatment

S. pneumoniae

H. influenzae

Group A Streptococcus pyogenes

Vancomycin

+

Ceftriaxone or Cefotaxime

Empiric Meningitis Therapy: Penetrating Head Trauma

Common Bacteria and Treatment

Staph. aureus

Coagulase - Staph.

Aerobic G - (including P. aeruginosa)

Vancomycin + Cefepime, Ceftazidime, or Meropenem

Important to cover for MRSA and P. aeruginosa

Empiric Meningitis Therapy: Post-Neurosurgery

Common Bacteria and Treatment

Aerobic G- bacilli

Staph. aureus

Coagulase - Staph.

Vancomycin + Ceftazidime, Cefepime, or Meropenem

Important to cover MRSA and P. aeruginosa

Empiric Meningitis Therapy: CSF Shunt

Common Bacteria and Treatment

Coagulase - Staph.

Staph. aureus

Aerobic G- bacilli

Propionibacterium acnes

Vancomycin + Cefepime, Ceftazidime, or Meropenem

Important to cover MRSA and P. aeruginosa

Targeted Therapy for Meningitis

Streptococcus pneumoniae

Vancomycin

+

3rd Gen Cephalosporin

Targeted Therapy for Meningitis

Neisseria meningitidis

Targeted Therapy for Meningitis

Listeria monocytogenes

Ampicillin

OR

Penicillin G

Consider adding an aminoglycoside to these

Targeted Therapy for Meningitis

Streptococcus agalactiae

Ampicillin

OR

Penicillin G

Consider adding an aminoglycoside to these

Targeted Therapy for Meningitis

Haemophilus influenzae

Targeted Therapy for Meningitis

Escherichia coli

• TMP/SMX
• Rifampin
• Chloramphenicol
• Anti-TB

• Aminoglycosides
• 1st and 2nd Gen Cephalosporins
• Clindamycin
• Most Anti-Fungals (Ampho B, Ketoconazole, Itraconazole)

• 3rd Gen Cephalosporins
• Vancomycin
• Penicillins
• Carbapenems
• Aztreonam
• Fluoroquinolones
• Anti-Virals (Acyclovir, Ganciclovir)
• Fluconazole

1. Hypotension
2. Altered Mental Status
3. Seizures

Length of Therapy: Streptococcus agalaciae

• Inpatient antibiotics for > 6 days
• Afebrile for 24-48 hrs
• No neurologic dysfunction or seizures
• Clinically stable or improving
• Home health nursing access
• Reliable IV access
• Daily availability of physician if needed
• Patient and family compliance
• Safe environment

Infants - haven't completed vaccine series

Elderly - vaccine may be decreasing in effect