Meningitis%20-%20acute,%20bacterial Management

• Use of mask, gloves, and gowns prevents spread of disease as meningitis is a droplet infection

• Completion of recommended schedule of vaccination is an effective way of protecting individuals from certain types of bacterial meningitis
  • Eg meningococcus (N meningitidis), pneumococcus (S pneumoniae), and H influenzae type B
• Pneumococcal vaccine is recommended in patients who had an episode of bacterial meningitis, cerebrospinal fluid (CSF) leakage to reduce recurrences
  • Adults ≥19 years old with CSF leak should receive PCV13 followed by PPSV23 at least 8 weeks after PCV13
    • Pediatric dose depends on child’s immunization history
  • In patients with CSF leakage, additional vaccination with H influenzae type B and N meningitidis is recommended
• Meningococcal serogroup A, C, W, and Y conjugate vaccine is recommended by the Advisory Committee on Immunization Practices (ACIP) and Centers for Disease Control and Prevention (CDC) to be given to persons aged ≥2 months at increased risk for meningococcal disease, and adolescents aged 11-12 years old with booster dose at age 16 while serogroup B meningococcal vaccine is recommended for patients aged ≥10 at increased risk for meningococcal disease, and to adolescents and young adults aged 16-23 years in need of short-term protection against serogroup B meningococcal disease
• H influenzae type B conjugate vaccine is recommended by CDC to be given to all children starting at 2 months of age, to patients with anatomic or functional asplenia, and post-stem cell transplant patients

¹Recommendation for vaccination may vary between countries. Please refer to your local guidelines.

• Determine the need for chemoprophylaxis of patient’s contacts
  • Prophylaxis of meningitis patient’s contacts using antimicrobial agents may be appropriate for certain types of bacterial meningitis

• Chemoprophylaxis eradicates nasopharyngeal colonization, thereby preventing transmission to young, susceptible contacts along with stopping the development of invasive disease in those already colonized
• Chemoprophylaxis is recommended for all household contacts with at least 1 unvaccinated or incompletely vaccinated child <48 months, or an immunocompromised child of any age
• Recommended agents: Rifampicin, Ciprofloxacin or Ceftriaxone

• Chemoprophylaxis is used to eliminate nasopharyngeal colonization
• Recommended for all household and other contacts of patients, including day care center members and anyone directly exposed to the patient’s oral secretions
  • Not recommended for school, work or transportation contacts
• Recommended for healthcare workers whose mouth or nose has been directly exposed to respiratory secretions or droplets from a patient with meningococcal meningitis during the acute phase of illness and before completion of antibiotics for 24 hours
• Administer to all at-risk contacts promptly and at the same time, ideally within 24 hours after the index case is identified
• Recommended agents: Rifampicin, Ciprofloxacin or Ceftriaxone
  • Alternative agent: Azithromycin

• All pregnant patients should be screened at 35-37 weeks gestation for anogenital colonization with group B streptococci
• Maternal group B streptococci carriers should receive chemoprophylaxis if they have ≥1 of the following risk factors:
  • Preterm labor at 37 weeks gestation
  • Fever (temperature >38^oC) during labor or after membranes have been ruptured 18 hours or more during any gestation
  • If previous delivery of sibling with invasive group B streptococcal disease
• Recommended agents: Ampicillin or Penicillin G
  • Alternative agents: Clindamycin or Erythromycin

General Follow-up Principles

• Do repeat cerebrospinal fluid (CSF) exam in patients in whom there is doubt about the success of therapy or the accuracy of the initial diagnosis
  • Patients who respond promptly to therapy may no longer need repeat CSF exams

• Monitor for hydrocephalus and treat the condition appropriately
  • Hydrocephalus usually manifests within the first few weeks of infection and is treated with ventriculoperitoneal shunting

• Monitor for neurologic sequelae and provide appropriate supportive therapy
  • Sequelae include hearing impairment, cranial nerve palsies and motor deficits
  • Supportive therapy should be individually tailored

• In adults with meningococcal infection treated with antibiotics other than 3rd-generation cephalosporins, give either Rifampicin (600 mg PO 12 hourly for 48 hours), Ciprofloxacin (500 mg PO single dose) or Ceftriaxone (1g IV/IM single dose) for eradication of nasopharyngeal colonization
  
  • Age >60 years
  • Elevated CSF pressure
  • Presence of focal neurological deficits
  • Seizures
  • Presence of debilitating disorders
  • Low admitting Glasgow coma score
  • Low CSF cell count
  • Low CSF to glucose ratio
• Refer patient to a neurologist if with presence of persistent neurologic deficits