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Fast review of CNS Infections

Fast review of CNS Infections. Husain Alawadhi Consultant intensivist, pulmonologist and Infectious disease. Guideline in Progress :summer 2008. "The Management of Encephalitis:  Clinical Practice Guidelines by the Infectious Diseases Society of America“ Coming soon. ACUTE CNS INFECTIONS.

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Fast review of CNS Infections

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  1. Fast review of CNS Infections Husain Alawadhi Consultant intensivist, pulmonologist and Infectious disease.

  2. Guideline in Progress :summer 2008 • "The Management of Encephalitis:  Clinical Practice Guidelines by the Infectious Diseases Society of America“ • Coming soon

  3. ACUTE CNS INFECTIONS 1. Bacterial meningitis 2. Meningoencephalitis 3. Brain abscess 4. Subdural empyema 5. Epidural abscess 6. Septic venous sinus thrombophlebitis

  4. Etiology • Pathogenesis • Microbiology • Diagnosis • Treatment • Complication • Prevention

  5. ETILOGY

  6. Mucrobiology by age

  7. Figure 24-8

  8. Bacterial MeningitisImportant Changes in Epidemiology • Marked decline in the occurrence of Hib • ↑’ing incidence of S. pneumo (50+% of cases in US) • Shift from peds disease to adult disease • ↑’ing incidence of ATB-resistant organisms, esp. S. pneumo • PCN resistance ~ 35% (15-20% high level) • Ceph resistance 15-20% (5-10% high level)

  9. Risk Factors for Drug-Resistant S. pneumoniae (DRSP) • Extremes of age • Recent ATB Rx • Significant comorbid disease • HIV infection or other immunodeficiency • Day care or day care parent/sib • Recent hospitalization • Congregate settings (Institutions, military)

  10. Enteroviruses Polioviruses Coxsackieviruses Echoviruses Togaviruses Eastern equine Western equine Venezuelan equine St. Louis Powasson California West Nile Herpesviruses Herpes simplex Varicella-zoster Epstein Barr Cytomegalovirus Myxo/paramyxoviruses Influenza/parainfluenzae Mumps Measles Miscellaneous Adenoviruses LCM Rabies HIV VIRAL MENINGITIS/ENCEPHALITIS

  11. Rare parsitic meningitis • The most important are in the genera Naegleria and Acanthamoeba. Naegleria fowleri, the main protozoan causing primary amebic meningoencephalitis in humans, has been recovered from lakes, puddles, pools, ponds, rivers, sewage waters.

  12. DIAGNOSIS

  13. CSF: Some Catches • Protein least specific • TB: early neutrophilic predominance • Encephalitis, RMSF, tick-borne illnesses: inc CSF WBC • Listeria: misread as “contamination”/diphtheroids • Listeria: bacterial meningitis that can have significant encephalitis and abscess, and CSF with lymphocytes! • RBCs that do not clear: SAH or HSV

  14. CSF: More Pearls • Correction factors for traumatic tap • “trauma” and RBCs increase protein and with an increase in RBCs come an increase in WBCs • True CSF protein = subtract 1 mg/dL protein for every 1000 RBC/mm3 • True WBC in CSF: actual WBC in CSF – (WBC in blood x RBC in CSF)/ RBC in blood

  15. Contraindications to LP Absolute: Skin infection over site Papilledema, focal neuro signs, ↓MS Relative: Increased ICP without papilledema Suspicion of mass lesion Spinal cord tumor Spinal epidural abscess Bleeding diathesis or ↓ plts

  16. CSF pressure Normal opening pressure in adults is 90~180mmH2O, 10~100mmH2O in children. Elevated in : Congestive heart failure Meningitis Superior vena cava syndrome Cerebral edema Mass lesion Decreased In Spinal-subarachnoid block Dehydration Circulatory collapse CSF leakage

  17. Diagnostic Accuracy of Signs of Meningeal Irritation in Pts with Suspected Meningitis SignSensSpecPPVNPV+LR-LR Nuchal 30% 68% 26% 73% 0.94 1.02 rigidity Kernig’s 5% 95% 27% 72% 0.97 1.0 Brudzin- 5% 95% 27% 72% 0.97 1.0 ski’s Thomas KE et al, CID 2002, 35:46-52

  18. CSF Findings

  19. CSF SMEARS & STAINS • GmS + in 60-90% of pts with untreated bacterial meningitis • With prior ATB Rx, positivity of GmS decreases to 40-60% • REMEMBER: + GmS = Heavy organism burden & worse prognosis

  20. CCT Before LP in Patients with Suspected Meningitis • 301 pts with suspected meningitis; 235 (78%) had CCT prior to LP • CCT abnormal in 56/235 (24%); 11 pts (5%) had evidence of mass effect • Features associated with abnl CCT were age >60, immunocompromise, H/O CNS dz, H/O seizure w/in 7d, & selected neuro abnls Hasbun, NEJM 2001;345:1727

  21. Guidelines : Do CT before LP in the following cases • Any immunocompromised patient. • New Convulsion • Papillodema • Any previous CNS pathology • Abnormal Lovel of consciousness • Focal neurological deficits • Age > 65

  22. BACTERIAL VS VIRAL MENINGITIS Predictors of bacterial etiology: • CSF glucose < 40 • CSF protein > 60 • CSF neutrophil count > 80% • CSF WBC count > 100 • CSF: Serum glucose ratio < 0.23 [Presence of any ONE of the above findings predicts bacterial etiology with > 75% certainty]

