PYOGENIC MENINGITIS

DR .A. APTE (D.M)

CONSULTANT NEUROLOGIST
SURAT
 STRUCTURE OF THE TALK
• 1. WHEN TO SUSPECT THAT PATIENT HAS
PYOGENIC MENICGITIS.
• 2. HOW TO CONFIRM THE SUSPICION
• 3.TREATMENT
• 4.COMPLICATIONS.
• 5.PYOMENINGITIS IN SPECIAL SITUATIONS.
 PRE TEST
• Q1. The commonest cause of community
acquired meningitis is .
• A) Pseudomonas aeroginosa.
• B) Strept pneumoniae.
• C) Staph aureus
• D) H infuenzae.
 PRE TEST
• Q 2 The CSF parameter which most reliably
differentiates bacterial from viral meningitis is
• A) CSF sugar.
• B) CSF protein
• C) CSF cytology
• D) CSF lactate
 PRE TEST
• Q3 .CT scan of brain must precede LP in all
cases of suspected pyogenic meningitis.
• A) Yes
• B) No
 PRE TEST
• Q 4 . The empiric antimicrobial treatment for
suspected pyomeningitis in a adult over 50 years
is
• A) 3rd generation cephalosporin + Vancomycin.
• B) 3rd generation cephalosporin + Vancomycin +
Amipcillin.
• C) 3rd generation cephalosporin + Vancomycin +
Chloremphenicol.
• D) 3rd generation cephalosporin + Vancomycin +
Meropenem
 WHEN TO SUSPECT PYOMENINGITIS
• Typical Clinical Features.
• Symptoms --
• Fever + headache + vomiting
• All of short duration (few hours to 2-3 days)

• Signs ---
• Neck rigidity + altered mental status.
• Median duration of presentation 24 hrs.
• Classic triad –
• Fever + neck rigidity + headache/altered
mental status.
• This triad is present partially or fully in 50- 90
%.
• Various studies quote the following
percentages for the signs/symptoms.
• Fever -- 77 – 85 %
• Headache 79 – 94 %
• Neck stiffness 83 – 94%
• Altered mental 78 – 83%
status ( Out of these coma in 14- 16%)
 Special case scenarios
• If you see skin manifestations as petechiae or
palpable purpura or rash alongwith the triad
of meningitis think of meningococcal
infection.
• In Listeria meningitis patients may present
with rhombencephalitis( ataxia + cranial nerve
palsies &/or nystagmus)
 Neck rigidity signs & their value
• Kernigs sign - inability to fully extend the
knee with the hip at 90 degree flexion.
• Brudzinski sign– spontaneous flexion of hips
during attempted neck flexion.
• These signs have a low sensitivity ( approx
5%) but the specificity is high ( 95%)
• Jolt accentuation of headache – accentuation
of headache by horizontal rotation of head at
a frequency of 2-3/sec.
• Sensitivity - 21- 97%
• Specificity - 43- 82%
 How to Confirm the suspicion of
meningitis.
• Must do test--
• CSF Examination– gold standard.
• Ancillary tests--
• CT Brain
• Blood culture.
 CSF EXAMINATION
• Cell count - increased (1000- 5000/mm3)
Predominantly polymorphs.
• Proteins--- > 200mm%
• Sugar usually < 40mg%
• CSF sugar/Blood sugar <0.4
• Gram stain – will help identify the organism.
• C/S will help in deciding which antibiotic to
use
 CSF Gram Stain
CSF Gram stain
Meningitis Patient
CSF & Blood culture in Blood agar
CSF culture Blood culture
 CSF EXAMINATION

