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Diseases » Viral meningitis » Treatments
 

Treatments for Viral meningitis

Contents
  1. Viral meningitis: Introduction
  2. Treatment list for Viral meningitis
  3. Discussion of treatments for Viral meningitis
  4. Buy Products Related to Treatments for Viral meningitis
  5. Viral meningitis: Introduction

Treatments for Viral meningitis

The list of treatments mentioned in various sources for Viral meningitis includes the following list. Always seek professional medical advice about any treatment or change in treatment plans.

  • Watchful waiting
  • Symptomatic and supportive treatment
  • HSV, varicella and CMV have a specific antiviral therapy; most other viruses do not. For HSV the treatment of choice is acyclovir
  • Treatment is needed for fungal or mycobacterial causes of aseptic meningitis. Herpesvirus/varicella (chicken pox) virus can be treated with anti-viral medicines. Supportive treatment for non-infectious causes consists of pain medications and management of complications, if they occur
  • No specific treatment is available for enteroviral aseptic meningitis

Viral meningitis: Is the Diagnosis Correct?

The first step in getting correct treatment is to get a correct diagnosis. Differential diagnosis list for Viral meningitis may include:

Hidden causes of Viral meningitis may be incorrectly diagnosed:

Viral meningitis: Marketplace Products, Discounts & Offers

Products, offers and promotion categories available for Viral meningitis:

Viral meningitis: Research Doctors & Specialists

Research all specialists including ratings, affiliations, and sanctions.

Hospital statistics for Viral meningitis:

These medical statistics relate to hospitals, hospitalization and Viral meningitis:

  • 0.02% (3,040) of hospital episodes were for viral infections of the central nervous system in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
  • 78% of hospital consultations for viral infections of the central nervous system required hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
  • 47% of hospital episodes for viral infections of the central nervous system were for men in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
  • 53% of hospital episodes for viral infections of the central nervous system were for women in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
  • more hospital information...»

Discussion of treatments for Viral meningitis:

No specific treatment for viral meningitis exists at this time.  Most patients recover completely on their own, and doctors often will recommend bed rest, plenty of fluids, and medicine to relieve fever and headache. (Source: excerpt from Viral (Aseptic) Meningitis: DVRD)

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Book Excerpts: Treatment of Viral meningitis

Treatments of Viral meningitis: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the treatments of Viral meningitis.

Headache: Treatment
(In a Page: Signs and Symptoms)

  • Tension-type headache: Regular exercise, stress management, tricyclic antidepressants, analgesics
  • Migraine headache: Avoid triggers; serotonin agonists (e.g., sumatriptan), NSAIDs, ergotomines
  • Temporal arteritis: High-dose corticosteroids
    • Meningitis: Search for and treat the primary source (e.g., pneumonia, sinusitis, neoplasm)
      –Urgent antimicrobial administration for infections
      –Treat inflammatory causes with steroids
  • Subarachnoid hemorrhage requires attention to airway, breathing, and circulation, and management of increased intracranial pressure (maintain normal blood pressure; hypertension may cause the aneurysm to rebleed, hypotension may cause cerebral ischemia); administer nimodipine to prevent cerebral vasospasm, seizure prophylaxis with IV phenytoin, surgery
  • Cluster headache: Oxygen inhalation for 5–10 minutes; serotonin agonists, ergotamines, and/or methysergide

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Photophobia: Treatment
(In a Page: Signs and Symptoms)

  • Corneal abrasion: Topical antibiotics with or without cycloplegic agents; NSAIDs; patching may be the preferred treatment, depending on the size of the abrasion and the patient's level of discomfort
  • Bacterial conjunctivitis: Topical antibiotics
  • Allergic conjunctivitis: Topical antihistamine/mast cell stabilizers
  • Chemical conjunctivitis: Copious irrigation, topical cycloplegics, and topical antibiotics
  • Anterior uveitis: Cycloplegic agents, topical steroids, treat secondary glaucoma and underlying disorder
  • Migraine: Abortive therapy (triptans), oral pain medication, antiemetics
  • Meningitis: IV antibiotics
  • Episcleritis: Topical steroids in moderate to severe cases
  • Subarachnoid hemorrhage: Emergent neurosurgical consult

