Meningitis, Bacterial


Article Author:
Tyler Runde


Article Editor:
John Hafner


Editors In Chief:
Marlon Bayot
John Sanchez
Bruce Blanchard


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/5/2019 10:47:16 PM

Introduction

Bacterial meningitis is a bacterial infection of the meninges, which is the protective covering for the brain and spinal cord resulting in inflammation. It is a serious and life-threatening condition that requires prompt diagnosis and treatment.[1][2][3]

Etiology

Bacterial meningitis is caused by a bacterial infection of the meninges, resulting in inflammation. The infection is either community-acquired or nosocomial. Community-acquired bacterial meningitis is the result of the invasion of the bacteria into the meninges from bacteremia or direct extension from local infection. The most common bacterial culprit varies by age. Streptococcus pneumoniae is common in adults older than age 60. Neisseria meningitidis is common in patients 17 to 59 years old. Listeria monocytogenes and gram-negative bacteria such as Escherichia coliKlebsiella, Enterobacter, Pseudomonas aeruginosa are other less common causes. Nosocomial infections are caused by S. pneumonia, Staphylococcus aureus, Staphylococcus albus, and gram-negative bacilli. Infectious meningitis may also be caused by viruses, fungi, and protozoa. Meningitis may also be non-infectious in etiology and can be caused by cancer, medications, or inflammatory conditions.[4][5]

Epidemiology

Bacterial meningitis was previously more common in pediatric patients. However, vaccinations have increased the median age of patients infected. In 2006 there were 72,000 meningitis-related hospitalizations in the United States. The majority of these cases were due to viral infection (54.6%). Bacterial infections accounted for 21.8% of cases, and 7.3% were due to fungi and parasite infections, while 17.2% were due to an unspecified cause. There was an 8% in-hospital mortality rate for patients with bacterial meningitis, and it rose substantially for patients older than 45. [6][7][8]

Several possible risk factors for bacterial meningitis have been identified. Patients with an abnormal communication between the nasopharynx and subarachnoid space are thought to be at increased risk. This abnormal communication can be due to a congenital abnormality or a result of trauma. Patients who have undergone neurosurgery, sustained skull fractures, or have cochlear implants are also at increased risk. Other at-risk patient populations are the immunosuppressed and people that live in close personal contact with others in places like college dorms or military barracks.

Pathophysiology

Bacteria require access to the meninges to cause meningitis. There are several mechanisms for entry. Bacteremia, or bacteria in the blood, can result in bacteria crossing the blood-brain barrier. This can only be accomplished by certain bacteria, most notably N. meningitidis and S. pneumoniae. Direct extension of otitis media or sinusitis to the central nervous system (CNS) may also occur. Dural defects, either congenital or acquired, allow bacteria to enter the CNS. Nosocomial bacterial meningitis is the result of manipulation of the meninges during neurosurgical procedures. Invasion of bacteria into the subarachnoid space results in inflammation of the meninges. This causes the patient to experience headaches and fevers. Blood-brain barrier breakdown occurs secondary to the infection and inflammatory response. This causes cerebral edema and increases the patient's intracranial pressure and decreases cerebral blood flow. Altered mental status, seizures, and focal neurologic deficits occur due to the decreased perfusion and increased intracranial pressure. 

History and Physical

Fever, neck stiffness, and altered mental status are the classic triad of symptoms for meningitis; however, all three are only present in 41% of cases of bacterial meningitis. The triad is most commonly seen in elderly patients. Seventy percent of patients will present with at least one of these symptoms. Common early symptoms of the disease include fever, headache, and confusion which can progress to obtundation, focal neuro deficits, and seizures. History should include questioning about any recent neurosurgical procedures, immunization status, and living arrangements. A physical exam may reveal nuchal rigidity or positive Kernig's or Brudzinski's signs. However, the absence of these does not reliably rule out the disease. Brudzinski's sign occurs when passive flexion of the neck causes involuntary flexion of the knee. Kernig's sign is resistance or pain with knee extension when the patient is supine, and their hip is flexed to 90 degrees. These signs are thought to be secondary to meningeal irritation. The fundoscopic exam may reveal papilledema due to increased intracranial pressure. A rapidly spreading petechial rash, known as purpura fulminans, would suggest a Meningococcal infection.

