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ID Exam 5 B
Dr. Shah Meningitis; Antimicrobial Stewardship
| Question | Answer |
|---|---|
| Types of Meningitis includes: | ⭐️ Bacterial; Viral; Fungal; Mycobacterial; Parasitic; Non-infectious causes |
| Meningitis is? | inflammation of the meninges |
| Describe the pathogenesis of Meningitis? | Bacteria cross tight junctions of cerebral vessels--> Multiply upon entry into CSF--> cause direct cell death and release cytokines--> increased inflammation, alter vascular permeability, and induce influx of leukocytes--> injury to vascular causes meningitis, cerebral edema, and increased pressure (Change cell composisiton of CSF |
| The use of Dexamethasone in Meningitis helps to: | decrease inflammation, decrease cerebral edema, and decrease neuronal injury |
| What are the risk factors associated with Meningitis? | Chronic medical conditions (renal failure, diabetes, adrenal insufficiency, cystic fibrosis); < 2yo and the elderly; unvaccinated; immunosuppressed; living in crowded conditions; day care attendance; Pregnancy; alcohol use disorder; ventriculoperitoneal (VP) shunt; Bacterial endocarditis; IV drug use; Splenectomy |
| What are the hallmark clinical presentations of Meningitis? | Headache, Fever, Neck stiffness (Nuchal rigidity), and altered mental status |
| Other clinical presentations of Meningitis include? | photophobia, seizures, vomiting; *use a neurological exam (kernig's and Brudzinski's signs of meningeal irritation |
| Timeline of Meningitis symptoms: Early-Late | Fever/HA--> Confusion and decrease in CSF glucose--> Impaired Consiousness, Increased CSF pressure, Increased CSF protein; Obtundation, seizures, Neurologic symptoms--> Paralysis, Coma, Death |
| Clinical presentation of Meningitis seen in children--> | Neonates and infants--> irritabilitiy, altered sleep, vomiting, decreased oral intake; Children --> lethargy, confusion, somnolence |
| Suspicion of Acute Bacterial Meningitis (ABM) Presence of immunocompromised, certain CNS diseases, papilledema, new seizures, or focal neurological deficit (YES)--> | Blood cultures and CT head--> initiate empiric therapy--> Negative CT head scan? Obtain lumbar puncture--> CSF findings confirm bacterial meningitis?--> Continue therapy; narrow based on culture results |
| Suspicion of Acute Bacterial Meningitis (ABM) Presence of immunocompromised, certain CNS diseases, papilledema, new seizures, or focal neurological deficit (NO)--> | Blood cultures and lumbar puncture--> initiate empiric therapy--> CSF findings confirm bacterial meningitis?--> Continue therapy; narrow based on culture results |
| So you get back a CSF cytology and look at lab levels during NORMAL: Appearance is (1); WBC: (2); Differential (3); Protein (4); Glucose: (5); Gram stain: (6) | 1. Clear 2. <5 (mm^3) 3. No predominance 4. <50 mg/dL 5. 2/3 of serum 6. Negative |
| So you get back a CSF cytology and look at lab levels (Bacterial Meningitis): Appearance is (1); WBC: (2); Differential (3); Protein (4); Glucose: (5); Gram stain: (6) | 1. Turbid, cloudy, purulent 2. > 100 (mm^3) 3. >80% PMNs (polymorphonucleosides) 4. > 50 mg/dL 5. <50% of serum or < 40, </= 0.6 in neonates 6. 60-90% sensitive; > 97% specific |
| Serum glucose is less than 50 during bacterial meningitis. Bacteria love to eat glucose, feed on it and spit out ________ | Proteins *Bacterial meningitis is highly PMN driven (high protein and low glucose) |
| When we get a gram stain back what are the typical gram (+) bugs in bacterial meningitis? | Streptococcus pneumoniae; Streptococcus agalactiae; Listeria monocytogenes |