• After antibiotics gram stain becomes negative

in 2hrs in Nisseria infection & in 4-10 hrs in
S.Pneumococci infection

• CSF Lactate – Useful to differentiate between

bacterial and viral meningitis
• Increased in bacterial meningitis(> 31.5mg/dl)
 Points to remember
• Early CSF exam is must .White cell count goes
down if---
- CSF is allowed to stand for hours.
- Allowed to get warm.
- Is launched through a hospital tube system.
 Points to remember
• CSF examination contraindicated if—
-Platelet count < 50,000
-Use of antithrombotic agents other than
aspirin.
-Skin/Spine infection at site of LP.
-Use of anticoagulants & PT-INR > 1.4
 Blood tests
• TLC – Usually raised.
• Blood culture- must be obtained before giving
first shot of antibiotics.
• Blood cultures are positive in 50 – 90% if
blood is taken before giving antibiotics.
• S.Procalcitonin– if > 0.5ng/ml it suggests a
bacterial meningitis rather than viral
meningitis.
 Is CT Brain necessary before LP
IDSA Guidelines for doing CT before LP-
1.Altered mental status
2.Focal neurological deficit.
3.Papilloedema.
4.Seizure within past 1 week.
5.Age > 60 yrs.
6. History of CNS disease.
7.Immunocompromised state.
8.High clinical suspicion of SAH.
Drawback of waiting for CT report
1. Delays the start of antibiotics.
2.Mortality increased by13% for every hour of
delay in starting antibiotic therapy.
3.Swedish guidelines in 2009 have removed
altered mental status as contraindication
for LP .
 TREATMENT.
• Give the first shot of antibiotics empirically.
• 3rd generation cephalosporin + Vancomycin .
• If patient age > 50 add ampicillin to cover
Listeria monocytogenes.
• Also give a shot of Dexamethasone 0.15mg/kg
 If gram stain results available modify
treatment.
Gram stain result Antibiotic

Gram –positive cocci in pairs Vancomycin + 3rd gen cephalosporin

Gram- cocci in pairs 3rd gen cephalosporine

Gram positive bacilli Ampicillin/Crystalline penicillin

Gram – positive cocci in chains Ampicillin/Crystalline penicillin

Gram –negative bacilli 3rd gen cephalosporins

 If gram stain fails to show anything
continue empiric treatment as follows
Age Common bacterial Antibiotic treatment
pathogen

2-50 yrs N.meningitidis,S.pneumoni Vancomycin+ 3rd gen

ae cephalosporin

> 50yrs N.meningitidis,S.pneumoni Vancomycin+ 3rd gen

ae,Listeria,Aerobic GNB cephalosporin + Ampicillin
 Drugs & Doses
Drug Dose in adults
Amikacin 5 mg/kg every 8 hrs.
Ampicillin 2 gm every 4 hrs
Cefepime 2 gm every 8 hrs.
Cefotaxime 2 gm every 4 to 6 hrs.
Ceftazidime 2 gm every 8 hrs.
Ceftriaxone 2 gm every 12 hrs.
Chloramphenicol 1 to 1.5 gm every 6 hrs.
Meropenem 2 gm every 8 hrs.
Penicillin G potassium 4 million units every 4 hrs.
Vancomycin 15 to 20 mg/kg 8 to 12 hrs.
Treatment based on isolated pathogen
Microorganism Standard treatment
S.pneumoniae 3rd gen cepalosporin + vancomycin
N.meningitidis 3rd gen cepalosporin
Listeria monocytogenes Ampicillin
Grp B streptococcus Ampicillin + gentamycin
E .coli & other enterobacteriacae 3rd gen cepalosporin + Meropenem

