Treatment and

ProphylaxisNur Amalina bt. Aminuddin Baki

60

Objectives

• Treatment: – Supportives measures– Drugs

• Prophylaxis:– Chemoprophylaxis– immunoprophylaxis

Introduction

Bacterial Meningitis• More severe• Requires treatment• Available vaccine present

Viral Meningitis• Less severe• Supportives measures• Self -limited

Recommended Empiric Antibiotics for Suspected Bacterial Meningitis

Age or Predisposing Feature AntibioticsAge 0-4 wk Ampicillin plus either cefotaxime or an

aminoglycosideAge 1 mo-50 y Vancomycin plus cefotaxime or ceftriaxone

Age >50 y Vancomycin plus ampicillin plus ceftriaxone or cefotaxime plus vancomycin

Impaired cellular immunity Vancomycin plus ampicillin plus either cefepime or meropenem

Recurrent meningitis Vancomycin plus cefotaxime or ceftriaxone

Basilar skull fracture Vancomycin plus cefotaxime or ceftriaxone

Head trauma, neurosurgery, or CSF shunt Vancomycin plus ceftazidime, cefepime, or meropenem

Bacterial Meningitis

• Neisseria meningitidis

• B,C,Y serogroup = developed region• A, w-135 serogroup = less developed region

Treatment Prevention

•Penicillin /chloramphenicol•Ciprofloxacin / Rifampicin for close contacts•Meningococcal vaccine

Meningococcal Vaccine • Quadrivalent (A,C , W-

135, Y)– MCV-4 (9m-55y)

– MPSV-4• Elderly (>55 years old)• Last for 3 year

• Bivalent (C,Y): – infant >6w – to prevent meningitis

C ,Y and HiB disease

• Serogroup A: MenAfriVac

• Serogroup B : difficult as too similar to neural antigen

•11-18y •HIV adolescent •>16y•Two doses

1: 11-12y2: 16y

•Three doses2 doses 2 months apart at 11-12yBooster : 16y

•X booster dose

• Haemophilus influenzae

Treatment Prevention

•ceftriaxone or cefotaxime•Ampicillin,

•Rifampicin X 4 days for close contact•Hib PRP vaccine

HiB PolyribosylRibitolPhosphate Vaccine

• Polysaccharide: limited usefulness• Conjugate:– Tetanus toxoid, diphteria toxoid, N. meningitidis

OMP– >2 months ( 2 doses at 2 month interval)

• Combination – Hib + DPT in USA

• Streptococcus pneumoniae

Treatment Prevention

•Penicillin• ceftriaxone / cefotaxime•Vancomycin

•PPSV23•PCV13•PCV7

Pneumococcal Vaccine• Polysaccharide : PPSV23

For increased risk groupoDysfunctional spleen,

nephrotic synd., sickle cell anemia, multiple myeloma, DM, immunodeficiency patient.

Single dose injection , last 5 years

(-): <2 years old, not lifelong

• Conjugated:PCV13 children at 2, 4,

6, and 12–15 months oldPCV7 bind to diphteria

toxoido 2-23monthso Increased risk in 2-5 years

old

• Mycobacterium tuberculosis

Isoniazid• Only in risk groups( 5mg/kg daily X 6-12M)

Unavoidable contact with patient with open TB Children which is tuberculin +ve but radiology clear adult with radiological evidence of inactive disease

Treatment Prevention•Isoniazid (H),rifampin (R), pyrazinamide (Z) , ,streptomycin(E)

•Isoniazid•BCG vaccination

Bacille Calmette Guerin Vaccine

• Strain of M bovis weakened by 239 serial subculture in glycerine- bile- potato medium (13 ears)

• 0.1ml ID small nodule (2-3w)• Given soon after birth • Complications :

Local : abscess, keloid formationRegional: lymphadenitisGeneral: fever , erythema nodosum

• Escherichia coli and group B streptococci

• Listeria monocytogenes

Treatment Prevention

•Gentamicin + cefotaxime or ceftriaxone (or chloramphenicol)

•No vaccines available

Treatment Prevention

Penicillin or ampicillin + gentamicin No vaccines available

Viral Meningitis

• Self-limited, offer supportive measureso Herpes simplex virusoMumpso Lymphocytic choriomeningitiso Enteroviruses including coxsackievirus, echovirus

and poliovirusPicornaviruses o Japanese encephalitiso HIV

• Complete recovery

Fungal Meningitis

• Cryptococcus neoformans

• Coccidioides immitis

Treatment Prevention

•Amphotericin B and flucytosine

•No vaccines available

Treatment Prevention•amphotericin B, fluconazole or miconazole

•No vaccines available

Protozoal Meningitis

Treatment•not fully satisfactory

Naegleria :Amphotericin B, with miconazole and rifampinBalamuthia mandrillaris :albendazole and itraconazole

Conclusion

Pathogen Prevention

•Neisseria meningitidis

•MCV-4 •MPSV-4

•Haemophilus influenzae

•Hib vaccine

•Streptococcus pneumoniae

•PPSV23•PCV13•PCV7

•Mycobacterium tuberculosis

•BCG vaccination

Reference • Richard V. Goering, Hazel M. Dockrell, Mark

Zuckerman, Peter L. Chiodini, and Ivan M. Roitt, Mims’ Medical Microbiology,5th edition

• Ananthanarayan and Paniker , Textbook of Microbiology, 8th edition

• Prof CP Baveja, Textbook of Microbiology, 2nd edition

• http://www.cdc.gov/vaccines