Bacterial Meningitis


  Normal Bacterial Viral Fungal Tb Abscess
WBC/mL 0–5 >1000* <1000 100–500 100–500 10–1000
%PMN 0–15 >80* <50 <50 <50 <50
%lymph >50 <50 >50 >80 ↑ monos variable
Glucose 45–60 <40 45–65 30–45 30–45 45–60
Ratio ≥ 0.6 ≤0.4 45–65 <0.4 <0.4 0.6
Protein 15–45 150–1000 50–100 100–500 100–500 >50
Pressure 6–20 20–50 variable >20 >20 variable

Background

Pathophysiology

Diagnosis

Treatment

  1. ABCs: Consider airway support, intubation/ O2
  2. IV fluids if shock or dehydration
  3. Monitor pulse & vital signs
  4. Treat ASAP when suspected
  5. Antibiotic treatment:
  6. Steroids

Disposition

  1. All suspected cases should be admitted
  2. Contacts need prophylaxis

 

 

Admit Orders: Meningitis (Adult)

1. Admit to:

2. Diagnosis: Meningitis.

3. Condition:

4. Vital Signs: q1h. Call physician if BP systolic >160/90, <90/60; P >120, <50; R>25, <10; T >39°C or less than 36°C

5. Activity: Bed rest with bedside commode.

6. Nursing: Respiratory isolation, inputs and outputs, lumbar puncture tray at bedside.

7. Diet: NPO

8. IV Fluids: D5 ½ NS at 125 cc/h with KCL 20 mEq/L.

9. Special Medications:

No known immunodeficiency:

-Ceftriaxone (Rocephin) 2 g IV every 12 hours OR

-Cefotaxime (Claforan) 2 g IV every four to six hours PLUS

-Vancomycin 30 to 60 mg/kg IV per day in two or three divided doses PLUS

-In adults >50 years of age, ampicillin 2 g IV every four hours.

Impaired cell-mediated immunity:

-Vancomycin 30 to 60 mg/kg IV per day in two or three divided doses PLUS

-Ampicillin 2 g IV every four hours PLUS EITHER

-Cefepime (Maxipime) 2 g IV every eight hours OR

-Meropenem (Merrem) 2 g IV every eight hours.

Nosocomial Meningitis:

-Vancomycin 30 to 60 mg/kg IV per day in two or three divided doses PLUS

-Ceftazidime (Fortaz) 2 g IV every eight hours OR

-Cefepime (Maxipime) 2 g IV every eight hours OR

-Meropenem (Merrem) 2 g IV every eight hours.

Allergy to beta-lactams:

-Vancomycin 30 to 60 mg/kg IV per day in two or three divided doses PLUS

-Moxifloxacin (Avelox) 400 mg IV once daily PLUS

-If Listeria coverage is required (>50 and/or in those with defects in cell-mediated immunity), TMP-SMX: 10 to 20 mg/kg (of TMP component) IV per day divided q6-12h.

10. Symptomatic Medications:

-Dexamethasone (Decadron) 0.4 mg/kg IV q12h x 2 days to commence with first dose of antibiotic.

-Heparin 5000 U SC q12h or pneumatic compression stockings.

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Acetaminophen (Tylenol) 650 mg PO/PR q4-6h prn temp >39°C.

-Docusate sodium 100-200 mg PO qhs.

11. Extras: CXR, ECG, CT scan.

12. Labs: CBC, CMP. Blood C&S x 2. UA with micro, urine C&S. Antibiotic levels peak and trough after 3rd dose, VDRL.

Lumbar Puncture:

CSF Tube 1: Gram stain, C&S for bacteria (1-4 mL).

CSF Tube 2: Glucose, protein (1-2 mL).

CSF Tube 3: Cell count and differential (1-2 mL).

CSF Tube 4: Antigen tests for S. pneumoniae, H. influenzae (type B), N. meningitides, E. coli, group B strep, VDRL, cryptococcal antigen, toxoplasma titers. Fungal cultures, AFB (8-10 mL).