Meningitis

Last Updated on by FRCEM Intermediate

Causes

  • Neisseria meningitis, Streptococcus pneumoniae, and Haemophilus influenza type b (Hib) are the most common causative organisms of acute bacterial meningitis in children aged 3 months or older and adults.
  • In neonates (younger than one month of age), Streptococcus agalactiae, Escherichia coli, S. pneumoniae, and Listeria monocytogenes are the most common causative organisms

Clinical features

History

  • malaise
  • fever
  • headache
  • vomiting
  • stiff neck
  • risk factors

Examination

  • non-blanching rash
  • normal -> altered LOC -> coma
  • meningism
  • head jolt accentuation test (lateral head rotation worsens headache = very sensitive)
  • Kernig’s sign
  • Brudzinski’s sign
  • papilloedema (indicates raised ICP)
  • tense fontanelle in babies
  • focal neurological deficit
  • shock

Investigations

  • Bloods – FBC and CRP
  • Blood cultures
  • Blood PCR testing for N. meningitidis and S. pneumoniae
  • CT Head first if:
    • Abnormal mental states
    • new onset seizures
    • immunocompromised
    • GCS < 10 focal neurological signs in keeping with a space occupying lesion.
    • Signs suggesting raised intracranial pressure.
  • Perform a lumbar puncture unless contraindicated.do not delay antibiotics
    • Contraindications for LP
      • GCS 8 or less or deteriorating
      • Focal neurological signs or abnormal posture
      • Prolonged seizure lasting 10 minutes or more and a GCS of 12 or less
      • Shock
      • Systemic meningococcal disease
      • Signs of raised intracranial pressure: unilateral or bilateral dilated pupils or sluggish pupillary reaction
      • Bradycardia or hypertension Abnormal breathing pattern

Treatment

  • out of the hospital, a single dose of benzylpenicillin (IM or IV)
  • Empirical antibiotics for suspected bacterial meningitis (ideally following LP, but do not delay > 30 minutes):
    • All adult patients should receive their first dose of 2G Ceftriaxone
    • For adults aged over 50 years or immunocompromised, add IV ampicillin PLUS Gentamicin
    • Children < 3 months – Cefotaxime 80 mg/kg IV + amoxicillin/ampicillin
    • Children ≥ 3 months – Ceftriaxone 80 mg/kg IV
  • If herpes simplex meningoencephalitis is part of the differential diagnosis give appropriate antiviral treatment
  • Give dexamethasone (0.15 mg/kg to a maximum dose of 10 mg)-with or before the first dose of antibiotics.
    • If dexamethasone was not given before or with the first dose of antibiotics, but was indicated, try to administer the first dose within 4 hours of starting antibiotics, but do not start dexamethasone more than 12 hours after starting antibiotics.
    • Do not use corticosteroids in children younger than 3 months with suspected or confrmed bacterial meningitis.

Control of Infection Action

  • The patient should be admitted to a side-room and barrier nursed
  • requires droplet precautions
  • Contact the Hospital Control of Infection team.
  • Arrange for treatment of patient and prophylaxis of appropriate contacts
  • Contact Community Health Service appropriate to the residence of your patient

Prophylaxis

Prophylaxis is recommended for

  • Family contacts.
  • Kissing contacts.
  • Children under five who have attended a party at which a child was incubating the infection.
  • Children under five in the same crèche (not school) class.
  • Health care workers only recommended chemoprophylaxis if “mouth or nose is directly exposed to respiratory droplets and/or secretions from a case of meningococcal disease”.

Prophylactic Drugs: Either rifampicin or ciprofloxacin

Complications

  • Hearing loss
  • Seizures
  • Motor deficit
  • Cognitive impairment
  • Hydrocephalus
  • Visual disturbance

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