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Nuchal Rigidity: Treatment
(In A Page: Pediatric Signs and Symptoms)

    • Meningitis/encephalitis
      –Broad-spectrum antibiotics
      –Neurologic checks
      –Dexamethasone may improve neurologic outcome and lower incidence of postmeningitic deafness
  • Subarachnoid hemorrhage
    –Immediate neurosurgical evaluation
    –Consider MRA/conventional angiography
    –Surgical clipping and excision
    –Pharmacologic management of cerebral vasospasm
    –Nimodipine is often used to prevent delayed ischemia
  • Torticollis: Treat with valium, botulinum toxin type A
  • Adenitis/dental abscess: Antibiotic treatment
  • Injury: Soft collar, NSAIDs
  • Cervical muscle spasms
    –Heat, massage, soft cervical collar, analgesics

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Headache: Treatment
(In A Page: Pediatric Signs and Symptoms)

  • Explanation and reassurance alone may provide relief
  • Avoid triggers
    –Trauma, sunlight, insomnia, stress, diet, dehydration
  • Symptomatic treatment:
    –Acetominophen, NSAIDs, Midrin, Fioricet, Fiorinal
    –Selective serotonin-1 receptor agonists
    –Dihydroergotamine (DHE); Migranal nasal spray
    –Antiemetics
  • Prophylaxis
    –NSAIDs, β-blockers, tricyclic antidepressants, cyproheptadine, calcium channel blockers, antiepileptic drugs, biofeedback
    • Cluster headaches
      –Treated with inhalation of oxygen; sumatriptan
    • Pseudotumor
      –Weight reduction, Diamox
      –Optic nerve sheath decompression or shunting
    >>

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Nuchal rigidity: Emergency interventions
(Handbook of Signs & Symptoms (Third Edition))

After eliciting nuchal rigidity, attempt to elicit Kernig’s and Brudzinski’s signs. Quickly evaluate the patient’s level of consciousness (LOC). Take his vital signs. If you note signs of increased intracranial pressure (ICP), such as increased systolic pressure, bradycardia, and a widened pulse pressure, start an I.V. line for drug administration and deliver oxygen as necessary. Keep the head of the bed at least as low as 30 degrees. Draw a specimen for routine blood studies such as a complete blood count with a white blood cell count and electrolyte levels.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Brudzinski's sign: Emergency interventions
(Handbook of Signs & Symptoms (Third Edition))

If the patient is alert, ask him about headache, neck pain, nausea, and vision disturbances (blurred or double vision and photophobia) — all indications of increased intracranial pressure (ICP). Next, observe the patient for signs and symptoms of increased ICP, such as an altered level of consciousness (LOC) (restlessness, irritability, confusion, lethargy, personality changes, and coma), pupillary changes, bradycardia, widened pulse pressure, irregular respiratory patterns (Cheyne-Stokes or Kussmaul's respirations), vomiting, and moderate fever.

Keep artificial airways, intubation equipment, a handheld resuscitation bag, and suction equipment on hand because the patient's condition may suddenly deteriorate. Elevate the head of his bed 30 to 60 degrees to promote venous drainage. Administer an osmotic diuretic, such as mannitol, to reduce cerebral edema.

Monitor ICP and be alert for ICP that continues to rise. You may have to provide mechanical ventilation and administer a barbiturate and additional doses of a diuretic. Also, cerebrospinal fluid (CSF) may have to be drained.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Encephalitis: Treatment (Tx)
(Professional Guide to Diseases (Eighth Edition))

Anticonvulsants, acyclovir (if viral), glucocorticoids, mannitol, furosemide, supportive care (mild analgesics, bed rest, seizure precautions)

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Headache: Treatment
(Professional Guide to Diseases (Eighth Edition))

Depending on the type of headache, analgesics — ranging from aspirin to codeine or meperidine — may provide symptomatic relief. Other measures include identification and elimination of causative factors and, possibly, psychotherapy for headaches caused by emotional stress. Chronic tension headaches may also require muscle relaxants.

