Adults vs Peds question: management of meningitis

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[was doing a UW question, #3633 if you wanna follow along]

In an Adult: if you're clinically suspicious of meningitis, you start IV ceftriaxone and vanc first, then do the LP. I think the logic here (correct me if I'm wrong) is that you wanna get the antibiotics on board ASAP, to fight the infection. A nurse could throw up the antibiotics in 2 minutes, whereas it might take you 20 minutes to do the LP (get consent, set up, do it, etc). Ok i get that.

In kids: the opposite management is done. The LP is obtained first, then you start antibiotics. Why is this so? If you have a high enough clinical suspicion, by the same logic as above (that you'd wanna start fighting the infection sooner than later, wouldn't it be wise to start antibiotics first??? (According to UWorld, you do the LP first, b/c LPs are easier to do in kids. Ok, I get that, but isn't it a safer bet to start the medicine first....again, provided that your clinical suspicion is high enough?)

thanks,

This exact topic was recently posted before, not sure what the conclusion attendings came up with, but its just something you gotta live with and remember.

Also, remember in adults to give steroids

Originally Posted by septoplasty

This exact topic was recently posted before, not sure what the conclusion attendings came up with, but its just something you gotta live with and remember.

Also, remember in adults to give steroids

Thanks. Where was this discussion? (i tried searching, no joy). If you have a link, please redirect. If not, no worries.

Originally Posted by DrMetal

[was doing a UW question, #3633 if you wanna follow along]

In an Adult: if you're clinically suspicious of meningitis, you start IV ceftriaxone and vanc first, then do the LP. I think the logic here (correct me if I'm wrong) is that you wanna get the antibiotics on board ASAP, to fight the infection. A nurse could throw up the antibiotics in 2 minutes, whereas it might take you 20 minutes to do the LP (get consent, set up, do it, etc). Ok i get that.

In kids: the opposite management is done. The LP is obtained first, then you start antibiotics. Why is this so? If you have a high enough clinical suspicion, by the same logic as above (that you'd wanna start fighting the infection sooner than later, wouldn't it be wise to start antibiotics first??? (According to UWorld, you do the LP first, b/c LPs are easier to do in kids. Ok, I get that, but isn't it a safer bet to start the medicine first....again, provided that your clinical suspicion is high enough?)

thanks,

Wait wait wait. Back up.

Adult
If fever and a headache the first step is to ask "can I LP this guy safely?" If there is Focal Neurolgical Deficit, Altered Mental Status, Immunosuppresion, Lesion over the puncture site, or Seizure (FAILS) than you CANNOT safely LP somebody. The risk of intracranial pressure is too high. If you put a needle in somone's back, the pressure is going to be relieved through the spinal column, and the brain will herniate through the foramen magnum.

So if they are negative for FAILS, you do the LP FIRST then give antibiotics. This way you get the highest yield on CSF cultures. Once the LP is done, you start empiric antibiotics waiting for cultures and sensitivities. That is discussed in this review lecture. BUT, if they are positive for FAILS, then you cannot safely do an LP until you exclude an intracranial lesion. So... you give antibiotics and get a CT. This DOES disrupt the culture sensitivity, but you'd rather have a live patient with a bad test than a dead patient with a good culture.

In adults the only time you give antibiotics before the LP is if the LP cannot be safely performed, i.e. they have one of the FAILS because you are worried about intracranial pressure.

Kids
And we're talking young-ins. Like, those who still have open fontenelles. The reason you can safely LP these kids is because of teh fontenelles. They have a blow-off valve, a place to release that intracranial pressure, so you have a reduced risk of herniation with LP. Same logic applies as for adults, only there is a reluctance to give children CT scan level radiation and you already have a meter for how much intracranial pressure is around (flat, sunken, or bulging fontenelles).

Thank you for the reply, was very helpful.

Originally Posted by OveractiveBrain

Adult
So if they are negative for FAILS, you do the LP FIRST then give antibiotics.

So (in the setting of negative FAILS), what if your patient has a very impressive clinical presentation (lethargic, deteriorating vitals, petechial coalescing rash, positive brudzinski, etc etc), you would still LP first? That just doesn't make sense to me. Why would you do a diagnostic procedure on a patient that might die in the time it takes you to do and interpret said procedure? What's the harm in starting antibiotics first? (I understand that you lose Cx sensitivity, but so be it).

