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ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination.

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Presentation on theme: "ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination."— Presentation transcript:

1 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Acute Pneumococcal and Meningococcal Meningitis Penny Lewthwaite Penny Lewthwaite is a Consultant in Infectious Diseases. Her interests include brain infections, HIV, tropical and imported infections. Edited by Prof Tom Solomon and Dr Agam Jung This session provides an overview of issues relating to the diagnosis and treatment of acute pneumococcal and meningococcal meningitis.

2 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Learning Objectives By the end of this session you will be able to: Describe the impact of vaccination on the changing epidemiology of acute bacterial meningitis. Define the varied way in which meningitis can present and examination findings. Explain the diagnosis and treatment of pneumococcal and meningococcal meningitis. List the outcomes and prevention of meningitis.

3 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Introduction This session explores the epidemiology, presentation and initial examination findings in patients with acute bacterial meningitis due to S. pneumoniae and N. Meningitidis. It then explains treatment and diagnostic tests and finally, it provides information about outcomes following meningitis and prevention of meningitis. The first section begins with an overview of the epidemiology of meningitis. Pneumococcal Meningitis (Welcome Images)

4 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Epidemiology I Acute bacterial meningitis has an incidence of per per year in adults in developed countries with estimates of this being 10 times higher in resource poor-countries. The impact of immunisation programmes has had a marked effect on the aetiological agents responsible in recent years: Haemophilus influenza B Childhood immunization against Haemophilus influenza B has dramatically reduced the incidence of this infection Meningococcal vaccine Similarly, increasing use of the meningococcal vaccine against serogroups A & C have reduced the incidence acute bacterial meningitis from these serogroups. Quadrivalent vaccine More widespread use of the quadrivalent vaccine against serogroups A,C Y and W135 may further decrease the incidence from these other serogroups.

5 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Epidemiology II Infections from serogroup B are rising and as yet there is no vaccine against this serogroup. The focus of this module is on acute bacterial meningitis due to S.pneumoniae (Pneumococcal Meningitis) and N. meningitidis (Meningococcal Meningitis), which cause 80-90% of all cases in adults.

6 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment History and Presentation of Acute Bacterial Meningitis I Initial presentation can be very non-specific with symptoms such as fever and cold limbs, the classic triad of: Fever Neck stiffness Altered mental status (Glasgow coma score ≤14) These are only found in 44% of patients presenting with acute bacterial meningitis. In those with culture proven bacterial meningitis, 95% of patients have 2 of the following signs or symptoms and 99% have at least one: Headache Fever Neck stiffness Altered mental status

7 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment History and Presentation of Acute Bacterial Meningitis II Additional information which is important to obtain: Detailed travel history As the number of possible aetiological agents may increase and the risk of resistant bacteria may be greater (for example there is more resistant S.pneumoniae in certain parts of Europe). Medication history This should include “over the counter” and herbal remedies. Occupational history This is important for exposure risk, e.g. students. Teacher, care worker and also for contact tracing if Meningococcal meningitis is confirmed.

8 ACUTE ANEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Physical Examination Findings in Acute Bacterial Meningitis I Rash is only present in 11-26% of adults with acute bacterial meningitis. The purpuric rash of meningococcal meningitis is non-blanching. Hence the advice to parents to perform the 'glass test', rolling a glass over the rash to see if the rash disappears. If it does not urgent medical attention should be sought. If there is purpuric meningococcal rash and the presentation is one of septicaemia then no lumbar puncture is required and empiric IV antibiotics (2g ceftriaxone of cefotaxime) should be started immediately, although ideally after blood cultures and plasma samples for PCR have been taken. Neisseria meningitides is responsible for causing meningococcal meningitis. This photomicrograph depicts Neisseria meningitidis Group-B bacteria using a gram-stain from a culture Magnified 2250X.

