History

Fact Explanation
Introduction Meninges are the lining that covers the brain and spinal cord. Meningitis is inflammation of the meninges around the brain and spinal cord. It is usually caused by an infectious pathogens such as bacteria, virus, fungi and parasites. Depending on the duration of the symptoms, it can be subdivided into acute and chronic form. Bacterial meningitis is a medical emergency requiring immediate treatment. Streptococcus pneumoniae is the most commonest causative pathogens for bacterial meningitis. [1] Among bacterial causes of meningitis and is associated with the highest case-fatality rate in meningitis. [4] It and is most commonest bacteria causing the permanent sequelae in the affected person. [4]
Headache Once the organism entered through the blood brain barrier, immune system of the body gets activated to release various cytokines and chemokines with infiltration of granulocytes. [2] Further it releases reactive oxygen radicals to cause more endothelial and nearby tissue damage. These can cause meningeal irritation, increased intracranial damage and cerebral edema. [5]
Fever [1] TNF-α, IL-1β, and IL-6 are released during the inflammatory response, triggering a series of other inflammatory mediators including pro- and anti-inflammatory cytokines, chemokines, reactive oxygen species and reactive nitrogen intermediates. [7] Inflammation of the meninges and endothelium releases pyrogens causing fever. [1]
Vomiting Vomiting is a common finding in the meningitis. [6] Vomiting is the actual oral expulsion of gastrointestinal contents, due to the contractions of the gut and the thoracoabdominal wall musculature. [8] Vomiting center is activated directly by irritants/toxic substances by the organism or indirectly by the stimuli from the cerebral cortex and thalamus, vestibular region, and chemoreceptor trigger zone (CRTZ) [8] and due to the inflammatory response triggering the part of the brain which is in contact with blood. Also it can be due to the increased ICP and meningeal stretching.
Sensitivity to light (photophobia) Inability to tolerate light is due to the meningism that indicates inflammatory activation of the trigeminal sensory nerve fibers in the meninges. [1]
Pain during retraction of the neck [1] Due to the meningeal irritation. [1]
Seizures [1,6] Altered cerebral perfusion pressure can cause reduction of the cerebral blood flow and ischaemia. [1]
Decreased alertness and drowsiness [1] There can be increased intracranial pressure which may be due to the increased blood brain barrier permeability, swelling of the cellular elements of the brain, [2] interstitial edema results from obstruction of flow in normal CSF pathways etc. Neuronal cell death and cerebral edema may also contribute to the drowsiness. [1]
Excessive crying, refusing the feeds Infants and young children present with nonspecific features. [6]
Hearing loss Inflammation can extends to the cranial nerves, [2] when the 8th nerve is involved that causes sensorineural type hearing loss. [5]
Visual problems Visual problems Involvement of the optic and other cranial nerves related to the vision can be the cause. [6]
History of immunodeficiency People with immune deficiency [8] like malignancy, chemotherapy, long term steroid use, organ transplant and HIV AIDS are particularly vulnerable for the disease. [3]
References
  1. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  2. TäUBER MG, KENNEDY SL, TUREEN JH, LOWENSTEIN DH. Experimental pneumococcal meningitis causes central nervous system pathology without inducing the 72-kd heat shock protein. Am J Pathol [online] 1992 Jul, 141(1):53-60 [viewed 21 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1886581
  3. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08
  4. GOUVEIA EDILANE L, REIS JOICE N, FLANNERY BRENDAN, CORDEIRO SORAIA M, LIMA JOSILENE BT, PINHEIRO RICARDO M, SALGADO KáTIA, MASCARENHAS ANA, CARVALHO M GLORIA, BEALL BERNARD W, REIS MITERMAYER G, KO ALBERT I. Clinical outcome of pneumococcal meningitis during the emergence of pencillin-resistant Streptococcus pneumoniae: an observational study. Array [online] 2011 December [viewed 21 October 2014] Available from: doi:10.1186/1471-2334-11-323
  5. LEE GT, CHIU CY, HALLER BL, DENN PM, HALL CS, GERBERDING JL. Streptococcus suis Meningitis, United States Emerg Infect Dis [online] 2008 Jan, 14(1):183-185 [viewed 23 September 2014] Available from: doi:10.3201/eid1401.070930
  6. LARDHI AMER A. Neonatal group A streptococcal meningitis: a case report and review of the literature. Array [online] 2008 December [viewed 23 September 2014] Available from: doi:10.1186/1757-1626-1-108
  7. CARROL ED, BAINES P. Elevated cytokines in pneumococcal meningitis: Chicken or egg? Crit Care Med [online] 2005 May, 33(5):1153-1154 [viewed 21 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1343527
  8. BECKER DE. Nausea, Vomiting, and Hiccups: A Review of Mechanisms and Treatment Anesth Prog [online] 2010, 57(4):150-157 [viewed 23 October 2014] Available from: doi:10.2344/0003-3006-57.4.150

