Management of Bacterial Meningitis: 1998

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Abstract
1. Loretta Wubbel, DO* 2. George H. McCracken Jr, MD† 1. 2. *Fellow, Pediatric Infectious Diseases. 3. 4. †Professor of Pediatrics and The Sarah M. and Charles E. Seay Chair in Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, TX. 1. Streptococcus pneumoniae resistance requires a change in the initial antibiotic regimens for bacterial meningitis. 2. The combination of vancomycin and a third-generation cephalosporin is recommended for initial treatment of suspected bacterial meningitis. 3. To be effective, steroids must be given before the first dose of parenteral antibiotics. 4. Fluids should not be restricted in the initial phases of meningitis. Watch for syndrome of inappropriate antidiuretic hormone, but maintain normal to high-normal systolic blood pressure. 5. Cerebrospinal fluid protein concentrations greater than 110 to 120 mg/dL should raise the suspicion for bacterial meningitis; this is unusual in enteroviral meningitis. Meningitis remains an important and serious infection in childhood. Inflammation of the meninges is caused by a wide variety of infectious and chemical agents. The definition of inflammation in the central nervous system (CNS) includes three specific pathologic diagnoses that often are clinically indistinct: meningitis, encephalitis, and meningoencephalitis. All three entities result from a foreign agent stimulating inflammation in the CNS. Bacteria, viruses, fungi, chemical agents, and drugs such as sulfonamides and intravenous immune globulin can stimulate the cytokine cascade, leading to localized inflammation within the CNS. Meningitis is defined as inflammation of the membranes surrounding the brain and spinal cord, including the dura, arachnoid, and pia mater. Inflammation of these membranes can cause stiff neck and neck pain upon movement, and the cerebrospinal fluid (CSF) shows evidence of the inflammatory response. Encephalitis involves inflammation of the cerebral cortex, with clinical symptoms ranging from slight confusion to coma. These symptoms usually are coupled with headache and photophobia, and the CSF usually contains fewer polymorphonuclear cells (PMNs) than in meningitis. Meningoencephalitis represents inflammation of both the meninges and the cortex of the brain. Symptoms frequently are a combination of those associated with meningitis and encephalitis, and concentrations of PMNs in the CSF can be normal or increased. …

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