9 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Physical Examination Findings in Acute Bacterial Meningitis II Other tests: Kernig’s sign Originally performed sitting now done supine. Flexing the hip and extending the knee. A positive result causes pain in the back and the legs. Kernig’s sign has poor sensitivity (5%) but high specificity (95%). Brudzinski’s sign Performed supine. Head is passively flexed A positive result is when flexion at the hips occurs to lift the legs. Brudzinski’s sign has poor sensitivity (5%) but high specificity (95%). Nuchal Rigidity Clinical determination of neck stiffness and inability to passively flex and extend the neck. Similarly nuchal rigidity has a sensitivity if only 30% and specificity of 68%. Sensory-motor long-tract and/or cerebellar signs are seen in 82% of cases.

10 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Physical Examination Findings in Acute Bacterial Meningitis III The classic triad (fever, neck stiffness and altered mental status) is found in only 44% of prospectively studied cases of acute bacterial meningitis. In those with culture proven bacterial meningitis: 95% had at least 2 of the signs or symptoms in the table at presentation. 99% had at least one.

11 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Clinical Diagnosis I A clinical diagnosis of acute bacterial meningitis must be made on a combination of the history and presentation together with the clinical findings. Once the clinical index of suspicion is raised urgent treatment and investigation must be instigated to confirm or exclude the diagnosis. A list of possible alternative diagnoses are given on the next slide. Delays in starting antibiotic therapy must be avoided as a delay of more than 3 hours in starting treatment can severely affect outcomes. Learning Bite: It's important to perform a thorough physical examination, including ears and throat as severe tonsillitis can mimic bacterial meningitis. Skin rashes and eschars (from tick bites) might suggest alternative aetiologies (eg tick borne encephalitis or rickettsial infections if there is an appropriate travel history).

12 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Clinical Diagnosis II A list of possible alternative diagnosis to acute bacterial meningitis:

13 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Diagnosis and Treatment of Acute Bacterial Meningitis I Do not delay. A rapid assessment of the patient should be made: A Airway B Breathing C Circulation M Mental status N Neurological status: focal neurology, seizures If signs of shock or 'warning signs' listed on the next slide are present urgent fluid resuscitation and oxygen therapy and critical care review are requested. Antibiotic therapy should be started as soon as diagnostic samples have been taken.

14 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Diagnosis and Treatment of Acute Bacterial Meningitis II Reproduced with permission of the British Infection Association (BIA )

15 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Diagnosis and Treatment of Acute Bacterial Meningitis III Diagnostic tests include: Lumbar puncture -Glucose-Protein-Gram stain culture & sensitivity -PCR-Store sample Blood tests -FBC-U&E-LFT -CRP-Clotting profile glucose-Blood gases Microbiology -Blood culture-Plasma PCR-Throat swab Imaging -CT brain Of these, lumbar puncture is the most important. In the majority of cases lumbar puncture can be safely performed without CT brain imaging first. The exceptions are listed on the next slide.

16 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Diagnosis and Treatment of Acute Bacterial Meningitis IV LP exclusion criteria:

17 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Diagnostic Tests in Acute Bacterial Meningitis LP I Lumbar puncture is the most important of these and should be performed wherever possible and can help differentiate the causes of meningitis. Opening pressure measurement in mmCSF Gives information about intra-cranial pressure Normal range 7-18 mmCSF CSF glucose Plasma ratio gives an indication of the likely pathogens as does CSF protein. Normal CSF plasma glucose ratio is 2/3 In Bacteria meningitis it is LOW TB meningitis it is VERY LOW – LOW Fungal meningitis it is LOW Viral meningitis it is normal (can be LOW) Direct microscopy and gram stain Gives a rapid answer if organisms are seen. Culture and sensitivity Culture and sensitivity provides further information about the organisms identity and resistance profile.

18 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Diagnostic Tests in Acute Bacterial Meningitis LP II Pneumococcal and meningococcal PCR Further PCRs Further PCRs for viral infections, TB, fungi etc can be carried out at a later date if no diagnosis is made. Advances in molecular diagnostics mean that PCR of 16S ribosomal gene of eukaryotic organisms can be used in their identification. The 16S region is widely conserved and so can be used to detect most bacterial pathogens. Sequencing of the identified organism can lead to its identification. At present this is largely a research tool but it may be of help in the future in identifying atypical organisms i.e. non Neisseria meningitis and S.pneumoniae infections.