Evaluation

Patients presumed to have bacterial meningitis should receive a lumbar puncture to obtain a cerebrospinal fluid (CSF) sample. The CSF should be sent for Gram stain, culture, complete cell count (CBC), and glucose and protein levels. Bacterial meningitis typically results in low glucose and high protein levels in the cerebrospinal fluid. A neutrophil predominance on cell count would be expected. The diagnosis would be confirmed with bacteria identified on gram stain or culture. A non-contrast CT scan of the head should be performed before lumbar puncture if the patient has a risk of herniation. Risk factors include papilledema on the exam, new onset seizures, focal neurologic deficits, or is immunocompromised. Consider delaying the lumbar puncture if the patient has unstable vital signs, coagulation abnormalities, or has had a recent seizure. Treat with antibiotics empirically if testing is going to be delayed. Blood cultures should be obtained as 53% of patients have concurrent bacteremia. Elevated C-reactive protein or procalcitonin levels would suggest a bacterial rather than viral etiology.[9][10][11]

Treatment / Management

Timely administration of antibiotics is essential. Delays in the administration of 3 to 6 hours are associated with increased mortality. The identified bacteria determine antibiotic selection. Empiric treatment with ceftriaxone and vancomycin should strongly be considered if the diagnosis is going to be delayed. Patients who are immunocompromised or older than 50 should also receive ampicillin. Patients with bacterial meningitis due to head trauma or post-neurosurgical procedure need to be covered for methicillin-resistant Staphylococcus aureus and aerobic gram-negative organisms. They should receive vancomycin and ceftazidime or cefepime. Acyclovir can also be administered for HSV coverage. Antibiotics can then be narrowed once the culture and sensitivities have resulted. Dexamethasone may increase survival if given at the time of antibiotic administration for S. pneumoniae infections. It has not been shown to improve outcomes for meningitis caused by other bacteria. Patients suspected of having meningococcal meningitis should be placed in droplet precautions until they have received 24 hours of antibiotics. Close contacts should also be treated prophylactically. Ciprofloxacin, rifampin, or ceftriaxone may be used. Close contacts are defined as people within 3 feet of the patient for more than 8 hours during the seven days before and 24 hours after receiving antibiotics. People exposed to the patient's oral secretions during this time should also be treated.[12][13][14]

Enhancing Healthcare Team Outcomes

Bacterial meningitis is a serious CNS infection with high morbidity and mortality. To improve patient outcomes, it is best managed by a multidisciplinary team that includes an infectious disease expert, emergency department physician, laboratory professional, internist, nurse practitioner, and a pediatrician. The key is to start prompt treatment without delay. One should not wait for cultures if suspicion is high of meningitis. These patients need inpatient treatment until all symptoms have disappeared. The outlook for patients with delayed diagnosis or treatment is poor. More important, delays also lead to litigation. [15][16]

 

 


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Meningitis, Bacterial - Questions

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Which organism shows the greatest increased risk of meningitis in older adults?



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A patient present with a high fever, extreme lethargy, stiff neck, loss of appetite and vomiting for the past 2 days. The patient appears very ill, is hypotensive, and dehydrated with no urine output in the last 12 hrs. Which of the following may be cause of the problem?



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A patient with a headache and fever has bright green cerebrospinal fluid. What is the most likely cause?



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Which of the following is associated with low levels of glucose in the cerebrospinal fluid?



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Which third-generation cephalosporin does not cross the blood-brain barrier?



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Which of the following statements is true regarding the use of corticosteroids in the treatment of acute bacterial meningitis?



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A patient has bacterial meningitis and a complete blood count shows elevation of leukocytes. What is released by the leukocytes?



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A patient with meningitis has a LP with the following CSF findings: WBC-5000/L, 90% PMNs, low glucose, high protein and Gram positive diplococci on gram stain. What is the organism?



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Low levels of glucose in the CSF are usually associated with which diagnosis?



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Which of the following is not used to treat Meningococcal meningitis in adults?



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A young male who is found unconscious at home has a temperature of 37.9 C and neck stiffness. His pupils are normal. Examination shows upper motor signs in both lower limbs with a positive Babinski sign. CT reveals diffuse cerebral edema. What is the most likely diagnosis?



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A patient has bacterial meningitis with an elevated WBC. What substance is usually released by the leukocytes?



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A patient is examined and the following findings on examination of the CSF are recorded: WBC 5000/L, 90% PMNs, low glucose, high protein and gram-positive diplococci on gram stain. What is the causative organism of meningitis?



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In adults, what is the most common cause of bacterial meningitis?



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What is the most common cause of meningitis in people over the age of 65?



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Globally, what is the most common cause of epidemic meningitis?



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In a patient with a ventriculo-peritoneal shunt, what is the most common organism responsible for meningitis?



