Meningitis Orders

meningitis

Diagnostics

  1. Blood culture
  2. CSF and serum bio markers
      *community-acquired meningitis can be reliably diagnosed using CSF lactate >30 mg per dL and CRP >57 mg per dL and reliably excluded using CSF absolute neutrophil count and CSF lactate levels.
      *Serum CRP and procalcitonin highly Sn Sp in differentiating bacterial and viral meningitis
  3. Multiplex-PCR assays and DNA-microassay techniques
  4. Lumbar puncture

**Imaging prior to LP

  • Age >60
  • H/o CNS disease, seizures or immunocompromised state
  • Abnormal neurologic exam
  • *newer data suggests that LP can be performed safely in a large majority of patients with bacterial meningitis

5. EEG?

  • Few data

Capture.JPG

Additional testing on CSF for CNS infection

Test Utility
Cryptococcal antigen High in immunosuppressed patients; recommended in suspected cases
Pneumococcal antigen High; recommended when Gram’s stain/culture not available or when antibiotics have been administered prior to culture. Urinary pneumococcal antigen testing is an alternative when CSF examination cannot be performed
Herpes simplex virus (HSV) PCR High; common, treatable cause of viral meningoencephalitis
West Nile virus (WNV) IgM High in appropriate clinical setting: viral encephalitis, WNV endemic area, appropriate season
HHV-6 PCR High in appropriate clinical setting: viral encephalitis in an immunocompromised host
Cytomegalovirus (CMV) PCR Low; not routinely recommended even in immunocompromised patients
Epstein–Barr virus (EBV) PCR Low; false positives common, not routinely recommended even in immunocompromised patients

When to consider TB or fungal?

  1. high risk patients
  2. presenting with complications that are atypical:
    • CN deficits
    • HCP
    • Brain abscess
    • Hyponatremia from SIADH or CSF

NOSOCOMIAL / POST-SURGICAL MENINGITIS

11-30% of nosocomial meningitis are culture-negative

Risk factors:

  • Experience
  • CSF leaks
  • Concomitant infection at surgical site
  • Duration and type of surgery
  • Situational: tumor surgery, severe head injury, SAH

Etiology

1. Community acquired – Streptococcus pneumoniae, Neisseria meningitidis, Listeria monocytogenes

2. Nosocomial – cutaneous gram-positive (CONS, staph, proprionobacterium acne); GN increasing

**differentiate post-neurosurgical and EVD-related infections

TREATMENT:

1. Start empiric antibiotics within 1h presentation

2. Dexamethasone, if indicated, to be given simultaneously with first dose of antibiotic

3. Discontinue steroids if organism is other than H. Influenza or S. Pneumoniae

4. Treatment of nosocomial meningitis: vancomycin + either antipseudomonal cephalosporin or carbapenem; if beta-lactam allergic, then use FQ or aztreonam

5. Duration based on common practice rather than evidence

      • 21 days for GN
      • 10-14days for GP
      • Consider longer duration if implants or shunts in place

6. Implants or shunts in place – hardware removal and extended treatment recommended; early device removal and reimplantación avoidance associated with shorter illness duration

INTRATHECAL ANTIBIOTICS

  • FDA has not approved any ABx for intrathecal use
  • No consensus exists on indications for intrathecal treatment
  • Consider in the following situations
      1. Severe ventriculitis
      2. Persistente cultures despite appropriate IV dosing
      3. MDR pathogens
      4. Intolerance of systemic antibiotics
      5. Device removal not feasible

Who needs droplet precautions?

References:

O’Horo, J. and Sampathkumar, P. (2017). Infections in Neurocritical Care. Neurocritical Care.

Robinson, C. and Busl, K. (2019). Meningitis and encephalitis management in the ICU. Current Opinion in Critical Care, p.1.

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