19 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Treatment of Acute Bacterial Meningitis I Urgent treatment with IV antibiotics should be instigated once diagnostic samples have been taken. If there is likely to be a significant delay before lumbar puncture or CT then antibiotics should be given. If meningococcal septicaemia is the clinical presentation then no LP should be performed and 2g IV ceftriaxone or cefotaxime should be commenced. As much of the pathology in meningitis is inflammatory a role for steroids has been suggested. Studies have failed to show a consistent benefit from steroids although there may be a modest benefit in pneumococcal meningitis. No benefit has been shown in meningococcal meningitis. Current advice is to give 0.15mg/kg just before or at the same time as antibiotics. If steroids are not immediately available they should not delay the first dose of antibiotic being given as prompt antibiotic treatment is crucial. Learning Bite: It is important to seek advice from local microbiology department regarding resistance patterns and alternative antibiotic regimens.

20 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Treatment of Acute Bacterial Meningitis II Meningococcal meningitis Meningococcal meningitis if fully sensitive can be treated with benzyl penicillin although a cephalosporin is usually recommended due to concerns about antibiotic resistance. In those with penicillin allergies chloramphenicol can be used. A 7 day course of antibiotic is recommended. Pneumococcal meningitis Cefotaxime is first line with Benzyl penicillin an alternative if the organism is fully sensitive. If there is resistance or suspected resistance vancomycin can be added together with rifampicin if necessary. There have been reports of treatment failure with vancomycin alone if dexamethasone is used as this is thought to possibly reduce CSF penetration of vancomycin although studies have yet to conform this. A 14 day course of antibiotics is recommended. Listeria meningitis In the elderly or pregnant additional cover with ampicillin is recommended to treat Listeria monocytogenes. For further information, refer to the Listeria meningitis session.

21 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Notification Notification is of particular importance in meningococcal disease as treatment of contacts may be recommended by the public health team in an attempt to prevent secondary cases. Acute meningitis, acute encephalitis and meningococcal septicaemia are all notifiable diseases in England. lick to view the Health Protection Agency infectious diseases. Meningococcal disease is notifiable in Scotland. Click to view the Scottish Government guidelines on infectious diseasesClick to view the Scottish Government guidelines on infectious diseases.

22 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Outcomes I Prevention of Secondary Cases of Meningococcal Meningitis Up to 10% of people carry Neisseria meningitidis in their nose without ill effect. It is not understood why some people go on to develop septicaemia or meningitis. Eradication of nasal carriage in contacts of symptomatic patients can reduce the number of secondary cases, particularly in school and further education settings. Usually household contacts or those with >4 hours contact with the index case are advised to have prophylactic treatment. Recommended regimens are outlined in the table below. No secondary prevention is required for pneumococcal meningitis

23 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Outcomes II Primary Prevention of Meningitis Already the impact of Haemophilus influenzae B vaccination is reducing cases of meningitis in children. More widespread use of the 7 conjugate pneumococcal vaccine in children and the elderly may reduce the incidence of pneumococcal disease. Work is on-going in the development of a vaccine against serogroup B meningitis which if it came into widespread use might reduce infection from this serogroup.

24 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Outcomes III Outcomes: Meningococcal Meningitis Mortality from meningococcal meningitis is between 4 to 8% for children and up to 7% for adults. Most patients die of systemic complications, mostly sepsis. Unfavourable outcomes can be predicated by: Signs of sepsis Advanced age Infection due to meningococci of clonal complex 11 together with high bacterial load as determined by quantitative PCR. Survivors 10% suffer from hearing loss and 10% have arthritis as a complication. This is either due to haematogenous bacterial seeding of joints (septic arthritis) or by immune complex deposition in joints (immune-mediated arthritis). Immune-mediated arthritis Typically develops from day 5 of the illness or during recovery from the infection and generally involving the large joints.

