1. Case Discussion CMID 2010

2. Outline Epidemiology Clinical presentation Management: -Investigations -Antimicrobial therapy -Adjunct therapy Complications 2/16/2016

4. Routes of infection 1. Haematogenous 2. Contiguous spread -Infection from adjacent structures, -eg. Sinuses, ears, face 3. Traumatic -Direct inoculation 4. Via nerves -Viruses eg. Rabies, herpes simplex 4. Device associated eg. VP shunt 2/16/2016

5. Pathogenesis 2/16/2016

6. Clinical presentation 2/16/2016

7. Clinical presentation 2/16/2016

9. Clinical suspicion of meningitis 2/16/2016

10. CSF diagnostic tests Opening pressure  20 – 50cm H20 Macroscopic: cloudy Cell count: -neutrophil predominance -lymphocyte predominance in 10% Biochemistry -CSF glucose low -Protein high 2/16/2016

12. Micro Lab CSF for MC & S Gram stain -rapid -> 97% specificity -Sensitivity depends on various factors -Organism load -Type of organism -Prior antibiotics 2/16/2016

15. Adjunctive tests Latex agglutination Rapid Principle: serum containing bacterial antibodies/ commercially available antisera directed against capsular polysaccharides of the pathogen Good sensitivity in detecting common pathogens Negative test does not rule out infection!! 2/16/2016

16. Slide agglutination test 2/16/2016

17. Antimicrobial therapy Supportive Empiric antibiotics until organism identified and before specimens are taken! 2/16/2016 AgeAntibiotic choice Pre term - < 1 monthAmpicillin + Cefotaxime 1-24 monthsCefotaxime + Dexamethasone 2yrs – 50 yrs 3 rd generation cephalosporin + dexamethasone > 50 yrs or Immunocompromised Ampicillin + 3 rd generation cephalosporin + vancomycin + dexamethasone Adapted from Antimicrobial Therapy Guide 2 nd ed.

18. Role of steroids Dexamethasone Has been shown to attenuate the inflammatory response  decreasing pathophysiologic consequences Timing of administration Begun before 1 st dose of antibiotics Better neurological outcome and decrease in mortality Adults vs children 2/16/2016

19. Complications Usually secondary to the inflammatory response 2/16/2016 EarlyFatal Venous sinus thrombosis, Obstruction of CSF flow, Subdural empyema, Brain abscess. LateDeafness Obstructive hydrocephalus Brain parenchymal damage sensory and motor deficits cerebral palsy learning disabilities mental retardation cortical blindness seizures

20. Brain abscess 2/16/2016

21. Prevention Notification!! Chemoprophylaxis -Why? Following exposure  temporary nasopharyngeal carriage An association between carriage and the risk of disease has been described -Which organisms? -H influenzae, N meningitidis, and S pneumoniae. -Who should take it? -Does not treat incubating invasive disease, and closely monitor individuals at highest risk.

22. Prevention cont.. H.influenzae type B Rifampicin (20 mg/kg/d) for 4 days. The index patient may need chemoprophylaxis if the administered treatment does not eliminate carriage. N.meningitidis Contacts of persons with meningococcal meningitis Household contacts Daycare center members who eat and sleep in the same dwelling Military barracks or boarding schools Medical personnel performing resuscitation with exposure to infectious blood/body fluids Doses Rifampicin (600 mg PO q12h) for 2 days Ceftriaxone (250 mg IM) as a single dose in adults. Safest choice in pregnant patients. Ciprofloxacin (500-750 mg) as a single dose

23. Prevention cont… Immunoprophylaxis -Artifical induction of immunity -Vaccines against encapsulated organisms -Streptococcus pneumoniae -Haemophilus influenzae type B -Neisseria meningitidis 2/16/2016