The General’s Pearls and Ditty 6/4/16: Strep Pneumoniae Meningitis

Today’s case…

22M h/o PSA, FAS who p/w AMS in s/o facial assault w/ focal neuro deficits, found to have a WBC of 52K, LP w/ pus, blood cx’s growing S. pneumoniae and overall presentation consistent with S. pneumoniae bacterial meningitis.

 

Streptococcus pneumoniae meningitis

  • S. pneumonia is the most common cause of meningitis in adults, particularly older adults
  • Rates of meningitis are generally decreasing in light of the increasing vaccination rates w/ pneumococcal conjugate vaccine in children
  • First line treatment: CTX which has great blood brain barrier penetration and activity vs S. pneumoniae, and need to add VANC given concern for PCN/ctx resistant isolates (high MIC’s)
  • Give steroids before antibiotics because of the MORTALITY benefit in S. pneumoniae specifically and to reduce rate neurologic complications such as hearing loss.
    • See articles below including European RCT’s and Cochrane review for more info. Immunocompromised hosts not included in studies…
    • Dexamethasone 0.15mg/kg q6h x4d
  • Duration of therapy tends to be 10-14 days
  • Remember to screen for HIV in adult <50 who p/w S. pneumoniae meningitis
  • Brain infarcts can be seen in pt’s with S. pneumoniae meningitis via peri-infectious vasculitis and as septic emboli
  • Great example of a time where we would have wanted to ensure this person had the pneumovax, prevnar to reduce non-pulmonary complications of S. pneumoniae

A few other pearls:
*Dramatic leukocytosis >50K ddx: keep in mind in young healthy person, this can be a robust bacterial infxs process
*Leukostasis in AML, wbc >90-100K; in ALL, wbc >150K
*Addressing altered mental status in EMS or upon arrival to ED, consider whether “the coma cocktail” has been given or the mnemonic DONT:

Dextrose
Oxygen
Naloxone
Thiamine

Ditty:

NPPV applied immediately after extubation is recommended in patients with chronic lung disease and hypercapnia during pre-extubation SBT

Are they ready for extubation:

*adequate oxygenation: sat >92%, paO2 >/= 60

*minimal vent support: FiO2 </= 50%, delta 7/5, RSBI <100

*protection of airway: cough, mental status/alertness, secretions

*patent airway: cuff leak if risk factors for laryngeal edema (prolonged/traumatic intubation, large ETT, aspiration, OG/NG tube present)

*no pending emergent surgery, study/imaging

De Gans J et al. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002 Nov 14;347(20):1549-56.
Fritz D et al. Dexamethasone and long-term survival in bacterial meningitis. Neurology. 2012 Nov 27;79(22):2177-9. doi: 10.1212/WNL.0b013e31827595f7. Epub 2012 Nov 14. Castelblanco RL et al. Epidemiology of bacterial meningitis in the USA from 1997 to 2010: a population-based observational study. Lancet Infect Dis. 2014 Sep;14(9):813-9. doi: 10.1016/S1473-3099(14)70805-9. Epub 2014 Aug 4.
Brouwer MC et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015 Sep 12;(9):CD004405. doi: 10.1002/14651858.CD004405.pub5.

Evernote link: https://www.evernote.com/shard/s354/sh/69309d7a-4c1f-4b69-b26f-9fcd0803617a/c1f8f1b17b01c980dc6a0b2700b7269b

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