For migraine headaches, ergotamine alone or with caffeine may be an effective treatment. The Food and Drug Administration allows labeling of various analgesic preparations that include caffeine to state that they’re for the treatment of migraine headaches. Remember that these medications can’t be taken by pregnant women because they stimulate uterine contractions. These drugs and others, such as metoclopramide or naproxen, work best when taken early in the course of an attack. If nausea and vomiting make oral administration impossible, drugs may be given as rectal suppositories.

Drugs in the class of sumatriptan are considered by many clinicians to be the drug of choice for acute migraine attacks or cluster headaches. Drugs that can help prevent migraine headaches include antidepressants (such as nortriptyline or fluoxetine), beta blockers (propranolol), and calcium-channel blockers (verapamil). Corticosteroids provide short-term relief for some patients with cluster headaches.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Meningitis: Treatment (Tx)
(Professional Guide to Diseases (Eighth Edition))

Antibiotics, supportive care (analgesics; bed rest; sedatives, anticonvulsants, and cardiac glycosides, as appropriate)

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Meningococcal infections: Treatment
(Professional Guide to Diseases (Eighth Edition))

As soon as meningococcal infection is suspected, treatment begins with high doses of aqueous penicillin G, ampicillin, or ceph-alosporins such as ceftriaxone; or, for the patient who is allergic to penicillin, I.V. chloramphenicol. Therapy may also include mannitol for cerebral edema, I.V. heparin for DIC, dopamine for shock, and digoxin and a diuretic if heart failure develops. Supportive measures include fluid and electrolyte maintenance, ventilation (maintenance of a patent airway and oxygen, if necessary), insertion of an arterial or central venous pressure (CVP) line to monitor cardiovascular status, and bed rest.

Prophylaxis with ciprofloxacin or rifampin aids health care personnel who work in close contact with the patient, such as those administering cardiopulmonary resuscitation or assisting with intubation or suctioning without wearing a surgical mask.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

West Nile encephalitis: Treatment
(Professional Guide to Diseases (Eighth Edition))

There is no specific therapy utilized to treat West Nile encephalitis and no known cure. Treatment is generally aimed at controlling the specific symptoms. Supportive care, such as I.V. fluids, fever control, and respiratory support, is rendered when necessary.

There is no vaccine present to prevent the transmission of West Nile encephalitis. Research trials are underway to determine if ribavirin, an antiviral drug, may be helpful.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Nuchal rigidity: Emergency Interventions
(Professional Guide to Signs & Symptoms (Fifth Edition))

After eliciting nuchal rigidity, attempt to elicit Kernig’s and Brudzinski’s signs. Quickly evaluate level of consciousness (LOC). Take vital signs. If you note signs of increased intracranial pressure (ICP), such as increased systolic pressure, bradycardia, and widened pulse pressure, start an I.V. line for drug administration and deliver oxygen as necessary, and keep the head of the bed at least as low as 30 degrees. Draw a specimen for routine blood studies such as a complete blood count with a white blood cell count and electrolyte levels.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Brudzinski's sign: Emergency interventions
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient is alert, ask him about headache, neck pain, nausea, and vision disturbances (blurred or double vision and photophobia)—all indications of increased intracranial pressure (ICP). Next, observe the patient for signs and symptoms of increased ICP, such as an altered level of consciousness (LOC), pupillary changes, bradycardia, widened pulse pressure, irregular respiratory patterns (Cheyne-Stokes or Kussmaul’s respirations), vomiting, and moderate fever.

Keep artificial airways, intubation equipment, a handheld resuscitation bag, and suction equipment on hand because the patient’s condition may suddenly deteriorate. Elevate the head of his bed 30 to 60 degrees to promote venous drainage. Administer an osmotic diuretic, such as mannitol, to reduce cerebral edema.

Be alert for further increases in ICP. You may have to provide mechanical ventilation and administer a barbiturate and additional doses of a diuretic. Also, cerebrospinal fluid (CSF) may have to be drained.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Encephalitis: Treatment
(Handbook of Diseases)

The antiviral agent acyclovir is effective only against herpes encephalitis. Treatment of all other forms of encephalitis is entirely supportive.

Drug therapy includes phenytoin or another anticonvulsant, usually given I.V.; glucocorticoids to reduce cerebral inflammation and edema; furosemide or mannitol to reduce cerebral swelling; sedatives for restlessness; and aspirin or acetaminophen to relieve headache and reduce fever.

