Meningitis

Signs and Symptoms:

• Brudzinski sign and Kernig Sign
• Fever, altered mental status, neck, stiffness, seizures, neurological deficits

Treatment:

• <1-month-old – ampicillin (listeria coverage) and cefotaxime or gent
  Common pathogens: Group B Strep, E. coli, K. pneumoniae, Enterobacter, Listeria monocytogenes
• 1-23 months old – vancomycin and ceftriaxone or cefotaxime
  Common pathogens: S. pneumoniae, N. meningitidis, H. influenzae
• 18-50 years –  vancomycin and ceftriaxone or cefotaxime
  Common pathogens: S. pneumoniae, N. meningitidis
• 50+ or any age with predisposing conditions – vancomycin and ceftriaxone or cefotaxime + ampicillin
  Common pathogens:  S. pneumoniae, N. meningitidis, H. influenzae, Listeria monocytogenes
• Cover pseudomonas in penetrating trauma, post-surgical and shunts: vancomycin and cefepime or meropenam
• Dexamethasone: If used, administer the first dose within 10-20 minutes before or concomitant with first antimicrobial dose. Only continue if S. pneumonia, decreases complicaitions in peds especially.Who gets prophylaxis:
• If H. influenzae or N. meningitidis, household contacts and direct contacts should get prophylaxis.
  • N. meningitidis
    • Rifampin 5-10 BID for 2 days in kids
    • Rifampin 600 mg BID for 2 days in adults
    • Ceftriaxone 125 mg IM times 1 < 15 years old
    • Ceftriaxone 250 mg IM times 1 >15 years old
    • Ciprofloxacin 20 mg/kg up to 500 mg times 1
  • H. influenzae
    • Rifampin 20 mg/kg per dose up to 600 mg times 4 days

Bactrim can replace ampicillin in penicillin allergy

Must Know:

***Remember always treat for S. pneumoniae, N. meningitidis, vanc, except in newborns + a cephalosporin), listeria for the old and young (ampicillin)***

	Normal CSF	Syphilis*	Bacterial	Viral
Does it Gram’s stain	No	Maybe	Yes	No
WBC (cells/mm3)	<5	>20	>1000	<100
Neutrophils	All monos	All monos	>80%	1-50%
Glucose (mg/dL)	>40	<40*	<40	>40
CSF:Serum Glucose	>0.4	<0.4	<0.4	>0.4
Protein (mg/dL)	<50	>50	>200	>50

Age	Antimicrobial Therapy
< 1 month	Ampicillin 300 to 400 mg/kg/day IV or IM divided every 4 to 6 hours + gentamicin or tobramycin
1-23 months	Vancomycin + Ceftriaxone 100 mg/kg/day IV divided every 12 to 24 hours
2-50 years	Vancomycin + Ceftriaxone 2g IV every 12h
> 50 years	Vancomycin + Ceftriaxone 2g IV every 12h   +  Ampicillin 2g IV every 4h

Cover pseudomonas in penetrating trauma, post-surgical and shunts: use vancomycin and cefepime 2 g IV every 8 hours or meropenem 2 g IV every 8 hours

If dexamethasone used, administer the first dose within 10-20 minutes before or concomitant with first antimicrobial dose.  

Prophylaxis:

If H. influenzae or N. meningitidis are cultured, household contacts and direct contacts should get prophylaxis.

N. meningitidis

• Rifampin 5-10 BID for 2 days in kids
• Rifampin 600 mg BID for 2 days in adults
• Ceftriaxone 125 mg IM times 1 < 15 years old
• Ceftriaxone 250 mg IM times 1 >15 years old
• Ciprofloxacin 20 mg/kg up to 500 mg times 1

H. influenzae

• Rifampin 20 mg/kg per dose up to 600 mg times 4 days

Factors affecting drug entry into the CSF: