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Bacterial MeningitisBacterial MeningitisChelsea Mannebach, Pharm.D.

Boise Veterans Affairs Medical Center

April 8th, 2013

ObjectivesObjectives

� Identify pathogens that can cause bacterial meningitis

� Discuss signs and symptoms of meningitis infection

� Discuss antimicrobial agents commonly used to treat bacterial meningitis

PrePre--Lecture QuestionsLecture Questions

1. T/F: Common pathogens that can cause bacterial meningitis vary by age group.

2. T/F: Signs and symptoms of bacterial meningitis may include sudden onset of fever, headache, and stiff neck.

3. T/F: All patients with suspected meningitis should be treated with oral antibiotics to allow better cerebral spinal fluid penetration.

OverviewOverview

� Background

� Diagnosis

� Treatment

� Prevention

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Bacterial MeningitisBacterial Meningitis

� Bacterial infection that causes inflammation of the membranes that cover the brain and spinal cord

http://www.cdc.gov/meningitis/bacterial.html. Accessed 3/17/13.

Photo courtesy of : www.ucdmc.ucdavis.edu

AnatomyAnatomy

Photo courtesy of: studyblue.com

3 Layers: Dura, Arachnoid, Subarachnoid Space

http://emedicine.medscape.com/article/232915-overview#aw2aab6b2b2. Accessed 3/21/13.

BackgroundBackground

� 8000 cases per year

◦ 2000 deaths per year

� Attack rate 0.6-4 per 100,000 (U.S.)

� Epidemiologic shift due to vaccination

◦ Largely disease of older adults

� Incidence 10-fold higher in developing countries

◦ Lack of access to preventative services

Thigpen MC, Whitney CG, Messonnier NE, Zell ER, Lynfield R, Hadler JL, et al. Emerging Infections Programs Network. Bacterial meningitis in the United States, 1998-2007. N Engl J Med. 2011;364:2016-25. http://emedicine.medscape.com/article/232915-overview#a0156. Accessed 3/21/13.

Changing EpidemiologyChanging Epidemiology

http://emedicine.medscape.com/article/232915-overview#a0156. Accessed 3/21/13.

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ComplicationsComplications

� Brain Damage

� Hearing Loss

� Blindness

� Learning Disabilities

� Seizures

� Death

◦ 1 in 10 cases fatal

◦ 1 in 7 survivors left with severe handicap

http://emedicine.medscape.com/article/232915-overview#aw2aab6b2b6aa. Accessed 3/21/13.

PathogensPathogens

� Haemophilus influenzae

� Streptococcus pneumoniae

� Group B Streptococcus

� Listeria monocytogenes

� Neisseria meningitidis

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Mortality RatesMortality Rates

S. Pneumoniae meningitis 19-26%

H. Influenzae meningitis 3-6%

N. Meningitidis meningitis 3-13%

L. Monocytogenes meningitis 15-29%

http://emedicine.medscape.com/article/232915-overview#aw2aab6b2b6aa. Accessed 3/21/13.

CausesCauses

Newborns Causes

Newborns Group B Streptococcus, Escherichia coli, listeriamonocytogenes

Infants and Children

Streptococcus pneumoniae, neisseriameningitidis, haemophilus influenzae type B

YoungAdults Neisseria meningitidis, streptococcus pneumoniae

Older Adults Streptococcus pneumoniae, neisseriameningitidis, listeria monocytogenes

Table Adapted from: http://www.cdc.gov/meningitis/bacterial.html#reference

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Risk FactorsRisk Factors

� Age

� Community setting

� Comorbid conditions

� Microbiology work

� Travel

http://www.cdc.gov/meningitis/bacterial.html. Accessed 3/21/13.

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TransmissionTransmission

� Respiratory secretions

� Contaminated food

◦ Listeria monocytogenes

� Close contacts

Photo courtesy of: fisc.cals.wisc.edu

http://www.cdc.gov/meningitis/bacterial.html. Accessed 3/21/13.

PresentationPresentation

� Sudden onset of fever, headache, stiff neck

� Other symptoms include:

◦ Nausea

◦ Vomiting

◦ Sensitivity to light

◦ Altered mental status

http://www.cdc.gov/meningitis/bacterial.html Accessed 3/21/13.

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DiagnosisDiagnosis

� Lumbar puncture

◦ Cerebrospinal fluid sample

Photo courtesy of: www7.georgetown.edu

http://www.cdc.gov/meningitis/bacterial.html. Accessed 3/21/13.

TreatmentTreatment

TunkelAR, Hartman BJ, Sheldon LK, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis.2004;39:1267-84.

ManagementManagement

TunkelAR, Hartman BJ, Sheldon LK, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis.2004;39:1267-84.

TreatmentTreatment

� Antimicrobials

� Key: start ASAP!

� Appropriate antibiotic treatment reduces the risk of dying from meningitis to < 15%

� +/- corticosteroids (dexamethasone)

http://www.cdc.gov/meningitis/bacterial.html. Accessed 3/21/13.

