 Up to age 60:

 Age 60 and above

 S. pneumoniae 60%
 S. pneumoniae 70%
 N. meningitidis 20%
 L. monocytogenes 20%
 H. influenzae 10%
 group B streptococcus 4%
 L. monocytogenes 6%
 N. meningitidis 3%
 group B streptococcus 4%
 Up to age 60:
 GNB 33%
 Streptococci 9%  Risk Factors:
 Staphylococcus aureus 9%  neurosurgery
 Coagulase-negative staph 9%  head trauma
 S. pneumoniae, N.  neurosurgical device
meningitidis, and L.  CSF leak
monocytogenes 8%
 Predisposing
Organism Site of entry Age range
conditions
Neisseria Usually none, rarely
Nasopharynx Childhood-mid 20's
meningitidis complement deficiency

All conditions that

Nasopharynx or direct
Streptococcus predispose to
extension across skull All ages
pneumoniae fracture
pneumococcal
bacteremia

Listeria Defects in cell mediated

GI tract, placenta All ages
monocytogenes immunity

Surgery and foreign

Coagulase-negative
Dermal or foreign body All ages body, especially
staphylococcus ventricular shunt

Endocarditis, surgery
Staphylococcus Bacteremia, dermal, or and foreign body,
All ages
aureus foreign body especially ventricular
shunt

All ages, especially the Advanced medical

Gram negative rods Various
elderly illness, neurosurgery

Adults now, but infants

Haemophilus Diminished humoral
Nasopharynx and children if not
influenzae vaccinated
immunity
 predisposing factors
 Recent exposure to someone with meningitis
 A recent infection (especially respiratory or otic infection)
 Recent travel, particularly to endemic meningococcal areas
 Injection drug use
 Recent head trauma
 Otorrhea or rhinorrhea
 A progressive petechial or ecchymotic rash
 Frequency of defect
Host problem Organism favored actually leading to
infection

S. pneumoniae Common in all age groups

Absence of opsonizing
antibody H. influenzae
Common in very young
children

S. pneumonia Rare
Asplenia
surgical / functional N. meningitidis Very rare

Complement deficiency N. meningitidis Very rare

L. monocytogenes Rare
Corticosteroid
C. neoformans Rare

About five percent eventually

C. neoformans
get cryptococcal meningitis

HIV infection S. pneumoniae Common presenting illness

L. monocytogenes Rare

S. aureus various gram-negative

Bacteremia/Endocarditis rods
Rare

S. pneumoniae or other oral

Basilar skull fracture flora
Very rare
 Presenting manifestations

 Fever was present in 95%

 Neck stiffness was present in 88%
 Mental status was altered in 78%
 Headache 79%
 Neurologic complications:
 neurologic deficits 20%
 Seizures 15%
 Photophobia
 Jolt accentuation of headache
•sensitivity of 97 %
•specificity of 60 % for the diagnosis of CSF
pleocytosis
•Untreated or delayed treatment “FATAL”
•Markers for bad prognosis:

•Hypotension
•altered mental status
•seizures

• In-hospital mortality 27%

•Neurologic deficit on discharge 9%
CBC-D / BMP
Blood cultures positive in 50 to 75%
•Immunocompromised state.
•History of CNS disease.
•New onset seizure (within one week)
•Papilledema
•Abnormal level of consciousness
•Focal neurologic deficit
•Prior administration of antimicrobials tends to have
minimal effects on the chemistry and cytology
findings
• can reduce the yield of Gram's stain and culture
Opening Pressure
•cell count and differential
•glucose
•protein concentration
• Gram's stain
•Culture & sensitivity
 Normal values for CSF analysis

• protein < 50 mg/dL of

•CSF/serum glucose ratio >50%
•WBC < 5 white cells /microL
 Total white blood cell count
Glucose (mg/dL) Protein (mg/dL)
(cells/µL)

100-
<10* 10-45 >250 50-250 >1000 5-100
1000

More
common Early
Viral bacterial
meningitis Bacterial or meningitis
Bacterial Bacterial Bacterial Bacterial
Lyme viral Viral
meningitis meningitis meningitis meningitis
disease meningitis meningitis
Neurosyphilis Neurosyphilis
TB meningitis

Less
common Neurosyphilis
TB meningitis Some viral
Some cases
Fungal infections TB meningitis Encephalitis Encephalitis
of mumps
meningitis (such as
mumps)
•Antibiotic therapy should be initiated
immediately after (LP)

•“if CT scan indicated before LP”, ABx therapy

should be initiated immediately
are obtained
•Antibiotic therapy
• Bactericidal
• BBB penetration

•All Abx should be given I.V.

•Empiric drug regimen
•3rd generation cephalosporin:
•Ceftriaxone
•Ceftazidime

•Vancomycin
•Ampicillin
•Dexamethasone (0.15 mg/kg every six hours) be given
•Glasgow coma score of 8 to 11
•Therapy for 4 days in pneumococcal meningitis

•I.V.F
Pathogen
S. pneumoniae
N. meningitidis
H. influenzae
L. monocytogenes
Group B streptococci
Enterobacteriaceae
Pseudomonas or Acinetobacter
Antibiotics
•Vancomycin (500 mg Q6h) PLUS
•Ceftriaxone (2 g Q12h) or,
•Cefotaxime (2 g Q4-6h or Q6-8h)
•14 days
•Penicillin G (4 million units Q4h) for
seven days
•Ceftriaxone (2 g Q12h) or
•Cefotaxime (2 g Q6h)
•7 days
•Ampicillin (2 g Q4h)
•Penicillin G (3-4 million U Q4h)
• +Gentamicin (1-2 mg/kg Q8h).
•Penicillin G (4 million U Q4h)
•2-4 weeks
•Ceftriaxone (2 g Q12h) or
•Cefotaxime (2 g Q6-8h) PLUS
•Gentamicin (1-2 mg/kg Q8h)
•3 weeks
•Ceftazidime (2 g Q8h)
•21 days
•4% percent of invasive GBS infections involve (CNS)
•1% of all cases of meningitis.
•GBS meningitis has been described
•following elective abortion
•adult GBS meningitis has been noted recently in Southeast
Asia.
•equally among immunocompromised and immunocompetent
hosts.
•mortality rate of 27%.
•>(65 years) Mortality rate 56%.
•The incidence of infection has a bimodal distribution, with
peaks mid-20s &mid-60s.
•patients present with
•Fever.
•Meningismus.
•neurologic deficits.
•spinal fluid glucose, protein, and cell counts suggestive of
bacterial meningitis
•mortality rates of 15 to 38%