| Another name for Streptococcus Agalactiae is? | Group B Strep |
| When we get a gram stain back what are the typical gram (-) bugs in bacterial meningitis? | Neisseria meningitidis; Haemophilus influenzae; Aerobic gram (-) bacilli |
| >80% of cases in children and adults are caused by: | S. Pneumoniae and N. meningitidis |
| <10% of cases are caused by gram (-) bacilli, including ____________ and _________ ____________ | Enterobacteriaceae and Pseudomonas aeruginosa |
| Polymicrobial infections in meningitis are ______ | rare |
| Film Array Meningitis/Encephalitis Panel is a? | PCR test that runs DNA to all of these different viruses and bacteria and takes about an hour *1 test, 14 targets |
| (FYI)What are the 14 targets: | E. Coli; H. Influenzae; Listeria; N. meningitidis; S. Agalactiae; S. Pneumo; CMV, Enterovirus, HSV-1 and 2, Human herpes virus -6, Human parechovirus, Varicella Zoster Virus; Cryptococcus neoformans/gatti |
| What are the common pathogens in meningitis seen at different ages: <1 month? | Streptococcus agalactiae ⭐️ ; E. coli; Listeria monocytogenes; Klebsiella spp |
| What are the common pathogens in meningitis seen at different ages: 1-23 months? | S. Pneumo ⭐️ ; N. meningitidis ⭐️; Streptococcus agalactiae; Haemophilus Influenzae; E. coli |
| What are the common pathogens in meningitis seen at different ages: 2-50 years? | S. Pneumo ⭐️ ; N. meningitidis ⭐️ |
| What are the common pathogens in meningitis seen at different ages: > 50 years? | S. Pneumo ⭐️ ; N. meningitidis ⭐️; Listeria monocytogenes; Aerobic gram (-) bacilli (not typically Pseudomonas) |
| This is a gram + Cocci in Chains; its an alpha hemolytic, what am I? | Streptococcus Pneumoniae |
| This is a gram + Cocci in Chains; its an alpha hemolytic, its a Beta hemolytic and also goes by the name of Group B strep, what am I? | Streptococcus agalactiae |
| This is a gram (-) Cocci, what am I? | N. meningitidis |
| This is a gram (-) and is Coccobacilli, what am I? | Haemophilus Influenzae |
| Overall management of meningitis consists of? | Empiric abx, Steroids, Fluids, Electrolytes, Antipyretics, Analgesia |
| What are characteristics of my ideal abx to cross the BBB? | Low MW; Unionized; Low protein bound; Lipophilic |
| Empiric abx therapy is based on? | Age of pt; Drug allergies; Concurrent medical conditions |
| Empirc abx therapy should be initiated w/in _____ minutes of presentation. Should be continued for 48-72h or until ___ is ruled out | 30; ABM (acute bacterial meningitis |
| Once infecting organism is identified, _________ ________ | tailor therapy |
| Empiric abx includes? | Ceftriaxone 2g IV q12h ⭐️ or Cefotaxime + Vancomycin +/- Ampicillin |
| Ampicillin for empiric therapy is usually for which bacteria? which populations do we worry for with this bacteria? | Listeria; 1. Neonates <1 month; 2. Elderly > 50; 3. Immunocompromised *so if none of these populations apply to your pt stick to Ceftriaxone + Vanco |
| We have a love/hate relationship for inflammation when we start empiric therapy, it | improves CSF parameters and allows better abx penetration BUT increased ICP (intracranial pressure) leads to comorbidities and death |
| Due to our love/hate relationship with inflammation, we also have these feelings for the use of Dexamethasone, it | inhibits the production of pro-inflammatory cytokines and decreases ICP BUT we have concerns of increased GI bleeding and immunosuppression and decreases abx penetration |