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TreatmentTreatment

TunkelAR, Hartman BJ, Sheldon LK, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis.2004;39:1267-84.

Common Antimicrobial AgentsCommon Antimicrobial Agents

� Cephalosporins

� Penicillin G

� Ampicillin

� Vancomycin

� Gentamicin

� Meropenem

� Doxycycline

� Ciprofloxacin

� Clindamycin

http://emedicine.medscape.com/article/232915-overview. Accessed 3/21/13.

Duration of TherapyDuration of Therapy

TunkelAR, Hartman BJ, Sheldon LK, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis.2004;39:1267-84.

Supportive CareSupportive Care

� Shock/hypotension

� Seizure precautions

� Airway protection

� Oxygen

� Management of fever and pain

� Head elevation

http://emedicine.medscape.com/article/232915-overview. Accessed 3/21/13.

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PreventionPrevention

� VACCINATION

◦ Neisseria meningitidis (meningococcus)

◦ Streptococcus pneumoniae (pneumococcus)

◦ Haemophilus influenzae type b (Hib)

http://www.cdc.gov/meningitis/bacterial.html. Accessed 3/21/13.

VaccinationVaccination

Meningococcal VaccineMeningococcal Vaccine

� Age 11-12 years receive MCV4 Booster at age 16 years

� Adults can receive MPSV4 or MCV4

◦ College freshman in dorm

◦ Military recruit

◦ Damaged or removed spleen

◦ Microbiologist exposed to n. meningitidis

◦ Travel

http://www.cdc.gov/vaccines/vpd-vac/mening/who-vaccinate.htm. Accessed 3/22/13.

Pneumococcal VaccinePneumococcal Vaccine

� PCV13◦ Infants and children < 2 years of age � Series: 2 months, 4 months, 6 months, and 12-15 months

◦ Cochlear implants

� PPSV23◦ 65 years of age or older

◦ 2 through 64 years of age with long-term health problem or a condition/medication that lowers the body’s resistance to infection

◦ 19 through 64 years of age if smoker or asthma

◦ Nursing home or LTCF resident

http://www.cdc.gov/vaccines/vpd-vac/pneumo/in-short-both.htm. Accessed 3/22/13.

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HibHibVaccineVaccine

� All children < 5 years of age

� Series

◦ 2 months, 4 months, 6 months, 12-15 months

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http://www.cdc.gov/vaccines/vpd-vac/hib/default.htm#recs. Accessed 3/22/13.

Special PopulationsSpecial Populations

� Pregnant women

◦ Listeriosis (Listeria monocytogenes)

◦ Group B Streptococcus

www.cdc.gov/meningitis/bacterial.html. Accessed 3/21/13.

Photo courtesy of: yourlife.usatoday.com

http://www.nytimes.com/2011/10/20/business/listeria-outbreak-traced-to-colorado-cantaloupe-packing-shed.html?pagewanted=all&_r=0. Accessed 3/21/13.

Jensen Farms Jensen Farms –– Colorado, 2011Colorado, 2011

� Recalled 300,000 cases of melons following listeria outbreak

� 25 people killed

� 123 people ill

� Deadliest outbreak caused by foodbornediseases since 1985

http://www.nytimes.com/2011/10/20/business/listeria-outbreak-traced-to-colorado-cantaloupe-packing-shed.html?pagewanted=all&_r=0. Accessed 3/21/13.

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Photo courtesy of: http://www.cdc.gov/listeria/outbreaks/cheese-09-12/advice-consumers.html

Forever Cheese, Inc., 2012Forever Cheese, Inc., 2012

� Recalls:

◦ Frescolina Marte brand ricotta salata cheese

◦ All cheese from Fattorie Chiarappa

� Fast Facts:

◦ 22 cases

◦ 14 states

◦ 4 deaths

◦ 20 hospitalizations

http://www.cdc.gov/listeria/outbreaks/cheese-09-12/. Accessed 3/21/13.

SummarySummary

� Bacterial meningitis is a serious infection of the brain, that if left untreated can result in severe, long-term complications

� Numerous pathogens can cause bacterial meningitis – prevalence varies with age

� Bacterial meningitis can be treated with antibiotics and supportive care

PostPost--Lecture QuestionsLecture Questions

1. T/F: Common pathogens that can cause bacterial meningitis vary by age group.

2. T/F: Signs and symptoms of bacterial meningitis may include sudden onset of fever, headache, and stiff neck.

3. T/F: All patients with suspected meningitis should be treated with oral antibiotics to allow better cerebral spinal fluid penetration.

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ResourcesResources

� Infectious Diseases Society of America (IDSA)

◦ http://www.idsociety.org

� Centers for Disease and Control and Prevention (CDC)

◦ www.cdc.gov/meningitis/bacterial.html

� World Health Organization (WHO)

◦ http://www.who.int/nuvi/meningitis/en/index.htm

Questions?Questions?

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