Examination

Fact Explanation
Febrile Fever is one of the most common presenting features. This is due to the infection. [1]
Stiff neck Nuchal rigidity is present due to the meningeal irritation. [1]
Kernig sign [1] This is a bedside diagnostic sign used to evaluate suspected cases of meningitis. Patient is kept in supine position, hip and knee are flexed, the knee is slowly extended by the examiner. It is positive if there is a resistance or pain during extension. [2]
Brudzinki sign Another sign of meningeal irritation.[1] First one hand is kept behind the patient's head and the other on chest in order to prevent the patient from rising, passive flexion of the neck produces reflex flexion of the patient's hips and knees in a positive Brudzinski's sign. [2]
Tachycardia and hypotension Fast heart rate is observed in hypotensive, confused patients. [1]
Mental status changes Alteration in mental status is a poor prognostic indicator. [3]
Focal neurological signs Subdural effusion or cerebral-space-occupying lesions such as abscess formation can cause these symptoms. [4] Abscees may be due to perivascular extension of the lesions and are infrequent. [8] Pneumococcal meningitis may progress to an extensive suppurative myelitis causing focal signs. [8]
Growth retardation and cognitive impairment Ischaemia can cause neuronal cell death and tissue damage, if the developing brain is affected child may ends up with poor growth. Cognitive impairment is most prominent after pneumococcal meningitis. [4]
Sensorineural hearing loss Cranial nerve palsies specially VIII the nerve palsy is the cause for this hearing loss. [1]
Papilloedema This is due to the increased intracranial pressure. [7] Increased blood brain barrier permeability, swelling of the cellular elements of the brain, interstitial edema results from obstruction of flow in normal CSF pathways as in hydrocephalus are the possible causes for the raised intracranial pressure. [5]
Hydrocephalus There can be involvement of the ventricles causing ventriculitis. [2,6] Inflamed areas are gradually fibrosed with creating an obstruction to the cerebrospinal fluid outflow, leading to hydrocephalus.
Ear discharge/ inflammed pharynx Group a beta-hemolytic streptococci are a common cause of pharyngitis/ upper respiratory tract infections. [1]
Skin sepsis Group a beta-hemolytic streptococci are also responsible for the soft tissue infection. [1]
Hyperventilation There is ncreased lactic acid in cerebrospinal fluid (CSF) in patients with meningitis which can result in increased ventilation and respiratory alkalosis. This will increase with the duration of the disease. [7]
References
  1. PATTULLO AL, BOW EJ. A case of group A streptococcal meningitis in an adult Can J Infect Dis [online] 1993, 4(4):223-226 [viewed 23 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250794
  2. MEHNDIRATTA M, NAYAK R, GARG H, KUMAR M, PANDEY S. Appraisal of Kernig's and Brudzinski's sign in meningitis Ann Indian Acad Neurol [online] 2012, 15(4):287-288 [viewed 11 August 2014] Available from: doi:10.4103/0972-2327.104337
  3. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08
  4. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  5. LO S, PHILLIPS DI, PETERS JR, HALL M, HALL R. Papilloedema and cranial nerve palsies complicating apparent benign aseptic meningitis. J R Soc Med [online] 1991 Apr, 84(4):201-202 [viewed 23 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293181
  6. TäUBER MG, KENNEDY SL, TUREEN JH, LOWENSTEIN DH. Experimental pneumococcal meningitis causes central nervous system pathology without inducing the 72-kd heat shock protein. Am J Pathol [online] 1992 Jul, 141(1):53-60 [viewed 21 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1886581
  7. SEARS MR, O'DONOGHUE JM, FISHER HK, BEATY HN. Effect of Experimental Pneumococcal Meningitis on Respiration and Circulation in the Rabbit J Clin Invest [online] 1974 Jul, 54(1):18-23 [viewed 21 October 2014] Available from: doi:10.1172/JCI107740
  8. STEWART FW. LOCAL SPECIFIC THERAPY OF EXPERIMENTAL PNEUMOCOCCAL MENINGITIS : III. INCIDENTAL MYELITIS, ABSCESS, AND ORGANIZATION OF EXUDATES. J Exp Med [online] 1928 Jan 1, 47(1):1-7 [viewed 21 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2131346