Other supportive measures include adequate fluid and electrolyte intake to prevent dehydration and antibiotics for an associated infection such as pneumonia. Isolation is unnecessary.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Headache: Treatment
(Handbook of Diseases)

Depending on the type of headache, treatment interventions range from relaxation techniques, massage, and biofeedback to pharmacologic agents. Tricyclic antidepressants, beta-adrenergic blockers, and anticonvulsants may be prescribed for headache prevention; nonsteroidal anti-inflammatory drugs (NSAIDs), combination NSAIDs with caffeine, ergotamines, and dopamine antagonists  may be used for abortive measures. Narcotic agents are generally avoided or may be limited to twice weekly.

Abortive therapy using the synthetic form of serotonin (sumatriptan) is available in an oral form and as a nasal spray and can easily be carried for immediate use.

Other measures include identification and elimination of causative factors, stressors, or stimuli that might trigger an attack such as in the migraine-type headache. Diet history and examination of lifestyle patterns may help identify causative agents.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

West Nile encephalitis: Treatment
(Handbook of Diseases)

No specific therapy is used to treat West Nile encephalitis, and no known cure exists. Treatment is generally aimed at controlling the specific symptoms. Supportive care, such as intravenous fluids, fever control, and respiratory support, is rendered when necessary.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Kernig's sign: Nursing considerations
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Prepare the patient for diagnostic tests, such as a computed tomography scan, magnetic resonance imaging, spinal X-ray, myelography, and lumbar puncture. Closely monitor his vital signs, ICP, and cardiopulmonary and neurologic status. Ensure bed rest, quiet, and minimal stress.

If the patient has a subarachnoid hemorrhage, darken the room and elevate the head of the bed at least 30 degrees to reduce ICP. If he has a herniated disk or spinal tumor, he may require pelvic traction.

Patient teaching

Teach the patient the signs and symptoms of meningitis. Discuss measures to prevent meningitis. Explain the activities that a patient with a herniated disk should avoid. Teach the patient how to apply a back brace or cervical collar, as needed.

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Nuchal rigidity: Emergency Actions
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

After eliciting nuchal rigidity, attempt to elicit Kernig’s and Brudzinski’s signs. Quickly evaluate level of consciousness (LOC). Take vital signs. If you note signs of increased intracranial pressure (ICP), such as increased systolic pressure, bradycardia, and widened pulse pressure, start an I.V. line for drug administration and deliver oxygen as necessary, and keep the head of the bed at least as low as 30 degrees. Draw a sample for routine blood studies such as a complete blood count with a white blood cell count and electrolyte levels.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Brudzinski's sign: Emergency Actions
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient is alert, ask him about headache, neck pain, nausea, and vision disturbances (blurred or double vision and photophobia) — all indications of increased intracranial pressure (ICP). Next, observe the patient for altered level of consciousness (LOC) (restlessness, irritability, confusion, lethargy, personality changes, and coma), pupillary changes, bradycardia, widened pulse pressure, irregular respiratory patterns (Cheyne-Stokes or Kussmaul’s respirations), vomiting, and moderate fever.

Keep artificial airways, intubation equipment, a handheld resuscitation bag, and suction equipment on hand because your patient’s condition may suddenly deteriorate. Elevate the head of his bed 30 to 60 degrees to promote venous drainage. Administer an osmotic diuretic, such as mannitol, to reduce cerebral edema. Monitor and be alert for ICP that continues to rise. You may have to provide mechanical ventilation and administer a barbiturate and additional doses of a diuretic. Also, cerebrospinal fluid (CSF) may have to be drained.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Headache: Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Teach the patient and his family or caregiver how to recognize signs of reduced LOC and seizures. Discuss ways to maintain a safe, quiet environment and reduce environmental stress, if indicated. Discuss the use of analgesics to ease the headache.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Kernig's sign: Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Teach the patient how to recognize signs and symptoms of meningitis as well as measures to prevent this infection. If the patient has a herniated disk, tell him to avoid activities such as lifting, sleeping prone, climbing stairs, and riding in a car. Show the patient how to apply a back brace or cervical collar, as needed, then have him give a return demonstration.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Photophobia: Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If photophobia persists at home, suggest that the patient wear dark glasses. Prepare the patient for diagnostic tests, such as corneal scraping and slit-lamp examination.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Nuchal rigidity: Nursing considerations
(Nursing: Interpreting Signs and Symptoms)

▪ Prepare the patient for diagnostic tests, such as computed tomography scans, magnetic resonance imaging, and cervical spinal X-rays.