25 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Outcomes IV Most common causes of death are: Cardiorespiratory failure Stroke Status epilepticus Brain herniation Unfavourable outcomes can be predicted by: Low Glasgow coma score on admission Cranial nerve palsies on admission Raised erythrocyte sendimentation rate High CSF protein concentration CSF leukocyte count of less than 1,000 leukocytes per mm 3. Outcomes: Pneumococcal Meningitis Mortality from pneumococcal meningitis is from 8% in children in the developed world to 37% in resource-poor settings. Mortality in adults with pneumococcal meningitis ranges from 20 to 37% in developed countries to 51% in resource-poor areas.

26 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Outcomes V Pneumococcal Meningitis Survivors Neurological sequelae Up to 50% of survivors have some form of neurological sequelae including: Deafness Focal neurological deficits Epilepsy Cognitive impairment Cognitive impairment is found in up to 27% of patients, even those with apparent good recovery, (mainly of cognitive slowness). Improvement of physical impairment Loss of cognitive speed does not change over time after bacterial meningitis however, there is a significant improvement in physical impairment in the years after bacterial meningitis..

27 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Key Points Acute bacterial meningitis is a medical emergency and early antibiotic therapy can improve outcomes Lumbar puncture is safe to perform without prior CT brain in the majority of patients Dexamethasone if it is given should be given just before or with the fist dose of antibiotics particularly if pneumococcal meningitis is suspected Notification and prophylactic antibiotics are important in preventing secondary cases of meningococcal meningitis Sequelae including deafness, immune-mediated arthritis and neurological deficit may complicate recovery in survivors Future epidemiology of acute bacteria meningitis may alter with immunisation programmes.

28 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Session Summary Having completed this session you will now be able to: Describe the impact of vaccination on the changing epidemiology of acute bacterial meningitis Recognise the varied way in which meningitis can present and examination findings Explain the diagnosis and treatment of pneumococcal and meningococcal meningitis List the outcomes and prevention of meningitis Further Reading and References 1.Matthijs C. et al, Epidemiology, Diagnosis, and Antimicrobial Treatment of Acute Bacterial Meningitis. CLINICAL MICROBIOLOGY REVIEWS, July 2010, p. 467–492 Vol. 23, No Brouwer MC et al, Corticosteroids for acute bacterial meningitis (Review) Cochrane collaboration Chaudhuria, A et al, EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. for the EFNS Task Force European Journal of Neurology 2008, 15: 649– Fitch, MT et al, Emergency diagnosis and treatment of adult meningitis Lancet Infect Dis 2007;7:191– Wasiulla Rafi et al, Rapid Diagnosis of acute bacterial meningitis : role of a broad range 16S rRNA polymerase chain reaction. The Journal of Emergency Medicine, Vol. 38, No. 2, pp. 225–230, British Infection Society, Early Managemetn of Suspected Bacterial Meningitis and Meningococcal Septicaemia in Immunocompetent Adults. View pdf 7.Health Protection Agency, List of Notifiable Diseases. View 8.The Scottish Government, Guidance on Notifiable Diseases, Notifiable Organisms and Health Risk States. View

29 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 1 Regarding history and examination of patients with acute bacterial meningitis which of the following is correct? A.Fever and cold limbs may be an early featureFever and cold limbs may be an early feature B.Kernig’s sign is always presentKernig’s sign is always present C.Lumbar puncture must be delayed until after CT brain.Lumbar puncture must be delayed until after CT brain D.Dexamethasone is still of benefit after 24 hours of antibiotic therapy.Dexamethasone is still of benefit after 24 hours of antibiotic therapy. Regarding history and examination of patients with acute bacterial meningitis which of the following is correct? A.Fever and cold limbs may be an early featureFever and cold limbs may be an early feature B.Kernig’s sign is always presentKernig’s sign is always present C.Lumbar puncture must be delayed until after CT brain.Lumbar puncture must be delayed until after CT brain D.Dexamethasone is still of benefit after 24 hours of antibiotic therapy.Dexamethasone is still of benefit after 24 hours of antibiotic therapy.