Differential Diagnoses

Fact Explanation
Meningitis due to other infectious causes Neisseria meningitidis and Haemophilus influenzae are the most common causative pathogens for bacterial meningitis. [4] Organisms may differ according to the age of the patient. Eg:- During neonatal period-E.coli, gram negative bacilli, Listeria monocytogens and Group B streptococci, children older than 3 months-Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae, children between 1-3 months with the organisms from both above mentioned groups. [5]
Chronic meningitis Chronic meningitis is different from acute meningitis as it is an uncommon disease with a gradual onset over 2 weeks or more. Fungal infections are the common cause for chronic meningitis. Cryptococcal meningitis is one of the commonest fungal form of the disease.Cryptococcus neoformans is an encapsulated yeast causingopportunistic life-threatening infections, particularly in immuno-compromised patients. [6]
Encephalitis Encephalitis [1] is an acute, usually diffuse, inflammatory process of the brain. About 90% of cases are associated with herpes simplex virus (HSV-1). [3] They also present with the fever, headache, and clouding of consciousness which may be associated with seizures and focal neurology in some patients. Encephalitis associated with meningitis. Meningoencephalitis may give the same picture as in meningitis making diagnosis difficult. [2]
Encephalopathy due to non infectious causes Same clinical features of encephalitis presents with a history of anoxic/ischaemic damage, nutritional deficiency, alcoholism, critical illness, malignant hypertension, traumatic brain injury or epileptic (non-convulsive status). [2] Fever, headache like features are uncommon in encephalopathy than in encephalitis/ meningitis. Depressed mental status is steadily deteriorating in encephalopathy rather than that may be fluctuating in encephalitis/ meningitis. Focal neurological signs are uncommon in encephalopathy. Types of seizures are usually generalized.
References
  1. JAKKA S, VEENA S, ATMAKURI R, EISENHUT M. Characteristic abnormalities in cerebrospinal fluid biochemistry in children with cerebral malaria compared to viral encephalitis Cerebrospinal Fluid Res [online] :8 [viewed 16 August 2014] Available from: doi:10.1186/1743-8454-3-8
  2. KENNEDY P. VIRAL ENCEPHALITIS: CAUSES, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT J Neurol Neurosurg Psychiatry [online] 2004 Mar, 75(Suppl 1):i10-i15 [viewed 11 August 2014] Available from: doi:10.1136/jnnp.2003.034280
  3. BANATVALA JANGU E. Herpes simplex encephalitis. The Lancet Infectious Diseases [online] 2011 February, 11(2):80-81 [viewed 21 October 2014] Available from: doi:10.1016/S1473-3099(11)70012-3
  4. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  5. KLEIN NJ, HEYDERMAN RS, LEVIN M. Antibiotic choices for meningitis beyond the neonatal period. Arch Dis Child [online] 1992 Feb, 67(2):157-159 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1793401
  6. LEE CH, CHANG TY, LIU JW, CHEN FJ, CHIEN CC, TANG YF, LU CH. Correlation of anti-fungal susceptibility with clinical outcomes in patients with cryptococcal meningitis BMC Infect Dis [online] :361 [viewed 11 August 2014] Available from: doi:10.1186/1471-2334-12-361