▪ Monitor the patient's vital signs, intake and output, and neurologic status closely.

▪ Avoid routine administration of opioid analgesics because these may mask signs of increasing ICP.

▪ Enforce strict bed rest; keep the head of the bed elevated at least 30 degrees to help minimize ICP.

Patient teaching

▪ Explain all procedures and diagnostic tests to the patient and his family.

▪ Orient the patient, as appropriate.

▪ Explain the cause of nuccal rigidity and the treatment plan.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Brudzinski's sign: Nursing considerations
(Nursing: Interpreting Signs and Symptoms)

▪ Provide constant ICP monitoring and perform frequent neurologic checks.

▪ Monitor vital signs, intake and output, and cardiorespiratory status.

▪ To promote patient comfort, maintain low lights and minimal noise and elevate the head of the bed.

▪ Prepare the patient for diagnostic tests, such as blood, urine, and sputum cultures to identify bacteria; lumbar puncture to assess CSF and relieve pressure; and computed tomography scan, magnetic resonance imaging, cerebral angiography, and spinal X-rays to locate a hemorrhage.

Patient teaching

▪ Discuss the signs and symptoms of meningitis and subdural hematoma, if these are the cause of Brudzinski's sign.

▪ Advise the patient and his family to seek immediate medical attention if these signs and symptoms occur.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Headache: Nursing considerations
(Nursing: Interpreting Signs and Symptoms)

▪ Monitor the patient's vital signs and LOC.

▪ Watch for a change in the headache's severity or location.

▪ To help ease the headache, administer an analgesic, darken the patient's room, and minimize other stimuli.

▪ Prepare the patient for diagnostic tests, such as skull X-rays, a computed to-mography scan, lumbar puncture, or cerebral arteriography.

Patient teaching

▪ Explain all procedures and treatments to the patient.

▪ Discuss the signs of reduced LOC and seizures that the patient or his caregivers should report.

▪ Explain ways to maintain a safe, quiet environment and reduce environmental stress.

▪ Discuss the proper use of analgesics.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Kernig's sign: Nursing considerations
(Nursing: Interpreting Signs and Symptoms)

▪ Prepare the patient for diagnostic tests, such as a computed tomography scan, magnetic resonance imaging, spinal X-ray, myelography, and lumbar puncture.

▪ Closely monitor the patient's vital signs, ICP, and cardiopulmonary and neurologic status.

▪ Ensure bed rest, quiet environment, and minimal stress.

▪ If the patient has a subarachnoid hemorrhage, darken the room and elevate the head of the bed at least 30 degrees to reduce ICP.

▪ If he has a herniated disk or spinal tumor, he may require pelvic traction.

Patient teaching

▪ Teach the patient and his family signs and symptoms of meningitis and treatment.

▪ Discuss ways to prevent meningitis.

▪ Explain activities that the patient with a herniated disk should avoid.

▪ Teach the patient how to apply a back brace or cervical collar as ordered.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Photophobia: Nursing considerations
(Nursing: Interpreting Signs and Symptoms)

▪ Promote the patient's comfort by darkening the room and telling him to close both eyes. Encourage use of sunglasses.

▪ Prepare the patient for diagnostic tests, such as corneal scraping and slit-lamp examination.

▪ Administer eyedrops and ointments, as ordered.

Patient teaching

▪ Teach the patient how to instill eyedrops or ointments.

▪ Discuss ways to reduce the discomfort of photophobia.