30 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 1 Regarding history and examination of patients with acute bacterial meningitis which of the following is correct? A.Fever and cold limbs may be an early feature B.Kernig’s sign is always present C.Lumbar puncture must be delayed until after CT brain. D.Dexamethasone is still of benefit after 24 hours of antibiotic therapy. Regarding history and examination of patients with acute bacterial meningitis which of the following is correct? A.Fever and cold limbs may be an early feature B.Kernig’s sign is always present C.Lumbar puncture must be delayed until after CT brain. D.Dexamethasone is still of benefit after 24 hours of antibiotic therapy. A)CORRECT Kernig’s sign has poor sensitivity (5%) but high specificity (95%). In the majority of patients LP can safely be performed without prior LP. Dexamethasone has only been found to be of benefit in improving outcomes from pneumococcal meningitis if it is given before or at the same time as the first dose of antibiotic. Click here to move onto the next question A)CORRECT Kernig’s sign has poor sensitivity (5%) but high specificity (95%). In the majority of patients LP can safely be performed without prior LP. Dexamethasone has only been found to be of benefit in improving outcomes from pneumococcal meningitis if it is given before or at the same time as the first dose of antibiotic. Click here to move onto the next question

31 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 1 Regarding history and examination of patients with acute bacterial meningitis which of the following is correct? A.Fever and cold limbs may be an early featureFever and cold limbs may be an early feature B.Kernig’s sign is always present C.Lumbar puncture must be delayed until after CT brain.Lumbar puncture must be delayed until after CT brain. D.Dexamethasone is still of benefit after 24 hours of antibiotic therapy.Dexamethasone is still of benefit after 24 hours of antibiotic therapy Regarding history and examination of patients with acute bacterial meningitis which of the following is correct? A.Fever and cold limbs may be an early featureFever and cold limbs may be an early feature B.Kernig’s sign is always present C.Lumbar puncture must be delayed until after CT brain.Lumbar puncture must be delayed until after CT brain. D.Dexamethasone is still of benefit after 24 hours of antibiotic therapy.Dexamethasone is still of benefit after 24 hours of antibiotic therapy B. INCORRECT Please choose another option B. INCORRECT Please choose another option

32 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 1 Regarding history and examination of patients with acute bacterial meningitis which of the following is correct? A.Fever and cold limbs may be an early featureFever and cold limbs may be an early feature B.Kernig’s sign is always presentKernig’s sign is always present C.Lumbar puncture must be delayed until after CT brain. D.Dexamethasone is still of benefit after 24 hours of antibiotic therapy.Dexamethasone is still of benefit after 24 hours of antibiotic therapy. Regarding history and examination of patients with acute bacterial meningitis which of the following is correct? A.Fever and cold limbs may be an early featureFever and cold limbs may be an early feature B.Kernig’s sign is always presentKernig’s sign is always present C.Lumbar puncture must be delayed until after CT brain. D.Dexamethasone is still of benefit after 24 hours of antibiotic therapy.Dexamethasone is still of benefit after 24 hours of antibiotic therapy. C. INCORRECT Please choose another option C. INCORRECT Please choose another option

33 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 1 Regarding history and examination of patients with acute bacterial meningitis which of the following is correct? A.Fever and cold limbs may be an early featureFever and cold limbs may be an early feature B.Kernig’s sign is always presentKernig’s sign is always present C.Lumbar puncture must be delayed until after CT brain.Lumbar puncture must be delayed until after CT brain. D.Dexamethasone is still of benefit after 24 hours of antibiotic therapy. Regarding history and examination of patients with acute bacterial meningitis which of the following is correct? A.Fever and cold limbs may be an early featureFever and cold limbs may be an early feature B.Kernig’s sign is always presentKernig’s sign is always present C.Lumbar puncture must be delayed until after CT brain.Lumbar puncture must be delayed until after CT brain. D.Dexamethasone is still of benefit after 24 hours of antibiotic therapy. D. INCORRECT Please choose another option D. INCORRECT Please choose another option

34 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 Select true or false for the following statement Regarding meningococcal meningitis: a)Dexamethasone improves outcomes TrueFalse Select true or false for the following statement Regarding meningococcal meningitis: a)Dexamethasone improves outcomes TrueFalse