Investigations - for Diagnosis

Fact Explanation
Lumbar puncture Opening pressure will be elevated in meningitis. Regarding the protein content in the CSF, in bacterial meningitis there is markedly elevated protein (< 1 g/l), where as in other types that may be less prominent. CSF glucose level is decreased. [2] Markedly elevated white blood cell count with predominant neutrophils is seen in pneumococcal meningitis. [1] Bacterial antigen detection in the CSF for Streptococcus pneumoniae will be positive. [2]
Blood culture [1] Is done if the patient seems to be septic or lumbar puncture can not be done safely due to the possibility of increased intracranial pressure before the antibiotics. [4] Blood culture will isolate gram-positive cocci in pairs and chains. [3]
Full blood count There can be elevated leucocytes in the blood. [2]
Gram stain of the ear discharge Ear discharge analysis will show a small amount of pus cells and large numbers of Gram-positive cocci. [2]
Computer tomography(CT) scan of the head and Magnetic Resonance Imaging(MRI) CT scan will be even better as the first investigation specially to rule out the possibility of increased intracranial pressure before doing lumbar puncture. MRI will demonstrate the inflammatory dural meningeal process with enhanced uptake over the affected areas. This also show the intracranial complications such as brain edema, hydrocephalus and infarcts. [4]
Erythrocyte sedimentation rate(ESR) and C Reactive protein(CRP) Is elevated due to the inflammation. [4]
Random blood sugar Should be done immediately especially if the patient is drowsy, to rule out the hypoglycaemia. [5]
Chest x-ray Plain chest radiography will show homogenous opacity in the affected area compatible with consolidation that occurs in bacterial pneumonia. [6]
References
  1. TäUBER MG, KENNEDY SL, TUREEN JH, LOWENSTEIN DH. Experimental pneumococcal meningitis causes central nervous system pathology without inducing the 72-kd heat shock protein. Am J Pathol [online] 1992 Jul, 141(1):53-60 [viewed 21 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1886581
  2. PATTULLO AL, BOW EJ. A case of group A streptococcal meningitis in an adult Can J Infect Dis [online] 1993, 4(4):223-226 [viewed 23 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250794
  3. LEE GT, CHIU CY, HALLER BL, DENN PM, HALL CS, GERBERDING JL. Streptococcus suis Meningitis, United States Emerg Infect Dis [online] 2008 Jan, 14(1):183-185 [viewed 23 September 2014] Available from: doi:10.3201/eid1401.070930
  4. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  5. BRACKENRIDGE A, WALLBANK H, LAWRENSON RA, RUSSELL‐JONES D. Emergency management of diabetes and hypoglycaemia Emerg Med J [online] 2006 Mar, 23(3):183-185 [viewed 18 September 2014] Available from: doi:10.1136/emj.2005.026252
  6. JEON JW, YOON HJ, KIM JS, RYU IH, CHOI JW, KIM MG, NA YM, YUN HJ. A Case on Streptococcal Pneumonia Associated with Leptomeningitis, Osteomyelitis and Epidural Abscess in a Patient with AIDS Tuberc Respir Dis (Seoul) [online] 2014 Feb, 76(2):80-83 [viewed 23 October 2014] Available from: doi:10.4046/trd.2014.76.2.80

Investigations - Fitness for Management

Fact Explanation
Liver function tests Medications may alter the liver functions and therefore baseline value is needed before the treatment. [3]
Renal functions and serum electrolytes Syndrome of inappropriate Antidiuretic Hormone secretion is a complication of meningitis. This can cause hyponatraemia. [5] Reduced intake of fluids can cause electrolyte imbalances. Medications may alter the renal functions and therefore baseline value is also needed.
References
  1. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  2. PATTULLO AL, BOW EJ. A case of group A streptococcal meningitis in an adult Can J Infect Dis [online] 1993, 4(4):223-226 [viewed 23 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250794
  3. ELWIR SM, SHAFFER CC, ARVAN SW, KUPERMAN EF. Disseminated Varicella Zoster Virus Infection with Encephalitis in a UC Patient Receiving Infliximab Gastroenterol Hepatol (N Y) [online] 2013 Jan, 9(1):54-56 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975981
  4. BRACKENRIDGE A, WALLBANK H, LAWRENSON RA, RUSSELL‐JONES D. Emergency management of diabetes and hypoglycaemia Emerg Med J [online] 2006 Mar, 23(3):183-185 [viewed 18 September 2014] Available from: doi:10.1136/emj.2005.026252
  5. PILLAI BP, UNNIKRISHNAN AG, PAVITHRAN PV. Syndrome of inappropriate antidiuretic hormone secretion: Revisiting a classical endocrine disorder Indian J Endocrinol Metab [online] 2011 Sep, 15(Suppl3):S208-S215 [viewed 23 September 2014] Available from: doi:10.4103/2230-8210.84870
  6. CARROL ED, BAINES P. Elevated cytokines in pneumococcal meningitis: Chicken or egg? Crit Care Med [online] 2005 May, 33(5):1153-1154 [viewed 21 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1343527