| We can start dexamethasone _________ abx or ___________ with abx | BEFORE; CONCOMITANTLY |
| Available evidence supports the use of dexamethasone in the use with ________ and _________ with H. influenzae meningitis and adults with _____ ______________ meningitis | infants; children; Strep Pneumoniae |
| Pathogen-Specific tx: which pathogens are we treating for that can cause meningitis | Strep Pneumoniae; Neisseria meningitidis, Haemophilus influenzae, Listeria monocytogenes |
| With Streptococcus Pneumoniae (Streptococcus): If PCN is susceptible we use: | PCN 4 mU IV q4h or ampicillin 2g q4h IV for 10-14 days |
| With Streptococcus Pneumoniae (Streptococcus): If PCN is resistant but 3rd gen cephalosporins are susceptible we use: | Ceftriaxone 2g IV q12h or Ceftriaxone 2g IV q4-q6h for 10-14 days |
| With Streptococcus Pneumoniae (Streptococcus): If PCN resistant and 3rd gen cephalosporins intermediate/resistant we use: | Vanco + Ceftriaxone/Cefotaxime for 10-14 days |
| With Streptococcus Pneumoniae (Streptococcus): what is our Dexamethasone duration for ADULTS? | 4 days |
| With N. meningitidis (Meningococcus): If PCN MIC < 0.06 mg/L (meaning SUSCEPTIBLE), we use: | PCN G 4 mU q4h or 24 mU continuous infusion for 7 days *continuous--> time-dependent killing |
| With N. meningitidis (Meningococcus): If PCN MIC > 0.06 mg/L (meaning RESISTANT), we use: | Ceftriaxone 2g IV q12h or Cefotaxime 2g IV q4-6h for 7 days |
| If N. Meningitidis--> we do not use? | Vanco (only covers Gram (+) and no use of steroids once we narrow it to N. meningitidis |
| With Haemophilus Influenzae: If B-lactamase (+), we use: | Ceftriaxone 2g q12h or Cefotaxime 2g IV q4-6h) for 7 days |
| With Haemophilus Influenzae: If B-lactamase (-), we use: | Ampicillin 2g IV q4h for 7 days |
| With Haemophilus Influenzae and if infants and children, we also use: | Dexamethasone for 4 days |
| With Listeria Monocytogenes--> we use: | Ampicillin 2g IV q4h (Ampicillin duration for >/= 21 days) + Gentamicin 5-7 mg/kg/day (Genamicin duration for 10 days |
| Which abx is added for coverage of L. monocytogenes? | Ampicillin remember the 3 criteria: Neonates (<1 month); older than 50; immunocompromised |
| Which of the following pathogens should be treated with Dexamethasone? | Strep pneumoniae AND Haemophilus Inflenzae |
| Ceftriaxone review: MOA? Dosing? ADRs? Clinical Pearls? | Beta-lactam: covalently bind to PBP active site, blocking enzymatic activity and preventing wall synthesis; Dosing: 2g q12h for CNS infections ADRs: Hypersensitivity rxn, hemolytic anemia Clinical Pearls: CI in hyperbilirubinemic neonates due to risk of KERNICTERUS |
| PCN MOA? Dosing? ADRs? | Beta-lactam: covalently bind to PBP active site, blocking enzymatic activity and preventing wall synthesis; Dosing: 4 mU IV q4h or 24 mU continuous infusion ADRs: IgE-related anaphylaxis angioedema, infusion-site rxn, seizures, Jarish-Herxheimer rxn |
| Ampicillin MOA? Dosing? ADRs? | Beta-lactam: covalently bind to PBP active site, blocking enzymatic activity and preventing wall synthesis; Dosing: 2g IV q4h ADRs: rash, fever, anaphylaxis eosinophilia, thrombocytopenia, n/v/d |
| Vancomycin: MOA? Dosing? ADRs? | Binds to D-ala-D-ala and forms a stable complex and prevents the use of the precursor for cell wall synthesis = cell death Dosing: 15-20 mg/kg q8-12h in normal renal function, +/- LD, very variable dosing based on institution ADRs: Nephrotoxicity, VIS, ototoxicity, thrombocytopenia, neutropenia, hypersensitivity |
