Meningitis

NURSE

Dharshan.S, MSc.(N),
M.S.R.I.N.E.R
Bangalore
Defined:
…an inflammation of the
arachnoid and pia mater
of the brain and spinal
cord and cerbrospinal
fluid (CSF).

Three Major
Categories:
I.Viral
II.Fungal
III.Bacterial
Incidence of 500 cases per 100,000 people annually

Meningococcal 46 cases per 100,00 people annually

Meningitis 3 cases per 100,000 people annually

Incidence of
meningococcal
meningitis
I. Viral Meningitis
A. The most commonly
encountered form of
meningitis.
B. Sequela to viral
illnesses such as
measles, mumps, herpes
simplex, herpes zoster.
C. Fever, photophobia,
headache, myalgias,
nausea.
D. Treatment is
symptomatic.
 II. Fungal Meningitis
A. Typically seen in
immunosuppressed
individuals, usually HIV
B. Cryptococcus
neoformans is the usual
culprit.

C. Clinical presentation
varies, depending upon
how intact the
individual’s immune
system is. Headache,
nausea, decreased
mental status.
D. Treatment:
Symptomatic; IV
antifungals.

Cryptococcus neoformans
III. Bacterial
Meningitis
A. MEDICAL
EMERGENCY
MORTALITY RATE ~ 25%
USA Cases: ~ 17,500 /
year

B. Strep. pneumoniae
Neisseria
meningitidis

C. Meningococcal
meningitis occurs in
outbreaks: areas of
high population
density.
D. Meningococcal
vaccine (Menomune)
*With Symptoms of Meningitis, always
assume the worst, and treat for
meningococcal meningitis immediately.

*If you wait for the culture results, and they

show / grow meningococcal meningitis or
other bacterial meningitis, it is already too
late!
 PATHOLOGY
• In acute bacterial meningitis, the pia-arachnoid is
congested with polymorphs. A layer of pus forms. This
may organize to form adhesions, causing cranial nerve
palsies and hydrocephalus.
• In chronic infection (e.g. TB), the brain is covered in a
viscous grey-green exudate with numerous meningeal
tubercles. Adhesions are invariable. Cerebral oedema
occurs in any bacterial meningitis.
• In viral meningitis there is a predominantly lymphocytic
inflammatory CSF reaction without pus formation,
polymorphs or adhesions; there is little or no cerebral
oedema unless encephalitis develops.
 CLINICAL FEATURES
The meningitic syndrome
• This is a simple triad: headache, neck stiffness and fever.
• Photophobia and vomiting are often present.
• In acute bacterial infection there is usually intense malaise, fever, rigors,
severe headache, photophobia and vomiting. This develops within hours
or minutes.
• Neck stiffness and positive Kernig's sign usually appear within hours.
• In less severe cases (e.g. many viral meningitides) there are less
prominent meningitic signs, but fatal bacterial infection may also be
indolent, with a deceptively mild onset.
• In uncomplicated meningitis, consciousness remains intact, although
anyone with high fever may be delirious.
• Complications include: cerebral edema, venous sinus thrombosis, brain
abscess , septicemia, DIC and multiorgan failure (MOFS)
Physical Assessment:
Signs of meningeal Irritation / Inflammation: headache,
nausea, vomiting, fever. Photophobia.

Nuchal rigidity.
+ Kernig’s, + Brudzinski’s signs (~ 10%) of cases
Seizures, decreased mental status

Signs of increased intracranial pressure (IICP)

Laboratory /
Diagnostics:
1. Lumbar Puncture:
-CSF for gross appearance,
WBC’s, Glucose, pressure
-Gram stain
-Culture & Sensitivity
2. CBC with Diff
3. Blood cultures
4. CT or MRI
 MANAGEMENT
• Recognition and immediate treatment of acute
bacterial meningitis is vital. Minutes save lives.
Bacterial meningitis is lethal. Even with optimal
care, mortality is around 15%.
• The immediate management of suspected
meningococcal infection is benzylpenicillin 1200 mg
(adult dose) either by slow i.v. injection or
intramuscularly, prior to investigations. Cefotaxime
1 g i.v. is an alternative in cases of penicillin allergy.
In meningitis, minutes count: delay is unacceptable.
 Penicillin
Spectrum: GBS, Listeria, S. pneumoniae,
N. meningitidis