  23. BACTERIAL VS VIRAL MENINGITIS Predictors of bacterial etiology: • CSF glucose < 34 • CSF: Serum glucose ratio < 0.23 • CSF protein > 220 • CSF WBC count > 2000 • CSF neutrophil count > 1180 [Presence of any ONE of the above findings predicts bacterial etiology with > 99% certainty]

  24. Strep Pneumoniae Meningitis • Now most common cause (H flu rare) • 30-50% cases of bacterial meningitis in elderly • Otitis 30%, sinusitis 8%, pneumonia 18% • Elderly more often have pneumonia (bad) • Bad markers: older age, low platelets, dec CSF glucose, no otogenic focus • Vaccination: recommended in all over age 65 • Efficacy in elderly/immunocompromised NOT clear • Decrease bacteremia/meningitis

  25. Listeria • Food-borne outbreaks • Herd animals • Common, likely cause of mild GI illnesses • Invasive disease with bacteremia • Increased risk with depressed cellular immunity: pregnant women, elderly, AIDS, lymphoma, steroid use, transplant patients Small, anaerobic gm + baccillus • Look like diphtheroids, contaminants Diphtheroids in CSF: listeria unless proven otherwise • Cerebritis, brain abscess • Confusion, altered LOC, seizure, movement • Mortality 22% in older patients with CNS dz • 20% of all cases of bacterial meningitis in patients over age 60 • Brain abscess: 10% CNS infections • Concomitant meningitis in 25-40% (rare with other causes of brain abscess

  26. ER management of meningitis

  27. TREATMENT

  28. Empirical threapy

  29. Specific therapy

  30. Systematic review Age> 16 At least 1 fatality Jadad Scale Randomization 0-2 Double Blinding 01 Withdrawls/Dropouts 0-1 kkfsfa Outcomes Mortality Neurological deficits Organism S.Pneumo N. Meningitidis Other Adverse Events Review: Van Der Beek et al, Lancet March 2004 Conclusion: Steroid therapy in all pt’s with suspected bacterial meningitis Benefit in studies reviewed are seen when dexamethasone is started with or soon after antibiotics

  31. NEJM, 2006;354, 44-53

  32. NEJM, 2006;354, 44-53

  33. BACTERIAL MENINGITISDuration of ATB Rx Pathogen Duration of Rx (d) H. influenzae 7 N. meningitidis 7 S. pneumoniae 10-14 L. monocytogenes 14-21 Group B strep 14-21 GNRs 21 NEJM 1997;336:708

  34. THE PATIENT WITH SUSPECTED CNS INFECTIONRole of Repetitive LP’s 1. Rarely indicated in proven bacterial meningitis unless clinical response not optimal or as expected, fever recurs, or infection is due to ATB resistant pathogen 2. Essential in pts with “aseptic meningitis” syndromes to monitor course &/or response to empiric therapies 3. Essential in pts with subacute/chronic meningitis of proven etiology to assess response to Rx 4. Not routinely indicated at end-of-therapy for bacterial meningitis

  35. 後記 • The available evidence supports the use of adjunctive dexamethasone in infants and children with H. influenzae type b meningitis. ( 0.15 mg/kg every 6 h for 2-4 days) • Dexamethasone in adults with the adjunctive dexamethasone be administered to all adult patients with suspected or proven pneumococcal meningitis. ( 0.15 mg/kg every 6 h for 2-4 days)

  36. Rocephin (ceftriaxone sodium) for Injection Potential risk associated with concomitant use of Rocephin with calcium or calcium-containing solutions or products Cases of fatal reactions with calcium-ceftriaxone precipitates in the lungs and kidneys in both term and premature neonates were reported. FDA warning 9/11/2007

  37. COMPLICATIONS

  38. Extradural Abscess • Extradural abscess, • associated with osteomyelitis, • complication of sinusitis or a surgical procedure. • When the process occurs in the spinal epidural space, it may cause spinal cord compression and constitute a neurosurgical emergency.

  39. subdural empyema. • fungal infection of the skull bones or air sinuses can spread to the subdural space • subdural empyema may produce a mass effect. • thrombophlebitis may develop in the bridging veins that cross the subdural space, resulting in venous occlusion and infarction of the brain.

  40. CLINICAL MANIFESTATIONS • SPINAL EPIDURAL ABSCESS • Four clinical stages have been described: • Fever and focal back pain; • Nerve root compression with nerve root pain; “shooting pain” • Spinal cord compression with accompanying deficits in motor/sensory nerves, bowel/bladder sphincter function; • Paralysis (respiratory compromise may also be present if the cervical cord is involved). • Armstrong, ID, Mosby inc,2000

  41. PREVENTION

  42. Meningitis- Prevention • Chemoprophylaxis for close contacts of index case if Neisseria; treat contacts less than 4 years of age if H. flu • Vaccinate all children, especially those at risk or those with asplenia • H. flu • S. pneumo- 7 valent up to 2 years, then 23 valent vaccine • Neisseria- quadrivalent vaccine (A, C, Y, W-135) for high risk patients (asplenia, college age, military) over 2 years of age • Does not cover group B, which causes close to ½ of cases in US

  43. Ventricular shunt infections

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