BACTERIAL MENINGITIS. Gebre K. Tseggay, MD November 21, 2005. MAJOR CHANGES IN EPIDEMIOLOGY OF MENINGITIS SINCE THE 1990’S mainly due to the introduction of Hib vaccine. Dramatic drop in the number of H.influenzae meningitis cases Dramatic drop in the overall number of meningitis cases
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Gebre K. Tseggay, MD
November 21, 2005
(median age was 15 months in 1986, but 25 yrs in 1995)
Percentage of Total Cases
Organism (1978-81) (1985) (1995)
H. Influnezae 48 45 7
N. meningitidis 20 14 25
S. pneumoniae 13 18 47
Strep. agalactiae 3 6 12
Listeria m. 2 3 8
Other 8 14 -
Unknown 6 --
Per 100,000 population%
[Resulted in changes in empiric Rx]
[Resulted in change in recommendation for meningococcal vaccination]
BY PREDISPOSING CONDITION
Immunocompromised state: S. pneumoniae, N. meningitidis, Listeria, aerobic GNR (including Ps.aeruginosa)
Basilar skull fracture: S. pneumoniae, H. influenzae, beta-hemolytic strep group A.
Head trauma or post-neurosurgery: S. aureus, S. epidermidis, aerobic GNR
CSF shunt: S. epidermidis, S. aureus, aerobic GNR, Propionibacterium acnes
(e.g., endocarditis, pneumonia, UTI…)
Brain with inflammatory exudate covering the cortical hemispheres in purulent meningitis.
Cohen & Powderly: Infectious Diseases, 2nd ed., Copyright © 2004 Mosby
Symptom or SignRelative Frequency (%)
Spanos et al. JAMA 1989;262(19):2700-7
to Determine the Bacterial Etiology of Meningitis?
Latex Agglutination (the Practice Guideline Committee does not recommend routine use of this modality):
Does not appear to modify the decision to administer antimicrobial therapy
False-positive results have been reported
Some would recommend it for patients with a negative CSF Gram stain result and may be most useful for the patient who has been pretreated with antimicrobial therapy and whose Gram stain and CSF culture results are negative.
Polymerase Chain Reaction (PCR)
Broad-based PCR may be useful for excluding the diagnosis of bacterial meningitis, with the potential for influencing decisions to initiate or discontinue antimicrobial therapy.
Although PCR techniques appear to be promising for the etiologic diagnosis of bacterial meningitis, further refinements of the available techniques may lead to their use in patients with bacterial meningitis for whom the CSF Gram stain result is negative.
Ped.ID J.1992 11 423-32
Viral meningitis (early phase only)
Some parameningeal foci/ cerebritis
Leakage of brain abscess into ventricle
TB meningitis (rarely, & usu. only early)
Drug –induced ( NSAIDs, Sulfa, INH, IVIG, OKT3…)NEUTROPHILIC PLEOCYTOSIS & LOW CSF GLUCOSEMay Not Always Mean Bacterial Meningitis
. a Ceftriaxoneor cefotaxime.b Some experts wouldadd rifampin if dexamethasoneis also given (B-III).cGatifloxaxinor moxifloxacin.d Addition of anaminoglycoside should be considered.
(based on 248 cases from 4 states, in 1995)
(Nov 14, 2002 issue of NEJM)
Give immediately before or with the 1st dose of antibiotic.
Dexamethasone dose: 0.15 mg/kg q6 x 2-4 days
Jan de Gans, et.al., for the European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators
NEJM 2002. 347:1549-1556. (Nov. 14, 2002)
Use of Adjunctive Dexamethasone Therapy in Adults with Bacterial Meningitis
What Are the Indications for Repeated Lumbar Puncture in Patients with Bacterial Meningitis?
FDA and CDC Issue Alert on Menactra Meningococcal Vaccineand Guillain Barre Syndrome
10-14 day course of antimicrobial therapy should be used, although longer durations may be needed depending on the clinical response.
[Some experts also suggest that consideration be given to a 3-day period off antimicrobial therapy to verify clearing of the infection prior to shunt reimplantation; although this approach is optional, it may not be necessary for all patients].
Transmission by air-droplets, kissing, sharing saliva…
Most common cause of meningitis in children and young adults , with overall mortality rate of 3- 13%.
Causes epidemics in the “meningitis belt.”
Predisposing Factors :
Deficiencies in the terminal complement components (C5-C9)
Crowding (military recruits, college dormitory, Hajj…). Tarvel.
College freshmen in dormitory>>dormitory >> freshman>>college students overall.Neisseria Meningitidis
Risk groupRate per 100,000
Children aged 2-5 years 1.7
Persons aged 18-23 years 1.4
Non-college students aged 18-23 years 1.5
College students 0.6
Dormitory residents 2.2
Freshmen living in dormitories 4.6
Poorest prognosis: >60, seizure `24h, obtunded/coma
NOTE. Thereare no specific datathat define the exactdose of an antimicrobialagent that should beadministered by the intraventricularroute. a Most studies have useda 10-mg or 20-mgdose.b Usual daily dose is1 2 mg for infantsand children and 4 8mg for adults.c The usualdaily intraventricular dose is30 mg.d Dosage in childrenis 2 mg daily.e Dosageof 5 10 mg every48 72 h in onestudy .
What Laboratory Testing May Be Helpful in Distinguishing Bacterial from Viral Meningitis?
JAMA. Vol. 294 No. 16, October 26, 2005