| Prophylaxis in meningitis is only for: | The 2 gram (-) pathogens: N. Meningitidis and H. Influenzae |
| Meningitis prophylaxis is NOT for: | The 2 gram (+) pathogens: S. Pneumoniae and Listeria monocytogenes |
| Who gets meningitis prophylaxis? | People that are "CLOSE CONTACTS" |
| Close contacts, in meningitis prophylaxis, is defined as: | unvaccinated household members, day-care antendees, nursing home residents, crowded confined populations (>/= 4h of contact/day) |
| N. Meningitidis prophylaxis abx include: | Ceftriaxone 250 mg IM once OR Ciprofloxacin 500 mg PO once OR Rifampin 600 mg PO q12h for 4 doses |
| H. Influenzae prophylaxis abx include: | Rifampin 600 mg PO daily for 4 doses Children: 1 month-12yo: 20 mg/kg/daily for 4 doses |
| Meningococcal meningitis is a contagious disease that spreads through _______ and ________ droplets | saliva; respiratory |
| Summary of Therapy based on susceptibilities: S. Pneumo: | Continue Vanco +/- Ceftriaxone for 10-14 days Dexamethasone for 4 days (NO prophylaxis) |
| Summary of Therapy based on susceptibilities: N. Meningitidis: | Continue Ceftriaxone for 7 days *No steroids; Prophylaxis regiment: Ceftriaxone 250 mg IM once OR Rifampin 600 mg PO q12 for 4 doses |
| Summary of Therapy based on susceptibilities: H. Influenzae: | Ampicillin OR continue Ceftriaxone for 7 days; Dexamethasone for 4 days; Prophylaxis with Rifampin 600 mg PO q12h for 4 doses |
| Summary of Therapy based on susceptibilities: Listeria monocytogenes | Gentamicin for 10 days + Ampicillin >/= 21days; NO steroids/ No prophylaxis |
| We vaccinate to protect pts from 3 pathogens, which are? | S. Pneumoniae(Pneumococcal); N. Meningitidis (Meningococcal A, C, W, Y and MenB); H. Influenzae (Hib) |
| What is Antimicrobial Stewardship (AMS)? | The effort to measure and improve how abx are prescribed by clinicians and used by pts. Improving abx prescribing and use is critical to effectively treat infections, protect pts from harms caused by unnecessary abx use, and combat abx resistance |
| Abx resistance is an ______ global public health threat | URGENT |
| Antimicrobial Stewardship is a working relationship b/w _______ _______ and _________ __________ . It involves selection of antimicrobials from each class of drugs that does the LEAST collateral damage; appropriate de-escalation when culture results are available | infection control, antimicrobial management |
| What is the primary goal of antimicrobial stewardship? | Optimize clinical outcomes and minimizing unintended consequences of antimicrobial use |
| Unintended consequences of antimicrobial stewardship includes: | toxicity; selection of pathogenic organism such as C. Diff causing abx (Clinda; FQ's, Beta-lactams); Emergence of resistant pathogens |
| What is the secondary goal of antimicrobial stewardship? | Reduce healthcare costs w/o adversely impacting the quality of care |
| Outcomes of ASP (Antimicrobial Stewardship Programs) include: | increasing infection cure rate; decreasing (tx failures, C. diff infections, ADEs, Abx resistance, Hospital costs, Length of stay) |
| Antimicrobial stewardship means choosing: the right abx at the right dose, for the right duration, at the right time. what are the 10 considerations? | 1. Only use abx when indicated; 2.Follow guidelines; 3. optimize use of dx tests; 4. don't treat viruses w/ abx; 5. Discuss the harms of abx; 6. Educate on worsening infection and seeking medical care; 7. De-escalate; 8. Escalate; 9. IV-PO switch; 10. Dose optimization |
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