I remember this UW question... I think with adults you do antibiotics first then LP bc two reasons: 1) LP is more difficult and will take time to do it (doubt it will be just 20 mins.. More like 2 hours or so realistically by the time some one gets there to do it and actually doing it takes like 30 mins or more sometimes) .. 2) even if you give the pt abx it ll take a few hours before it reaches the csf anyway so you have a few hour window to get the LP done even after abx.

Vs.

Kids: where the LP is much easier technically to do and with less risk.. So it can be done much faster than an adult --> LP first then abx

That was my understanding?? Correct me if I am wrong bc I was wondering about this also a few days ago??

Originally Posted by DrMetal

Thank you for the reply, was very helpful.



So (in the setting of negative FAILS), what if your patient has a very impressive clinical presentation (lethargic, deteriorating vitals, petechial coalescing rash, positive brudzinski, etc etc), you would still LP first? That just doesn't make sense to me. Why would you do a diagnostic procedure on a patient that might die in the time it takes you to do and interpret said procedure? What's the harm in starting antibiotics first? (I understand that you lose Cx sensitivity, but so be it).

Ok. We are in Step 2. You can only choose ONE procedure, diagnostic, or intervention. The correct answer is get the CSF if no FAILS, then give antibiotics.

If you have a patient in front of you, and they are that ill... that is, they are ICU bound and are crashing in front of you, the antibiotics, fluid, and likely pressors are going to go on first. That's not "meningitis" that's "septic shock." And to be honest with you, unless they are coding, it takes a long ass time for people to die. Promise. In this situation you would bring your ICU team into the ER, get the LP tray, get the Triple Lumen IJ catheter, write the order for antibiotics, dump fluid, collect blood samples including cultures, get the LP while the nurse is hanging abx, etc. If they are that high acuity you would also tell three nurses to come into teh room with you and start helping getting things done.

In real life you do everything at the same time. All the orders are placed. Procedures done. And, it doesn't really matter if the ceftriaxone and vanc are started while you are putting the needle in. After, all, they needed that IJ for IV access for your pressors anyway. BTW this is NOT the typical meningitis patient presentation.

On the test they are evaluating you for the contraindications for LPs. "can you do the LP now, or do you need a CT?" A very important clinical question, but in the vignette a much more narrowed discussion.


P.S. Every child should get Meningococcal Vaccine prevention!

Originally Posted by OveractiveBrain

Ok. We are in Step 2. You can only choose ONE procedure, diagnostic,

ok, thanks for the help!

Originally Posted by OveractiveBrain

Ok. We are in Step 2. You can only choose ONE procedure, diagnostic, or intervention. The correct answer is get the CSF if no FAILS, then give antibiotics.

If you have a patient in front of you, and they are that ill... that is, they are ICU bound and are crashing in front of you, the antibiotics, fluid, and likely pressors are going to go on first. That's not "meningitis" that's "septic shock." And to be honest with you, unless they are coding, it takes a long ass time for people to die. Promise. In this situation you would bring your ICU team into the ER, get the LP tray, get the Triple Lumen IJ catheter, write the order for antibiotics, dump fluid, collect blood samples including cultures, get the LP while the nurse is hanging abx, etc. If they are that high acuity you would also tell three nurses to come into teh room with you and start helping getting things done.

In real life you do everything at the same time. All the orders are placed. Procedures done. And, it doesn't really matter if the ceftriaxone and vanc are started while you are putting the needle in. After, all, they needed that IJ for IV access for your pressors anyway. BTW this is NOT the typical meningitis patient presentation.

On the test they are evaluating you for the contraindications for LPs. "can you do the LP now, or do you need a CT?" A very important clinical question, but in the vignette a much more narrowed discussion.


P.S. Every child should get Meningococcal Vaccine prevention!

I looked it up on uptodate and what you say is correct and is intuitively what I always thought... But I distinctly remember this UW question bc I thought in was a little different than what I had read prior but what I stated in m previos post was their explanation.. I will look at that question again today.