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A patient with meningitis has the following findings on examination of the cerebrospinal fluid: WBC 5000/L, 90% PMNs, low glucose, high protein, and gram positive diplococci on gram stain. What is the most likely causative organism?



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Which of the following is not true of bacterial meningitis?



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A 6-month-old infant has 3 generalized seizures. The child had been healthy up to this point. She had a one-day history of loose stools. Exam shows a temperature of 39.0 C, a stiff neck, and lethargy. Which of the following is indicated?



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A 74 year old female is in a coma. She has a tonic clonic seizure after arrival. She had been sick for a week with a cough and lethargy. This morning she had blurred vision, headache, and vomiting. CT shows no mass so lumbar puncture is performed. What are the most likely findings?



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A patient has a spinal tap because of suspected meningeal irritation, lethargy, and fever. The cerebrospinal fluid (CSF) results are 8,000 WBC/mm3, protein of 60 mg/dl, and glucose of 15 mg/dl. The serum glucose is 100 and the white blood cells are mostly neutrophils. Gram stain is negative and opening pressure is 210 mm H2O. What is the most likely type of infection?



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Which of the following is least likely to be a sign of meningitis?



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Select the condition NOT characterized by predominantly mononuclear cells in the CSF.



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Which of the following pathogens is most often isolated in adults with bacterial meningitis that is community acquired?



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Which of the following is correct about the use of steroids for acute bacterial meningitis?



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What percentage of adults with community acquired bacterial meningitis has stiff neck, fever, and altered mental status?



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Select the most likely bacterial pathogen causing meningitis after closed traumatic skull fracture.



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A 13 month old girl is hospitalized with bacterial meningitis and treated with antibiotics. On the 2nd day of hospitalization she developed right sided twitching involving the face, arm, and leg. This was followed by right sided weakness that was persistent over the next 2 days despite increased appetite, resolution of fever, and generalized improvement. What is the most probable diagnosis?



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Which of the following is the most common cause of meningitis in children greater than one year in the United States?



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Lumbar puncture is done and the cerebrospinal fluid (CSF) analysis reveals a glucose of 20 mg/dl. Which of the following additional CSF findings do NOT go with the CSF glucose result?



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Which of the following is NOT a common complication of bacterial meningitis?



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What is the most common cause of bacterial meningitis in children in the United States?



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Meningitis is the provisional diagnosis in any infant with fever who is younger than what age?



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A patient has a witnessed generalized tonic-clonic seizure. He has no history of prior seizures, head trauma, stroke, or tumor. He is married, unemployed, and on no medications. The patient is postictal. His skin exam is normal but his neck is stiff. White blood cells are 20,000/ml, hematocrit 36 percent, and platelets are 200,000. Glucose is 100 mg/dl, sodium is 140 mEq/dl, calcium is 8.9 mg/dL, magnesium 2.0 mg/dL, SGOT 20 U/L, BUN 12 mg/dL, and creatine 1.0 mg/dL. Urine toxicology screen shows marijuana and cocaine. Select the next appropriate steps.



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In adults, which bacteria most commonly causes acute pyogenic meningitis?



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Which of the following conditions is least likely to have cerebrospinal fluid lymphocytosis?



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A 17-year-old male presents to the emergency department with a 2-day history of fevers, headache, photophobia, and neck pain. Of note, the patient is 14 days status post craniotomy for a gunshot wound to the head. On exam, the patient is lethargic but oriented to person, place, and time. Workup is significant for a white blood cell count of 26,000 cells/microL and a lactate of 5.2 mmol/L. What should be the initial antibiotic therapy for this patient?



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A 78-year-old female, history of coronary artery disease, hypertension, diabetes mellitus, and hypothyroidism, presents to the emergency department with two days of fever, headache, and neck stiffness. Her physical examination is significant for fever of 101.1 F and heart rate of 110 bpm. She has a stiff neck, photophobia, and nuchal rigidity. Laboratory values are significant for leukocytosis. Lumbar puncture is pending. What is the most appropriate empiric regimen of antibiotics?



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A nursing professor is quizzing a student regarding the physical exam of a client with suspected bacterial meningitis. Which of the following make up the classic triad or four most common symptoms of bacterial meningitis? Select all that apply.



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Which of the following groups of people are at a higher risk for acquiring bacterial meningitis compared to the general population? Select all that apply.



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A 17-year-old patient has been admitted with a diagnosis of bacterial meningitis and is being treated with antibiotics. While in hospital, the nurse will monitor the patient for which of the following? Select all that apply.



