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Central nervous system

infections
Antal Gbor Kondsz Med.
Resident doctor of infectious diseases

Szeged 2017 september 29


Stucture of central nervous sytem
Localisation of infection
Meningitis
Encephalitis
Myelitis
Meningo-encephalo-myelitis
Intracerebral absces
Epiduralis empyema
Meningitis
The inflammation of meninx involved the
liquorspace

No time to lose, dieases required urgent,


immediate diagnose and treatment

The delay causes the death of the patient or


causes serious residual symptoms
The routes of the infection
Hematogenous (abcess)
Nose and paranasal sinuses
Airways (meningoencephalitis)
Skull fractures (abscess,
epidural empyema, meningitis)
Periferial nerv (rabies, HSV, VZV)
Epidemiology
Predisposing
Elderly people (above 60 years)
Alcoholism, liver cirrhosis, malnutriction homo canaliculus
Chronic renal diseases
HIV and other immundeficiencies
Diabetes, malignancies
Head injuries (neurological surgery)
Brain ventricular drainage or shunts
Leak of the meningx
Community (dorms or army base in early 2000 Neisseria menigitis
epidemic in Hungary)
Otitis media, sinusitis, mastoiditis
Pneumonia (abcessus)
Special predisposing factors by
presumable agents
Clinical signs which sign meningitis
THESE ARE ALARM SIGNS, BUT MISSING ARE
NOT EXCLUDE MENINGITIS
Signs of meningeal Maneuver Positive test
irritation
Kernig sign Place patient supine with The test is positive when
hip flexed at 90 degrees. there is resistance to
Attempt to extend the leg extension at the knee to
at the knee. >135 degrees or pain in the
lower back or posterior
thigh.
Brudzinski sign Place patient in the supine The test is positive when
position and passively flex there is flexion of the
the head toward the chest. knees and hips of the
patient.
Jolt accentuation of Patient rotates his/her The test is positive if the
headache head horizontally two to patient reports
three times per second. exacerbation of his/her
headache with this
maneuver.
CT scan
Every time needed:
Intracranial pressures
Differencial diagnosis:
Trauma
Vascular abnormalities
Neoplasms
Lumbal puncture
Make in experenced hand its safety procedure
with a minimal pain
So called a neurologist or a neurosurgeon
Liquor diagnostic tests
Cytology
Chemical
Microbiologycal
Cytology
Normal Purulent Serosus
Normal liquor
Microbiologycal diagnostic
The liquor in physiologycal is steril.
For the microbiologycal testing need more than 2 ml sample, much better
if 5-10 ml.
Need a rapid transport to the labory, but if isnt possible:
Suspicion of bacterial infection in room temperature
Suspicion of viral infection store in the fridge till the transport
Liquor cytology have result within 30 minute
Rapid test for the most common bacterial agents have result within 2
hours
Definitive result, with antibiotic sensitivity :
Aerob bacterias within 3 days with antiotic sensitivity
Anaerob bacteria within 10 days
Virus or Mycobacterium sp. PCR if it possible in the laboratotory with in 6-12
hours
Mycobacterium sp. Cultur within 30 days
Tipical bacterial agent of meningitis
Organism Site of entry Age range Predisposing conditions

Neisseria Nasopharynx All ages Usually none, rarely complement deficiency


meningitidis
Streptococcus Nasopharynx, direct extension across All ages All conditions that predispose to
pneumoniae skull fracture, or from contiguous or pneumococcal bacteremia, fracture of
distant foci of infection cribriform plate, cochlear
implants, cerebrospinal fluid otorrhea from
basilar skull fracture, defects of the ear ossicle
(Mondini defect)
Listeria Gastrointestinal tract, placenta Older adults Defects in cell-mediated immunity (eg,
monocytogenes and neonates glucocorticoids, transplantation [especially
renal transplantation]), pregnancy, liver
disease, alcoholism, malignancy
Coagulase-negative Foreign body All ages Surgery and foreign body, especially
staphylococci ventricular drains
Staphylococcus Bacteremia, foreign body, skin All ages Endocarditis, surgery and foreign body,
aureus especially ventricular drains; cellulitis,
decubitus ulcer
Gram-negative bacilli Various Older adults Advanced medical illness, neurosurgery,
and neonates ventricular drains, disseminated
strongyloidiasis
Haemophilus Nasopharynx, contiguous spread from Adults; Diminished humoral immunity
influenzae local infection infants and
children if not
vaccinated
Empirical therapy in CNS infections
Agaist cerebral oedema:
Mannitol
Dexamethason
Antibiotic therapy:
2x2 g Ceftriaxon intravenousos dosing
Antiviral thrapy:
Acyclovir 10 mg/ body mass kg intravenousos
dosin
Empirical antibiotic therapy
Predisposing factor Common bacterial pathogens Antimicrobial therapy

Age

<1 month Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes Ampicillin plus cefotaxime; OR ampicillin plus an
aminoglycoside

1 to 23 months Streptococcus pneumoniae, Neisseria meningitidis, S. agalactiae, Vancomycin plus a third-generation cephalosporin
Haemophilus influenzae, E. coli

2 to 50 years N. meningitidis, S. pneumoniae Vancomycin plus a third-generation cephalosporin

>50 years S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gram- Vancomycin plus ampicillin plus a third-generation
negative bacilli cephalosporin