35 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 Select true or false Regarding meningococcal meningitis: a)Dexamethasone improves outcomes TrueFalse Select true or false Regarding meningococcal meningitis: a)Dexamethasone improves outcomes TrueFalse Sorry INCORRECT answer. Dexamethasone if given at or just before the first dose of antibiotic has shown some outcome benefit in pneumococcal meningitis. No benefit has been found for meningococcal meningitis. The correct response is FALSE. Click here to move onto the next question Sorry INCORRECT answer. Dexamethasone if given at or just before the first dose of antibiotic has shown some outcome benefit in pneumococcal meningitis. No benefit has been found for meningococcal meningitis. The correct response is FALSE. Click here to move onto the next question

36 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 CORRECT answer. Dexamethasone if given at or just before the first dose of antibiotic has shown some outcome benefit in pneumococcal meningitis. No benefit has been found for meningococcal meningitis. Click here to move onto the next question. CORRECT answer. Dexamethasone if given at or just before the first dose of antibiotic has shown some outcome benefit in pneumococcal meningitis. No benefit has been found for meningococcal meningitis. Click here to move onto the next question. Select true or false Regarding meningococcal meningitis: a)Dexamethasone improves outcomes TrueFalse Select true or false Regarding meningococcal meningitis: a)Dexamethasone improves outcomes TrueFalse

37 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 Select true or false Regarding meningococcal meningitis: b)IV Benzyl penicillin can be used. TrueFalse Select true or false Regarding meningococcal meningitis: b)IV Benzyl penicillin can be used. TrueFalse

38 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 Select true or false Regarding meningococcal meningitis: b)IV Benzyl penicillin can be used. TrueFalse Select true or false Regarding meningococcal meningitis: b)IV Benzyl penicillin can be used. TrueFalse CORRECT answer. If there are no concerns re antibiotic resistance or a fully sensitive organism has been cultured then it can be used. Click here to move onto the next question. CORRECT answer. If there are no concerns re antibiotic resistance or a fully sensitive organism has been cultured then it can be used. Click here to move onto the next question.

39 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 Sorry INCORRECT answer. If there are no concerns re antibiotic resistance or a fully sensitive organism has been cultured then it can be used. The correct response is TRUE Click here to move onto the next question Sorry INCORRECT answer. If there are no concerns re antibiotic resistance or a fully sensitive organism has been cultured then it can be used. The correct response is TRUE Click here to move onto the next question Select true or false Regarding meningococcal meningitis: b)IV Benzyl penicillin can be used. TrueFalse Select true or false Regarding meningococcal meningitis: b)IV Benzyl penicillin can be used. TrueFalse

40 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 Select true or false Regarding meningococcal meningitis: c)Immune mediated arthritis commonly affects small joints. TrueFalse Select true or false Regarding meningococcal meningitis: c)Immune mediated arthritis commonly affects small joints. TrueFalse

41 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 Select true or false Regarding meningococcal meningitis: c)Immune mediated arthritis commonly affects small joints. TrueFalse Select true or false Regarding meningococcal meningitis: c)Immune mediated arthritis commonly affects small joints. TrueFalse Sorry INCORRECT answer. Post meningococcal immune mediated arthritis affects 10% of patients and commonly affects large joints. The correct response is FALSE Click here to move onto the next question Sorry INCORRECT answer. Post meningococcal immune mediated arthritis affects 10% of patients and commonly affects large joints. The correct response is FALSE Click here to move onto the next question

42 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 CORRECT answer. Post meningococcal immune mediated arthritis affects 10% of patients and commonly affects large joints Click here to move onto the next question. CORRECT answer. Post meningococcal immune mediated arthritis affects 10% of patients and commonly affects large joints Click here to move onto the next question. Select true or false Regarding meningococcal meningitis: c)Immune mediated arthritis commonly affects small joints. TrueFalse Select true or false Regarding meningococcal meningitis: c)Immune mediated arthritis commonly affects small joints. TrueFalse