Pseudomonas aeruginosa Ceftazidime/ Cefipime

Acinetobacter baumanni Meropemen
H.influenzae Ampicillin /3rd gen cephalosporin
Staph aureus Vancomycin
Staph epidermidis Vancomycin
Enterococcus species Vancomycin + gentamycin +/- linezolid
 Duration of Antimicrobial treatment
• Minimally 7-10 days.
• After temperature disappears ,the therapy
should be continued for 5 days.
• 7 DAYS– N.menigitidis, H.Infuenzae
• 14 days– S.pneumoniae, group B
streptococci,Staph aureus
• 21 days– Listeria,Pseudomonas,Acinetobacter
and other gram negative intestinal cocci.
 Role of Steroids.
• Dexamethasone iv 0.15 mg/kg 6 hrly for 4
days.
• Should be given 15-20 min prior or with the
dose of antibiotic.
• Found to decrease hearing loss , focal
neurological deficits & mortality.
 Supportive care
• Control of cerebral edema and raised ICP –
- elevation of head end by 30%
-Hyperventilation
- Mannitol
• Management of fluids and electrolyte balance.
• Prevention of DVT.
 Any Role of repeat CSF Analysis
• Not routinely recommended.
• Repeat CSF analysis done if—
1. No evidence of improvement in 48 hrs of
starting treatment.
2.Persistent fever for > 8 days without any
other explaination.
3. Healthcare associated infections( post
EVD/post neurosurgery) caused by gram
negative bacteria
Neurologic Complications of Pyogenic
Meningitis
1. Impaired mental status.
2.Increased intracranial pressure and cerebral
edema.
3.Seizures in 15- 30%
4.Focal neurologic deficits in 20 – 50%
– (hemiparesis/cranial nerve palsies)
Neurologic Complications of Pyogenic
Meningitis
5.Cerebrovascular complications like
thrombosis, vasculitis,acute intracerebral
bleeds,mycotic aneurysms.
6.Sensorineural hearing loss – 12-14% , more
common wit pnemococcal meningitis.
7.Intellectual impairement.
8 Unusual complications like subdural
empyema,brain abcess,myelitis,ventriculitis.
 Systemic Complications of Pyogenic
Meningitis
1.Septic shock
2. DIC
3.ARDS
4.Septic or reactive arthritis.
 Prognosis
• Three baseline clinical features independently
associated with adverse outcome are
1.Hypotension
2.Altered mental status
3.Seizures
 Prognosis
• Mortality is more in
1. elderly (> 65 yrs)
2. Healthcare associated meningitis(post
neurosurgery)
3.Pneumococcal menigitis comapred to
meningococcal meningitis( 30% vs 7%)
 Pyogenic Meningitis in special
situations
Predisposing factor Common bacterial Antimicrobial therapy
pathogen
Basilar skull fracture S.pnemoniae,H.infuenzae, Vancomycin + 3rd
group A beta- hemolytic generation cepalosporin
streptococci
Post Lumbar Staph aureus,Staph Vancomycin +
puncture/penetrating epidermidis, aerobic GNB Meropenem/ceftazidime/
trauma including Pseudomonas cefipime
aeroginosa
 Pyogenic Meningitis in special
situations
Predisposing factor Common bacterial Antimicrobial therapy
pathogen
Post neurosurgey Staph aureus,Staph Vancomycin +
epidermidis, aerobic GNB Meropenem/ceftazidime/
including Pseudomonas cefipime
aeroginosa Intrathecal colistin rarely
Acenitobacter baumanni

Immunocompromised S.pneumoniae,N.meningiti Vancomycin + ampicillin

state dis,L.monocytogenes,aerob +cefipime
ic GNB including OR
psedomonas aeroginosa Vancomycin + ampicillin +
meropenem
 POST TEST
• Q1. The commonest cause of community
acquired meningitis is .
A) Pseudomonas aeuroginosa.
B) Strept pneumoniae.
C) Staph aureus
D) H influenzae.
 POST TEST
• Q 2 The CSF parameter which most reliably
differentiates bacterial from viral meningitis is
• A) CSF sugar.
• B) CSF protein
• C) CSF cytology
• D) CSF lactate
 POST TEST
• Q3 .CT scan of brain must precede LP in all
cases of suspected pyogenic meningitis.
• A) Yes
• B) No
 POST TEST
• Q 4 . The empiric antimicrobial treatment for
suspected pyomeningitis in a adult over 50 years
is
• A) 3rd generation cephalosporin + Vancomycin.
• B) 3rd generation cephalosporin + Vancomycin +
Amipcillin.
• C) 3rd generation cephalosporin + Vancomycin +
Chloremphenicol.
• D) 3rd generation cephalosporin + Vancomycin +
Meropenem
 TAKE HOME MESSAGE
1.The most common organisms that cause
community acquired meningitis are
S.pneumoniae & N.meningitidis.
2.Listeria should be suspected in age > 50 yrs
and in compromised cell mediated immunity.
3.Symptoms and signs are not sensitive or
specific enough for diagnosis.
 TAKE HOME MESSAGE
4. CSF analysis should be performed ASAP.
5. CT head is not necessary in all patients.
6. Try to obtain samples for blood cultures and
CSF cultures before starting antimicrobial
therapy BUT DO NOT DELAY therapy if
obtaining them is not feasible.
7. START EMPIRIC TREATMENT IMMEDIATELY &
later modify it according to gram stain/culture
results
THANK YOU