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A 45-year-old male is brought to the emergency room by his wife. He presents with fever, stiff neck, photophobia, and altered mental status. Lumbar puncture is done, and the cerebrospinal fluid (CSF) has a very cloudy appearance. Analysis of the CSF returns from the lab roughly thirty minutes later showing a positive gram-stain, low glucose levels, high protein levels, and increased polymorphonuclear leukocytes (PMNs). What are the next steps?



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Meningitis, Bacterial - References

References

Ramgopal S,Walker LW,Vitale MA,Nowalk AJ, Factors associated with serious bacterial infections in infants ≤60 days with hypothermia in the emergency department. The American journal of emergency medicine. 2019 Apr 11;     [PubMed]
Lien CY,Lee JJ,Tsai WC,Chen SY,Huang CR,Chien CC,Lu CH,Chang WN, The clinical characteristics of spontaneous Gram-negative bacterial meningitis in adults: A hospital-based study. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2019 Apr 17;     [PubMed]
Fuentes-Antrás J,Ramírez-Torres M,Osorio-Martínez E,Lorente M,Lorenzo-Almorós A,Lorenzo O,Górgolas M, Acute Community-Acquired Bacterial Meningitis: Update on Clinical Presentation and Prognostic factors. The new microbiologica. 2019 Apr 17;     [PubMed]
Chacon-Cruz E,Roberts C,Rivas-Landeros RM,Lopatynsky-Reyes EZ,Almada-Salazar LA,Alvelais-Palacios JA, Pediatric meningitis due to {i}Neisseria meningitidis, Streptococcus pneumoniae{/i} and Group B Streptococcus in Tijuana, Mexico: active/prospective surveillance, 2005-2018. Therapeutic advances in infectious disease. 2019 Jan-Dec;     [PubMed]
Linder KA,Malani PN, Meningococcal Meningitis. JAMA. 2019 Mar 12;     [PubMed]
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Mohan A,Munusamy C,Tan YC,Muthuvelu S,Hashim R,Chien SL,Wong MK,Khairuddin NA,Podin Y,Lau PS,Ng DC,Ooi MH, Invasive Salmonella infections among children in Bintulu, Sarawak, Malaysian Borneo: a 6-year retrospective review. BMC infectious diseases. 2019 Apr 18;     [PubMed]
El-Naggar W,Afifi J,McMillan D,Toye J,Ting J,Yoon EW,Shah PS, Epidemiology of Meningitis in Canadian Neonatal Intensive Care Units. The Pediatric infectious disease journal. 2019 May;     [PubMed]
Haydar SM,Hallit SR,Hallit RR,Salameh PR,Faddoul LJ,Chahine BA,Malaeb DN, Adherence to international guidelines for the treatment of meningitis infections in Lebanon. Saudi medical journal. 2019 Mar;     [PubMed]
Simone L,Lyttle MD,Roland D,Stephens D,Schuh S, Canadian and UK/Ireland practice patterns in lumbar puncture performance in febrile neonates with bronchiolitis. Emergency medicine journal : EMJ. 2019 Mar;     [PubMed]
Le Turnier P,Navas D,Garot D,Guimard T,Bernard L,Tattevin P,Vandamme YM,Hoff J,Chiffoleau A,Dary M,Leclair-Visonneau L,Grégoire M,Pere M,Boutoille D,Sébille V,Dailly E,Asseray N, Tolerability of high-dose ceftriaxone in CNS infections: a prospective multicentre cohort study. The Journal of antimicrobial chemotherapy. 2019 Apr 1;     [PubMed]
Ferraro M,Morucci L,Coppeta L,De Carolis G,Pietroiusti A,Franco E,Magrini A, Managing the risk of bacterial meningitis among healthcare workers. Occupational medicine (Oxford, England). 2019 Apr 13;     [PubMed]
Young N,Thomas M, Meningitis in adults: diagnosis and management. Internal medicine journal. 2018 Nov;     [PubMed]
Poi BN,Pasupulety Venkata NK,Auckland CR,Paul SP, Neonatal meningitis and maternal sepsis caused by Streptococcus oralis. Journal of neonatal-perinatal medicine. 2018;     [PubMed]
Biondi EA,Lee B,Ralston SL,Winikor JM,Lynn JF,Dixon A,McCulloh R, Prevalence of Bacteremia and Bacterial Meningitis in Febrile Neonates and Infants in the Second Month of Life: A Systematic Review and Meta-analysis. JAMA network open. 2019 Mar 1;     [PubMed]
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