• Class • Contraindications
 Beta lactam  Hypersensitivity to
penicillin
• Dosing • Adverse Events
 400,000  Rash
units/kg/day IV Q4-  Eosinophilia
6h
 Neutropenia
 Max Dose =
 Fever
24 million units/day
 Ampicillin
Spectrum: GBS, S. pneumoniae, Listeria, N.
meningitidis, H. influenzae

• Class • Contraindications
– Penicillin – Hypersensitivity to
penicillin
• Dosing
• Adverse Events
– 400 mg/kg/day IV Q6h
– Injection site pain
– Max Dose = 12 g/day
– Rash
– Adjust in renal
impairment estimate – Urticaria
<10 ml/min/1.73m2 – Diarrhea
– Nausea/vomiting
– Seizure
 Cefotaxime
Spectrum: GBS, E. coli, S. pneumoniae, N.
meningitidis, H. influenzae

• Class • Contraindications
 Cephalosporin  Hypersensitivity to
cephalosporins

• Dosing • Adverse Events

 300 mg/kg/day IV  Injection site pain
Q6h  Rash, pruritus
 Max Dose = 12  Diarrhea, colitis
g/day  Nausea, vomiting
 Ceftriaxone
Spectrum: GBS, E. coli, S.pneumoniae, N.
meningitidis, H. influenzae

• Class • Contraindications
 Cephalosporin  Hypersensitivity to
cephalosporins
 Neonates
• Dosing
• Adverse Events
 100 mg/kg/day IV
q12h-QDay
 Rash
 Diarrhea
 Max Dose = 4 g/day
 Biliary sludging
 Eosinophilia
 Increased LFTs
 Vancomycin
Spectrum: S. pneumoniae

• Class • Contraindications
– Glycopeptide – Hypersensitivity to
vancomycin
• Dosing • Adverse Events
– 60 mg/kg/day IV q6- – Flushing
8h – Pruritis
– Per level, references – Redman’s syndrome
suggest max 4 g/day
– Neutropenia
– Check trough levels to –
determine appropriate Thrombophlebitis
dosing – Nephrotoxicity
• Trough goal – Ototoxicity
15-20 mcg/mL
Nursing Care:
1.Monitor Neurologic Status (“Neuro
Checks”)
**Particular attention to cranial
nerves, especially CN III, IV, VI,& VIII
2. Observing for signs & symptoms of
Increased intracranial pressure
3.Seizure precautions
4.Septic shock & DIC

Medications:
Broad-spectrum antibiotic, changed
to appropriate one after gram-stain
and C&S.
Others symptomatic
Patient Care, Client with Meningitis
-Vital signs at least q2-4 hours.
-Neuro checks, particularly Cranial Nerves,
especially CH III, IV, VI, VII, & VIII
-Pain management
-I&O
-Decrease environmental stimuli
-Bedrest, HOB elevated 30*
-Isolation precautions
-Prevent Complications:
IICP
Vascular dysfunction
F & E Imbalance
Seizures
Shock
 PROPHYLAXIS
• Meningococcal infection should be notified to public health
authorities, and advice sought about immunization and
prophylaxis of contacts, e.g. with rifampicin or ciprofloxacin.
• MenC, a meningococcal C conjugate vaccine, is part of
childhood UK immunization and often given to case
contacts.
• A combined A and C meningococcal vaccine is sometimes
used prior to travel to endemic regions, e.g. Africa, Asia;
and a quadrivalent ACWY vaccine for specific events, e.g.
Hajj and Umrah in Mecca.
• There is no vaccine for Group B. A polyvalent pneumococcal
vaccine is used after recurrent meningitis, e.g. after a CSF
leak following skull fracture.
• Hib (Haemophilus influenzae) vaccine is given routinely in
childhood in the UK, virtually eliminating a common cause
of fatal meningitis.