Acute meningitis remains a devastating disease. The professionals must have a low threshold to suspect meningitis, to carry out the appropriate studies and to treat it in time.
Meningitis is the inflammation of the meninges that cover the brain. The cerebrospinal fluid (CSF) of patients has numerous leukocytes (pleocytosis).
In adults,> 5 leukocytes / μl is considered a high number. Bacterial or viral meningitis is confirmed by detecting an infectious agent in the CSF. Bacterial meningitis can also be suspected by the symptoms of meningism and the finding of bacteremia.
The most frequent causes of meningitis in immunocompetent adults are viruses and bacteria
Viruses are causative in up to half of the cases. The enterovirus is the most frequent; herpes simplex and varicella zoster virus follow in frequency. Streptococcus pneumonia and Neisseria meningitidis are the most frequent bacteria and between them they are responsible for approximately 25% of cases. Other causes such as Haemophilus influenzae, Listeria monocytogenes, Mycobacterium tuberculosis and fungi (cryptococcus) are less frequent and represent
The clinical picture alone can not confirm the diagnosis of meningitis. Lumbar puncture (LP) is essential to confirm the diagnosis and determine the cause
In one study, 95% of patients with bacterial meningitis had at least two of the following symptoms: headache, neck stiffness, fever, and altered consciousness. Neurological deficiencies were found in about one third of patients. Other studies report similar data.
The presence of rash in an alleged meningitis increases the probability of N meningitidis. However, 37% of meningococcal meningitis do not have a rash. Varicella zoster virus and enterovirus can also be associated with erythema.
Treatment
If the patient has signs of respiratory or circulatory difficulty (eg in associated sepsis), the initial treatment should focus on stabilizing these systems.
All patients should be seen by a specialist in the first hours of their hospitalization. The Glasgow coma scale should be recorded due to its prognostic value and to enable changes to be monitored. The presence of a rash and the use of antibiotics before the patient’s admission should also be recorded.
If the patient arrives at the consultation with sepsis, it should be treated according to the guidelines for sepsis. If the infectious focus of sepsis is meningitis, antibiotic therapy should follow the recommendations for meningitis. For example, piperacillin / tazobactam is not recommended for sepsis secondary to meningitis due to its poor penetration through the blood-brain barrier.
A recent study showed no advantage of antibiotics prior to hospitalization in sepsis. Previous studies for meningitis were inconclusive, meaning that this issue is unclear. The treatment of other aspects of sepsis, such as circulation, should follow the recommendations for sepsis.
The treatment for bacterial meningitis is antibiotics, with or without corticosteroids
The choice of antibiotics is a three-stage process: an initial empirical decision based on clinical suspicion, a new evaluation after the results of the microscopy, and another evaluation when the culture or PCR results arrive.
When bacterial meningitis is suspected, dexamethasone should be started shortly before or concurrently with antibiotics at a dose of 10 mg intravenously (IV) every 6 hours.
Dexamethasone can be started up to 12 hours after the start of antibiotic therapy, although the impact of this on mortality has not been studied. If it is likely to be pneumococcal meningitis, dexamethasone should be continued for 4 days. When tuberculous meningitis is suspected, dexamethasone should be administered according to the guidelines.
There is no specific treatment for viral meningitis. Treatment with acyclovir is only useful for herpetic encephalitis, but not for meningitis. The use of acyclovir should be considered only if the patient has symptoms of encephalitis, such as altered consciousness, focal neurological signs, brain parenchyma inflammation in the temporal lobe area in imaging studies.
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