Severe CNS Infections are time dependent diagnoses! You must have a high index of suspicion, a good plan for your work-up, and rapid provision of treatment. After seeing a severely ill meningitis patient, I figured I would do a podcast on some tips and pearls on this topic.
When to Suspect
Here is the article I mentioned on establishing pretest prob:
What Antibiotics
Ceftriaxone 2g as empiric therapy in any suspected meningitis patient
If high risk or LP results are positive, also give
- Vancomycin 1 G
- Ampicillin 2g if age > 50 y/o
- Acyclovir 10 mg/kg if high RBC count, obtundation, seizures, or focal neurologic deficit
- Dexamethasone 10 mg
- Cefepime or Imipenem if hospitalized or neurosurgery patient
listen to the podcast for more and see the EMCrit chapter for more.
photo by Lapoland
Update:
Def. give Dex. (PMID: 12432041)
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An ED Intensivist from NY. No conflicts of interest (coi).
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Assuming you are unable to get CSF after multiple failed attempts while the pt is laying down, don’t have the resources to call Neuro or Radiology to do the procedure for you, do you have any thoughts on getting the needle in w/ good CSF flow while the pt is sitting, and then laying the pt down to get the opening pressure?
What is the numerical difference in opening pressures between laying and sitting?
If I can’t get it lying down, I have never seen benefit from sitting the patient up. But that is just me, I know for some folks sitting the pt up makes things much easier. I usually grab ultrasound in this situation. Also, if I am hitting ligaments that feel like bones, I use para-median approach. To answer you question, the seated pressure will be changed by the height of the CSF column from the patient’s brain to you needle; you can’t correct for this. If you were able to support the needle and lay the patient down, it would… Read more »
What’s the best way to do an LP on intubated pts? Does being intubated affect opening pressures?
i roll them on their side, move their legs way up in to fetal position and then put the bed rail back up. This keeps their knees from falling down. I then loop a sheet around their knees and tie it high up on the bed rail. Mech vent should not sig. affect the opening pressure, unless the PEEP is crazy high.
Can you comment on Academic Emergency Medicine Volume 10, Number 5 492-493, M Andrew Levitt Conclusion: Higher opening pressures are seen in the FSP compared to the LRP. However,the difference was not found to be of clinical significance and a conversion formula is developed to allow the FSP to be used and the pressure obtained to be converted to LRP.
Lateral Recumbent position pressure equal = 0.7 Flexed seated position cm H2O-0.8
Kurt,
I’d love to see the article when it is actually published, but I think the authors have only published the abstract. They derived the correction formula retrospectively; it needs to be prospectively validated before prime time use.
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You mentioned an article in the podcast talking about minimal cross-reactivity between penicillin and 3rd generation cephalosporins in pen-allergic patients…do you have a reference for that?
Studies of second- and third-generation cephalosporins show no increase in allergic reactions in patients who have a history of penicillin allergy (Ann Allergy Asthma Immunol 1995;74(2)) AAP cephalosporins in the pen allergic patient (Pediatrics 2005;115(4):1048) From EMEDHome: Prescribing Cephalosporins in the Setting of a Penicillin Allergy: What is the Truth? Conventional wisdom holds that there is a significant risk of an allergic reaction if a cephalosporin is prescribed to a patient with a history of a PCN allergy (2007 PDR: “cross-hypersensitivity among beta-lactam antibiotics has been clearly documented and may occur in up to 10% of patients with a history… Read more »
I have always been taught that adding acyclovir to someone with focal neurological signs and a meningitis picture was basically closing the barn door after the cows had gotten out, as it takes two days or so for the acyclovir to be incorporated into the HSV and kill the virus (time you obviously don’t have), and that the better solution was simply proper supportive care (fluids, pain management, etc). Have I just been getting bad advice?
untreated, HSV encephalitis has a mortality of ~70%. With acyclovir it goes down to about 28%, see (N Engl J Med. 1986 Jan 16;314(3):144-9. Vidarabine versus acyclovir therapy in herpes simplex encephalitis.) As you allude to, the earlier the better, but I had not come across the 2 day timing at all. I don’t think you will find many folks who would just treat presumed or known HSV enceph with only supportive care. So I don’t want to say the advice is bad, but I would love to see some data. : ) thanks so much for commenting. reply or… Read more »
Just curious– what did this guy have? Certainly sounds suspicious for herpes, WNV or other meningoencephalitis……
Just wondering. Love the podcast and catching up on back issues.
Mike whiting
Santa Fe NM
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First of all, real nice blog. Great job!
For ampicillin, age 50 (rather than 60) are recommended cut-offs for empiric tx for Listeria per IDSA guideline on bacterial meningitis.
Also, rather than imipenem, meropenem is a better choice per IDSA, if you are going to use a carbapenem for pseudomonas coverage, given higher propensity for imipenem to cause seizures, in baterial meningitis where your brain is already inflamed and susceptible to seizures.
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Severe Central Nervous System Infections, Meningitis, Encephalitis