Investigations - Followup

Fact Explanation
CT imaging CT imaging is performed if there is poor response within 48 hours of antibiotic treatment. [1]
References
  1. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975

Investigations - Screening/Staging

Fact Explanation
MRI/CT brain Increased intracranial pressure is evident on MRI by severe sulcal effacement and midline shift on brain imaging. [1] Therefore cranial CT should be done before the lumbar puncture, specially in those present with focal neurological deficits or seizures and those who have a disturbed consciousness due to the possible risk of cerebral herniation due to raised intracranial pressure.[1]
References
  1. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975

Management - General Measures

Fact Explanation
Immediate management This is particularly important if the patient presents with confusion and drowsiness. Airway, breathing, circulation, disability and environment need to be attended. Random blood sugar is done to exclude hypoglycaemia. [4] Lumbar puncture needs to be done before the antibiotics [5] started ( if the possibility of increased intracranial pressure can be rule out) If it is not safe to do the LP blood culture is done and antibiotics are started as soon as possible without delay.
Supportive management Antipyretics (i.e. acetaminophen) and antiemetics (i.e. promethazine) may be given. Hydration should be checked and due to the possibility of syndrome of inappropriate Antidiuretic hormone, 2/3 of maintenance is preferable. Usual recommended fluid intake is less than 800 mg/day. [1] Monitoring of the vital parameters should be done during the initial period.
Prophylaxis in high risk groups Patients who had a splenectomy are vulnerable for infections with encapsulated organisms like pneumococci. Therefore penicillin prophylaxis should be given after surgery. [8]
References
  1. PILLAI BP, UNNIKRISHNAN AG, PAVITHRAN PV. Syndrome of inappropriate antidiuretic hormone secretion: Revisiting a classical endocrine disorder Indian J Endocrinol Metab [online] 2011 Sep, 15(Suppl3):S208-S215 [viewed 23 September 2014] Available from: doi:10.4103/2230-8210.84870
  2. KENNEDY P. VIRAL ENCEPHALITIS: CAUSES, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT J Neurol Neurosurg Psychiatry [online] 2004 Mar, 75(Suppl 1):i10-i15 [viewed 11 August 2014] Available from: doi:10.1136/jnnp.2003.034280
  3. FLORET D. [Suppurative meningitis in infants and in children: adjuvant treatments and treatments of neurological forms]. Pediatrie [online] 1993, 48(1):21-7 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8392687
  4. FORD-JONES EL, MACGREGOR D, RICHARDSON S, JAMIESON F, BLASER S, ARTSOB H. Acute childhood encephalitis and meningoencephalitis: Diagnosis and management Paediatr Child Health [online] 1998, 3(1):33-40 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851260
  5. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08
  6. LEE GT, CHIU CY, HALLER BL, DENN PM, HALL CS, GERBERDING JL. Streptococcus suis Meningitis, United States Emerg Infect Dis [online] 2008 Jan, 14(1):183-185 [viewed 23 September 2014] Available from: doi:10.3201/eid1401.070930
  7. PATTULLO AL, BOW EJ. A case of group A streptococcal meningitis in an adult Can J Infect Dis [online] 1993, 4(4):223-226 [viewed 23 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250794
  8. HATCH JP, SIBBALD WJ, AUSTIN TW. Overwhelming pneumococcal infection in a hyposplenic adult. Can Med Assoc J [online] 1983 Oct 15, 129(8):851-854 [viewed 23 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1875618

