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Systemic Neurologic
Septic shock Impaired mental status
ARDS Increased ICP, herniation
DIC Seizures (25%)
Septic or reactive arthritis CN palsies, focal neurologic
Death (25%) deficits
Older age Sensorineural hearing loss
Obtundation at presentation Neurocognitive/intellectual
Seizures within 24 hours impairment
Strep pneumonia
TREATMENT:
GENERAL GUIDELINES
Age 18-50
S. pneumoniae, N. meningitidis; much less likely H. influenzae,
L. monocytogenes, Grp B streptococcus
Ceftriaxone 2 mg IV Q12 hr plus vancomycin 1 gm IV Q12 hr*
Consider adding doxycycline 100 mg IV Q12 hr (RMSF season)
Acyclovir if HSV or VZV suspected
Age >50
S. pneumoniae, N. meningitidis, L. monocytogenes; less often
Grp B streptococcus, H. influenzae, GNR
Above plus ampicillin 2 gm IV Q4 hr
Consider adding doxycycline 100 mg IV Q12 hr (RMSF season)
Acyclovir if HSV or VZV suspected
30-45 mg/kg per day divided every 8-12 hours
TREATMENT:
EMPIRIC THERAPY
Nosocomial meningitis
Coagulase negative staphylococcus, S. aureus, Gram-negative
bacilli, streptococci
Ceftazidime* 2 g IV Q8 hr plus vancomycin 1 gm IV Q12 hr
* Use ceftazidime instead of ceftriaxone for improved coverage of P. aeruginosa
TREATMENT:
PENICILLIN-ALLERGIC PATIENT
Options
Replace ceftriaxone or ceftazidime with meropenem (carbapenem
approved for meningitis) – small risk of cross reactivity
Coverage: MSSA, streptococci, penicillin-susceptible pneumococci,
meningococcus, GNRs, P. aeruginosa
Replace ceftriaxone or ceftazidime with aztreonam (monobactam) –
low risk of cross reactivity (no coverage for pneumococcus)
Coverage: Meningococcus, GNRs, P. aeruginosa
Replace ceftriaxone with chloramphicol (or moxifloxacin)
Coverage chloramphenicol: Streptococci, pneumococci, RMSF,
meningococcus, H. influenzae
DURATION OF THERAPY
Clinical presentation
Meningitis: Viral, bacterial, fungal, mycobacterial
Encephalitis (abnl brain function—motor/sensory, change in
MS, personality, speech/movement): Arboviruses, HSV
Onset
Acute: S. pneumoniae, N. meningitidis
Chronic: Fungal, mycobacterial
Recurrent: S. pneumoniae
Host
Normal
Immunocompromised: HIV, organ transplant, steroids
Aseptic Meningitis
9.00%
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2007 2008
ISOLATION FOR
AIRBORNE/DROPLET DISEASES
Regimen options:
Ciprofloxacin 500 mg PO x 1
Ceftriaxone 250 mg IM x 1 (children, pregnant women)
Rifampin 600 mg PO 2x/day for 2 days (resistance described)
Definition of exposure
Droplet spread disease
Close contact with respiratory secretions (mouth-to-mouth
resuscitation, intubation, nasotracheal suctioning)
IMPACT OF
DELAYED ANTIBIOTIC THERAPY