meningitis%20-%20acute,%20bacterial
MENINGITIS - ACUTE, BACTERIAL

Acute meningitis is the infection of the subarachnoid space and cerebrospinal fluid by bacteria that may cause local and systemic inflammatory response.
There is the classic triad of symptoms of fever, neck stiffness and altered level of consciousness.
Other symptoms include chills, myalgia, photophobia, severe headache, focal neurologic symptoms, nausea, vomiting, seizures and some patients may present with rash.

 

Prevention

Precautions
  • Use of mask, gloves, and gowns prevents spread of disease as meningitis is a droplet infection
Vaccination1
  • 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 Hib (H influenzae type B)
  • Pneumococcal vaccine is recommended in patients who had an episode of bacterial meningitis, cerebrospinal fluid 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 cerebrospinal fluid 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 in infants<1 year of age, and patients 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 Centers for Disease Control and Prevention 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.

Chemoprophylaxis of Contacts
  • 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
 H influenzae
  • 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
N meningitidis
  • 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
S agalactiae
  • 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 (temp >38oC) 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

Follow Up

General Follow-up Principles

  • Do repeat cerebrospinal fluid 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 cerebrospinal fluid 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 cerebrospinal fluid pressure
    • Presence of focal neurological deficits
    • Seizures
    • Presence of debilitating disorders
    • Low admitting Glasgow coma score
    • Low cerebrospinal fluid cell count
    • Low cerebrospinal fluid to glucose ratio
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