00:02
So, how do you manage bacterial meningitis
if the Gram stain is negative?
In other words,
you're not sure what you're treating.
00:12
Well, you would have to treat for
all pathogens that might be present.
00:17
So, in a patient from the age of
one month to 50 years of age,
you're going to be using
ampicillin-ceftriaxone and vancomycin.
00:29
And notice that we’re adding
a corticosteroid with that, dexamethasone.
00:34
And the main reason for dexamethasone
is to reduce the amount of inflammation that is present
because the inflammation causes
increased intracranial pressure
and may cause some of the irreversible damage
that happens because of the inflammatory
response in the cerebrospinal fluid.
00:56
Now, there –
I've listed there the alternatives for you
in patients that cannot take
cephalosporins or ampicillin,
and that would be meropenem plus vancomycin,
again plus dexamethasone.
01:13
Now, if the patient has had some neurosurgery
or a cochlear implant
or some head trauma,
then we need to think about what
bugs could cause meningitis there
and we’re thinking Staph,
we’re thinking Gram-negative rods.
01:29
So, the treatment is going to be vancomycin
to cover methicillin-resistant Staph
and cefepime, which is an antipseudomonal
fourth-generation cephalosporin
or ceftazidime, a third-generation,
which covers pseudomonas.
01:47
And so, that's what we’re thinking empirically.
01:50
And alternatively,
we would use once again meropenem,
a carbapenem,
plus vancomycin.
01:57
There's not evidence of whether you should
use corticosteroids in this setting,
but many patients who have
had a neurosurgical procedure
or trauma are already getting dexamethasone.
02:12
So, now,
what if you do have a positive Gram stain,
let's say Streptococcus pneumoniae.
02:19
What's recommended is
vancomycin plus ceftriaxone
plus dexamethasone.
02:27
Now, why vancomycin plus ceftriaxone?
There are some pneumococci that are
relatively resistant to ceftriaxone,
not very common,
but vancomycin would be expected to cover that
small percentage of pneumococci not susceptible.
02:46
Alternatively, once again,
we’re turning to meropenem
or moxifloxacin, a fluoroquinolone,
plus dexamethasone.
02:57
Or what if your Gram stain shows you
evidence of a gram-negative organism,
like Haemophilus influenzae
or Pseudomonas aeruginosa?
Sometimes H. flu can be elongate
and resemble other Gram-negative rods,
and so the Gram stain
doesn't give you certainty.
03:18
So, you're going to have to treat for both,
and antipseudomonal cephalosporin
will cover both H. flu and Pseudomonas.
03:27
But in this case,
because there may be a few percentage
that are not covered by these cephalosporins,
you would add gentamicin,
at least until you get the
results of your cultures back.
03:43
And alternatively,
you would use once again
meropenem, a fluoroquinolone,
plus dexamethasone.
03:54
All right.
03:54
If you're pretty sure the patient has
that bad meningococcal meningitis,
then the treatment of choice in babies, newborns,
is actually cefotaxime.
04:06
And cefotaxime and ceftriaxone are very, very similar
third-generation cephalosporins bug-wise.
04:14
But because a newborn's
liver is not mature,
they may not handle ceftriaxone,
which is partially excreted by the liver,
very well.
04:23
So, you use cefotaxime for newborns.
04:28
Everybody else would get
ceftriaxone plus dexamethasone.
04:33
And the reason for ceftriaxone
is that you can give it once a day
or twice a day at the most.
04:40
And alternatively,
it would be penicillin.
04:43
The meningococcus still is completely
susceptible to penicillin G
or ampicillin
or moxifloxacin if patients
cannot tolerate a beta-lactam.
04:58
The empirical treatment for a patient suspected
of having Listeria on Gram stain would be ampicillin.
05:07
In fact, the organism is more susceptible
to ampicillin than it is penicillin G.
05:12
Plus gentamicin for synergism.
05:17
Alternatively,
they can receive trim sulfa,
meropenem,
and questionably this
new agent called linezolid.
05:29
But because of some lack of certainty,
we add rifampin to that.
05:36
And because of this,
this organism is a little bit slow to grow
because it's intracellular
and more difficult to treat.
05:46
We usually treat this for 21 days,
Listeria meningitis.
05:53
Now, if it’s Staphylococcus,
we’re going to use vancomycin empirically
because of the possibility of
methicillin-resistant Staph aureus.
06:06
If we think it's a Streptococcus,
then like group B Strep, for example,
it would be ampicillin plus gentamicin
in a newborn and infants
and it would be penicillin in adults.
06:23
Alternatively,
if they can't take a beta-lactam,
it would be vancomycin.
06:31
Now, what if a patient has visited a doctor's office
or is brought to a private physician's office
and the private physician feels
like they have meningitis.
06:42
Well, of course,
they’ve got to transfer them to a hospital.
06:45
There may be valuable time wasted.
06:47
And so,
if a private physician happens to have the
availability of giving intravenous ampicillin or penicillin,
then he or she should do that,
just give the medication empirically
because of the danger of death with delay.
07:09
Now, the Infectious Disease Society of America guidelines,
I will now summarize for you.
Now, the Infectious Disease Society of America guidelines,
I will now summarize for you.
07:16
If you have a patient with a
suspicion of bacterial meningitis
and you have, for example,
a patient who is immunocompromised,
has a history of papilledema,
focal neurologic deficit,
or there's going to be some
kind of delay in therapy,
then that produces an algorithm.
07:41
And you go down one side
if the answer is yes
and on the other side
if the answer is no.
07:47
So, if they do not have any of these,
you would go ahead
and get blood cultures,
you would do a lumbar puncture immediately,
you would give dexamethasone
and empirical antibiotics.
08:00
You’ve got your cultures cooking.
08:02
And then you would get
the spinal fluid analyzed.
08:06
If the findings are consistent
with bacterial meningitis,
you would continue therapy.
08:13
So, that is if the patient has no immunocompromise,
no history of central nervous system disease,
no papilledema,
no focal neurologic deficit,
and you’ve been able to tap them immediately.
08:27
On the other hand,
if the answer to that question is yes,
then there's going to be a delay.
08:33
You can’t tap them immediately.
08:35
So, you’ve got to
get your blood cultures,
you go ahead and give them
dexamethasone and empirical antibiotics.
08:42
Now, there may be delay in x-ray.
08:46
Well, you don't want the
patient to be waiting an x-ray
and not have been given antibiotics.
08:52
So, that's why you give
them empirical antibiotics
and then send them off to x-ray.
08:58
If their head CT scan shows no evidence
of increased intracranial pressure,
you can now analyze their spinal fluid,
a spinal tap can be done.