▪ Explain the disorder and treatment plan.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Assure coverage for resistantStreptococcus pneumoniae with vancomycin if there is a concernfor meningitis: Management of Bacterial Meningitis
(Avoiding Common Pediatric Errors)

The broad-spectrum cephalosporins, cefotaxime and ceftriaxone, have traditionally been used as standard therapy for bacterial meningitis in infants and children. However, in the past decade, penicillin-and cephalosporin- resistant pneumococcal meningitis has been reported. In fact, cultures of cerebrospinal fluid (CSF) were positive for 3 to 14 days after the initiation of therapy. Therefore, in an attempt to identify an effective therapy, several antibiotic regimens including vancomycin, chloramphenicol, rifampin, erythromycin, and imipenem, alone and in combination were given to patients to identify an ideal anti–pneumococcal meningitis regimen.

Researchers concluded that on the basis of data from the pneumococcal meningitis models and limited clinical experience, it was impossible to make a single recommendation for initial empiric treatment that would be suitable forallpatientswithsuspectedorprovenpneumococcalmeningitis.However, the following guidelines could be considered in managing such patients:
• Physicians should be aware of the S. pneumoniae susceptibility patterns in their area and request their hospital laboratories to perform dilution susceptibility tests on any pneumococcal isolates recovered from usually sterile body sites.
• Because penicillin-resistant pneumococci have been identified in many areas of the United States, initial empiric therapy for bacterial meningitis should be based on the possibility that it is the etiology of the patient's illness. The recommended therapy is therefore ceftriaxone or cefotaxime and vancomycin (60 mg/kg/day divided in four doses), in addition to dexamethasone.
• A repeat lumbar puncture in patients with pneumococcal meningitis to document eradication of the pathogen should be performed 24 to 36 hours after the start of therapy, primarily in patients in whom the organism is cephalosporin resistant.
• Alteration of the initial antimicrobial regimen should be based on the clinical response of the patient and on the results of the CSF culture and susceptibility studies from the second lumbar puncture. In the event that the patients' clinical condition has worsened or that the follow-up Gram- stained smear or culture of CSF indicates failure to substantially reduce or eradicate the organism, substitution of rifampin for vancomycin in the therapeutic regimen is recommended.
• Patients without complications should be treated for a minimum of 10 days.

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Source: Avoiding Common Pediatric Errors, 2008

Meningitis: Management
(Pediatric Infectious Disease)

Empiric Therapy for Bacterial Meningitis

When faced with a patient with presumed bacterial meningitis, it is optimal to start appropriate antibiotics as early as possible. The “Gram stain game” can help in this decision. The following are the major pathogens of pediatric bacterial meningitis.

1. Streptococcus agalactiae: group B streptococcus. A gram-positive coccus, group B streptococcus is a common cause of neonatal meningitis. Up to one half of women are colonized with S. agalactiae in the genital tract; neonates become colonized at the time of delivery. A certain percentage of these neonates then become bacteremic, which can result in CSF infection. Therapy is with ampicillin and gentamicin.

2. Streptococcus pneumoniae. Another gram-positive coccus, this is the most common cause of infant and toddler meningitis. The mechanism is similar to that of group B streptococcus, whereby colonizing bacteria entering the bloodstream with subsequent infection of the CSF.

3. Neisseria meningitidis. A gram-negative diplococcus, this can cause rapid onset of meningitis, septic shock, and death. Septic shock associated with N. meningitidis is often associated with rapid onset of petechial and purpuric lesions. Therapy is with a third-generation cephalosporin or intravenous penicillin.

4. Listeria monocytogenes. A gram-positive rod, this organism is ubiquitous in the environment and commonly found in unpasteurized food products. Meningitis usually occurs in the neonatal period and in immunocompromised patients. This is the one cause of bacterial meningitis not sensitive to the third-generation cephalosporins. Ampicillin is the drug of choice, used in combination with gentamycin. For patients who cannot tolerate ampicillin, intravenous trimethoprim-sulfamethoxazole is recommended as the second choice. Vancomycin may be a successful alternative antibiotic, although treatment failures have also been reported.

5. Haemophilus influenzae (type b). Before the development of the conjugate vaccine, this gram-negative coccobacillus frequently caused invasive disease. Pediatricians rarely encounter type b H. influenzae meningitis in unvaccinated populations. There are increasing reports of nontypeable Haemophilus causing invasive disease, including meningitis. Treatment is with a third-generation cephalosporin; ampicillin can be used if the causative bacteria are β-lactamase negative.