Head trauma

Basilar skull fracture S. pneumoniae, H. influenzae, group A beta-hemolytic streptococci Vancomycin plus a third-generation cephalosporin

Penetrating trauma Staphylococcus aureus, coagulase-negative staphylococci Vancomycin plus cefepime; OR vancomycin plus
(especially Staphylococcus epidermidis), aerobic gram-negative ceftazidime; OR vancomycin plus meropenem
bacilli (including Pseudomonas aeruginosa)

Postneurosurgery Aerobic gram-negative bacilli (including P. aeruginosa), S. aureus, Vancomycin plus cefepime; OR vancomycin plus
coagulase-negative staphylococci (especially S. epidermidis) ceftazidime; OR vancomycin plus meropenem

Immunocompromised S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gram- Vancomycin plus ampicillin plus cefepime; OR
state negative bacilli (including P. aeruginosa) vancomycin plus ampicillin plus meropenem
Microorganism, susceptibility Standard therapy Alternative therapies
Streptococcus pneumoniae
Penicillin MIC
0.06 mcg/mL Penicillin G or ampicillin Third-generation cephalosporin,
chloramphenicol
Third-generation Third-generation cephalosporin Cefepime, meropenem
cephalosporin MIC <1
Third-generation cephalosporin Vancomycin plus a third-generation Fluoroquinolone
MIC 1 cephalosporin
Neisseria meningitidis
Penicillin MIC
<0.1 mcg/mL Penicillin G or ampicillin Third-generation cephalosporin,
chloramphenicol
0.1 to 1.0 mcg/mL Third-generation cephalosporin Fluoroquinolone, meropenem,
chlorampenicol
Listeria monocytogenes Ampicillin or penicillin G Trimethoprim-sulfamethoxazole
Streptococcus agalactiae (group B Ampicillin or penicillin G Third-generation cephalosporin
Streptococcus)
Microorganism, susceptibility Standard therapy Alternative therapies
Escherichia coli and other Third-generation cephalosporin Aztreonam, fluoroquinolone,
Enterobacteriaceae meropenem, trimethoprim-
sulfamethoxazole, ampicillin
Pseudomonas aeruginosa Cefepime or ceftazidime Aztreonam, ciprofloxacin, meropenem
Acinetobacter baumannii Meropenem Colistin or polymyxin B
Haemophilus influenzae
Beta-lactamase negative Ampicillin Third-generation cephalosporin,
cefepime, fluoroquinolone, aztreonam,
chloramphenicol
Beta-lactamase positive Third-generation cephalosporin Cefepime, fluoroquinolone, aztreonam,
chloramphenicol
Staphylococcus aureus
Methicillin susceptible Nafcillin or oxacillin Vancomycin, meropenem, linezolid,
daptomycin
Methicillin resistant Vancomycin Trimethoprim-sulfamethoxazole,
linezolid, daptomycin
Staphylococcus epidermidis Vancomycin Linezolid
Enterococcus species
Ampicillin susceptible Ampicillin plus gentamicin
Ampicillin resistant
Vancomycin plus gentamicin

Ampicillin and vancomycin resistant Linezolid


Meningoencephalitis
Usualy viral infection of the etiologycal agents
But some bacterial infection make a same
symptoms
Empiric terapy same as like in meningitis
In diagnostic use PCR and serological testing
of the blood and liquor
Suggested initial therapy for agents that cause
encephalitis
Agent Specific therapy Agent Specific therapy
Virus Bacteria
Cytomegalovirus Ganciclovir plus foscarnet Mycoplasma pneumonia Macrolide , doxycycline, or fluoroquinolone

Epstein-Barr No specific treatment Listeria monocytogenes Ampicillin plus gentamicin; trimethoprim-


sulfamethoxazole
Hepatitis B Valgancyclovir
Tropheryma whipplei Ceftiaxone, followed by either trimethoprim-
Herpes simplex Acyclovir sulfamethoxazole or cefixime
Human herpesvirus 6 Gancyclovir or foscarnet Anaplasma phagocytophilum
HIV Antiretroviral therapy Ehrlichia chafeensis Doxycyclin
St. Louis encephalitis Interferon-2-alpha Rickettsia rickettsii
Influenza Oseltamivir Borrelia burgdorferi Ceftriaxon cefotaxim
JC virus Reversal of Treponema pallidum Penicillin G
immunosuppression if possible
Mycobacterium tuberculosis 4-drug regimen; consider addition of corticosteroid
Measles Ribavirin
Nipah Ribavirin
Varicella-zoster Acyclovir
West Nile No specific treatment
Mycobacterium tuberculosis meningitis
Tuberculous meningitis accounts for about 1 percent of all cases of
tuberculosis
5 percent of all extrapulmonary disease in immunocompetent individuals
the case-fatality ratio remains relatively high (15 to 40 percent) despite
effective treatment regimens
Early recognition of tuberculous meningitis is of paramount importance
because the clinical outcome depends greatly upon the stage at which
therapy is initiated.
Empiric antituberculous therapy should be started
Cerebrospinal fluid (CSF) findings of low glucose concentration, elevated
protein, and lymphocytic pleocytosis
Serial examination of the CSF by acid-fast stain and culture is the best
diagnostic approach.
Smears and cultures will yield positive results even days after treatment
has been initiated.
Nucleic acid amplification testing also may be helpful.
Thank you for your patience!

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