Mgmt of Bacterial Meningitis

[dr1704]

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Kaplan says:

If there is Neurologic Deficit do Emperic Abx first then CT.

Another source says> If there is Focal Neurologic Def, do CT then Abx. Who's correct?

If there is no Focal Neurologic Def, do LP first then Abx (both source)

Inputs?????

 

[OveractiveBrain]

Kaplan says:

If there is Neurologic Deficit do Emperic Abx first then CT.

Another source says> If there is Focal Neurologic Def, do CT then Abx. Who's correct?

If there is no Focal Neurologic Def, do LP first then Abx (both source)

Inputs?????

Fever and Headache = Meningitis. If no signs of ICP, then go ahead an LP, waiting for LP to give Abx (you don't want to mess up the culture). After LP, its empiric abx (ceftriaxone) then switch once something grows out.

If Focal Neurologic Deficit, Altered Mental Status, papilledema, or any sign of increased ICP then the risk of intracranial mass is too great. Doing an LP will result in herniation of the pons (and death). So you do NOT do an LP. Instead, you look for the mass lesion with a CT scan. If the CT is clean, you get an LP, and culture.

What's better? A really accurate culture and a dead patient or an alive patient with a crap culture? Yeah, patients alive are usually what you're going for. So... Get the CT with Abx (though i suppose on an exam the abx are more important than the CT, so would come "first." IRL, you do them on the same order form), then LP once the CT is clear. But thats only when intracranial lesions are suspected.

If no s/s of intracranial pressure, just go to LP then Abx.

Savy?

 

[turkeyjerky]

two additions:

1. also CT immunodeficient people (aids, etc)

2. Empiric abx are ceftriaxone plus vancomycin (to cover resistant pneumococcus) and ampicillin (for listeria coverage, if less than 3 mo, greater than 50 yrs or immunodeficient). If immunodeficient or iatrogenic, you can use cefepime or meropenem instead of ceftriaxone. If pen allergic, use vancomycin plus moxifloxacin (plus bactrim for listeria coverage). Also use dexamethasone w/ initial therapy (stop it if it's not pneumococcus or hemophilus).

 

[OveractiveBrain]

two additions:

1. also CT immunodeficient people (aids, etc)

2. Empiric abx are ceftriaxone plus vancomycin (to cover resistant pneumococcus) and ampicillin (for listeria coverage, if less than 3 mo, greater than 50 yrs or immunodeficient). If immunodeficient or iatrogenic, you can use cefepime or meropenem instead of ceftriaxone. If pen allergic, use vancomycin plus moxifloxacin (plus bactrim for listeria coverage). Also use dexamethasone w/ initial therapy (stop it if it's not pneumococcus or hemophilus).

While as true as any or none of these recommendation may be, too many options confuse people. This is Step 2 prep. The answers are simple, direct, and based on "deet da dee" logic.


1) "If increased ICP get CT with abx"

2) "If no increased ICP get LP"

3) "Abx = Ceftriaxone" or if immunocompromised "Abx = Ceftriaxone + Ampicillin"

4) Increased ICP = Altered Mental, Focal Neurologic Deficit, Papilledema