Viral 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

Diagnostics

Treatment

  1. Do Not Withold Antibiotic therapy
  2. Care is mostly supportive
  3. Antiviral therapy
  4. Complications

Disposition

  1. IF ANY UNCERTAINTY about diagnosis
  2. Some patients can be cared for as outpatients
  3. Admit pts who have

 

 

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).