Management - Specific Treatments

Fact Explanation
Antibiotic therapy-Cephalosporin Emperical antibiotic therapy should be started without any delay. Preferably lumber puncture/ blood culture is done prior to the antibiotic therapy. Currently third generation cephalosporin (cefotaxime or ceftriaxone) are used as the first-line treatment for pneumococcal meningitis. [1] Ceftriaxone alone (100 mg/kg/24 hours) can be used as the empiric treatment for suspected bacterial meningitis for patients aged 2 months to 5 years of age. It is also used alone for patients older than 5 years and ampicillin plus an aminoglycoside or ceftriaxone plus ampicillin for infants less than 2 months of age. [1]
Antibiotic therapy-Ampicillin Suspected bacterial meningitis in patients aged 2 months to 5 years of age can be treated with ampicillin (200-400 mg/kg/24 hours) plus chloramphenicol (75-100 mg/kg/24 hours) and ampicillin alone can be given to patients older than 5 years. Ampicillin plus an aminoglycoside or cetriaxone plus ampicillin is given for infants less than 2 months of age. [1] Ampicillin is changed to ceftriaxone if the pneumococci are resistant to penicillin.
Antibiotic therapy - Penicillin Penicillin resistance is a recognized problem in treating pneumococcal meningitis. [3] Before this problem was identified penicillin was the standard treatment for pneumococcal meningitis. [1] When ampicillin was not available, Crystalline penicillin G (300,000 to 500,000 IU/kg every 4-6 h) can be used instead of ampicillin. Antibiotic treatment can be changed according to the sensitivity report.
Vancomycin Vancomycin (60 mg/kg/24 hours) can be used to treat pneumococcal meningitis with reduced susceptibility to ceftriaxone. [1]
Steroids Dexamethasone (4 mg every six hours) is given to reduce the inflammatory response occur during the anti microbial treatment. [2] Steroid therapy is of more value when given before or with the first dose of antibiotic. [5] Dexamethasone may reduce case fatality in pneumococcal meningitis. [1]
Pneumococcal conjugate vaccine Pneumococcal conjugate vaccine is important in preventing the invasive pneumococcal diseases. [4] It is a10 valen congugated pneumococcal and some countries have included it in the routine immunization programme. [4]
References
  1. GOUVEIA EDILANE L, REIS JOICE N, FLANNERY BRENDAN, CORDEIRO SORAIA M, LIMA JOSILENE BT, PINHEIRO RICARDO M, SALGADO KáTIA, MASCARENHAS ANA, CARVALHO M GLORIA, BEALL BERNARD W, REIS MITERMAYER G, KO ALBERT I. Clinical outcome of pneumococcal meningitis during the emergence of pencillin-resistant Streptococcus pneumoniae: an observational study. Array [online] 2011 December [viewed 21 October 2014] Available from: doi:10.1186/1471-2334-11-323
  2. LEE GT, CHIU CY, HALLER BL, DENN PM, HALL CS, GERBERDING JL. Streptococcus suis Meningitis, United States Emerg Infect Dis [online] 2008 Jan, 14(1):183-185 [viewed 23 September 2014] Available from: doi:10.3201/eid1401.070930
  3. NAU R, KAYE K, SACHDEVA M, SANDE ER, TäUBER MG. Rifampin for therapy of experimental pneumococcal meningitis in rabbits. Antimicrob Agents Chemother [online] 1994 May, 38(5):1186-1189 [viewed 21 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC188176
  4. GOUVEIA EDILANE L, REIS JOICE N, FLANNERY BRENDAN, CORDEIRO SORAIA M, LIMA JOSILENE BT, PINHEIRO RICARDO M, SALGADO KáTIA, MASCARENHAS ANA, CARVALHO M GLORIA, BEALL BERNARD W, REIS MITERMAYER G, KO ALBERT I. Clinical outcome of pneumococcal meningitis during the emergence of pencillin-resistant Streptococcus pneumoniae: an observational study. Array [online] 2011 December [viewed 23 September 2014] Available from: doi:10.1186/1471-2334-11-323
  5. CARROL ED, BAINES P. Elevated cytokines in pneumococcal meningitis: Chicken or egg? Crit Care Med [online] 2005 May, 33(5):1153-1154 [viewed 21 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1343527