Special Considerations: Treatment of Streptococcus pneumoniae

The most common cause of infant and toddler meningitis remains S. pneumoniae, although this may ultimately change owing to the recent addition of the conjugate vaccine to primary immunization series.

Resistance of S. pneumoniae. One of the major issues in the treatment of pneumococcal meningitis is the increasing resistance to penicillin and cephalosporins. Resistance is mediated by alterations in penicillin-binding proteins. This increases the minimal inhibitory concentration (MIC) to both these antibiotics; that is, increased concentrations of antibiotic are needed to inhibit growth of bacteria. The problem faced with treating meningitis in the context of increasing MIC is as follows:

The breakpoint is the highest MIC at which an organism is defined as sensitive to a given drug. The desire to achieve a CSF concentration of 10 times the MIC explains the breakpoints for penicillin and third-generation cephalosporins for the treatment of S. pneumoniae meningitis. The maximal concentration of penicillin obtained in the CSF is about 1.0 µg/mL. The breakpoint for the use of penicillin in pneumococcal meningitis is 0.06 µg/mL; any MIC to penicillin of an infecting pneumococcus greater than this does not guarantee a concentration 10 times the MIC. The maximal concentration for a third-generation cephalosporin in the CSF is about 5.0 µg/mL. The breakpoint for cefotaxime or ceftriaxone is 0.5 µg/mL; if the MIC is greater than 0.5, a concentration in the spinal fluid of 10 times the MIC cannot be ensured.

Rates of resistance vary from community to community. Rates of S. pneumoniae with an MIC to penicillin greater than 0.1 µg/mL can be as high as 75%. Rates of pneumococcus with an MIC to a third-generation cephalosporin greater than 0.5 µg/mL can approach 20%. These numbers may increase as antibiotic overuse persists. It is for this reason that empiric therapy for presumed pneumococcal meningitis includes vancomycin (15 mg/kg given intravenously every 6 hours) and a third-generation cephalosporin. All pneumococcal isolates from the CSF should be tested for MIC to penicillin and third-generation cephalosporins. After specific MICs are available, therapy can be tailored appropriately.

There is little experience, although justifiable concern, in the management of children with pneumococcal meningitis in which the isolated bacteria has an MIC to cefotaxime or ceftriaxone greater than 2.0 µg/mL. In those cases, treatment with both vancomycin and a third-generation cephalosporin is recommended. The addition of rifampin, 20 mg/kg in two divided doses, should also be considered.

Meropenem is a new antibiotic that has excellent gram-negative coverage and good CSF penetration. Although approved for children 3 months of age or older with penicillin-susceptible pneumococcal meningitis, there is little clinical experience with this drug in resistant pneumococcal isolates. In the coming years, more data regarding meropenem in the treatment of resistant pneumococcal meningitis will be available.

Steroid Therapy for Bacterial Meningitis

During the past decade, increasing attention has been given to adjunctive treatment for bacterial meningitis. It is recognized that bacterial meningitis is a disorder of intense inflammation and that this inflammation can result in substantial morbidity, primarily in the form of hearing loss. For patients with H. influenzae type B meningitis, dexamethasone is recommended. The dose is 0.15 mg/kg of dexamethasone every 6 hours for 4 days.

The use of steroids in pneumococcal meningitis is more controversial. A major concern is a possible decrease in antibiotic concentration in the CSF when steroids are given. In animal models, vancomycin concentration was altered up to 75% when concurrent steroids were used. The few clinical trials performed have not shown CSF differences in vancomycin and cefotaxime concentrations in the presence of dexamethasone. Two retrospective studies regarding outcome in patients with resistant pneumococcal meningitis receiving dexamethasone have been published, reaching different conclusions. In a small number of children with bacterial meningitis who received both vancomycin and dexamethasone, vancomycin levels in the CSF were comparable to those measured in children who receive vancomycin without dexamethasone. At this point, the opinion of the American Academy of Pediatrics is that the clinician needs to evaluate each case individually, weighing risks and benefits of steroid use.

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Source: Pediatric Infectious Disease, 2004



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