43 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 Select true or false Regarding meningococcal meningitis: d)Meningitis due to serogroup C is increasing. TrueFalse Select true or false Regarding meningococcal meningitis: d)Meningitis due to serogroup C is increasing. TrueFalse

44 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 Sorry INCORRECT answer. Due to immunization with vaccine containing serogroups A & C these serogroups are decreasing in prevalence, instead serogroups B for which there is no vaccine is increasing in prevalence. The correct response is FALSE Click here to move onto the next question Sorry INCORRECT answer. Due to immunization with vaccine containing serogroups A & C these serogroups are decreasing in prevalence, instead serogroups B for which there is no vaccine is increasing in prevalence. The correct response is FALSE Click here to move onto the next question Select true or false Regarding meningococcal meningitis: d)Meningitis due to serogroup C is increasing. TrueFalse Select true or false Regarding meningococcal meningitis: d)Meningitis due to serogroup C is increasing. TrueFalse

45 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 CORRECT answer. Due to immunization with vaccine containing serogroups A & C these serogroups are decreasing in prevalence, instead serogroups B for which there is no vaccine is increasing in prevalence. Click here to move onto the next question. CORRECT answer. Due to immunization with vaccine containing serogroups A & C these serogroups are decreasing in prevalence, instead serogroups B for which there is no vaccine is increasing in prevalence. Click here to move onto the next question. Select true or false Regarding meningococcal meningitis: d)Meningitis due to serogroup C is increasing. TrueFalse Select true or false Regarding meningococcal meningitis: d)Meningitis due to serogroup C is increasing. TrueFalse

46 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 Select true or false Regarding meningococcal meningitis: e)Prophylactic antibiotics are recommended for close contacts. TrueFalse Select true or false Regarding meningococcal meningitis: e)Prophylactic antibiotics are recommended for close contacts. TrueFalse

47 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 CORRECT answer. Household contacts and those who have spent more than 4 hours in contact with the patient are advised to take prophylactic antibiotics. Click here to move onto the next question. CORRECT answer. Household contacts and those who have spent more than 4 hours in contact with the patient are advised to take prophylactic antibiotics. Click here to move onto the next question. Select true or false Regarding meningococcal meningitis: e)Prophylactic antibiotics are recommended for close contacts. TrueFalse Select true or false Regarding meningococcal meningitis: e)Prophylactic antibiotics are recommended for close contacts. TrueFalse

48 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 2 Sorry INCORRECT answer. Household contacts and those who have spent more than 4 hours in contact with the patient are advised to take prophylactic antibiotics. The correct response is TRUE Click here to move onto the next question Sorry INCORRECT answer. Household contacts and those who have spent more than 4 hours in contact with the patient are advised to take prophylactic antibiotics. The correct response is TRUE Click here to move onto the next question Select true or false Regarding meningococcal meningitis: e)Prophylactic antibiotics are recommended for close contacts. TrueFalse Select true or false Regarding meningococcal meningitis: e)Prophylactic antibiotics are recommended for close contacts. TrueFalse

49 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 3 Regarding pneumococcal meningitis. Which of the following statements is incorrect? A.Delays in antibiotic therapy lead to poorer outcomesDelays in antibiotic therapy lead to poorer outcomes B.Low Glasgow coma score at admission is a predictor of poor outcome.Low Glasgow coma score at admission is a predictor of poor outcome. C.Most patients make a full recovery.Most patients make a full recovery D.Vancomycin and or rifampicin can be added if resistance is suspected.Vancomycin and or rifampicin can be added if resistance is suspected. Regarding pneumococcal meningitis. Which of the following statements is incorrect? A.Delays in antibiotic therapy lead to poorer outcomesDelays in antibiotic therapy lead to poorer outcomes B.Low Glasgow coma score at admission is a predictor of poor outcome.Low Glasgow coma score at admission is a predictor of poor outcome. C.Most patients make a full recovery.Most patients make a full recovery D.Vancomycin and or rifampicin can be added if resistance is suspected.Vancomycin and or rifampicin can be added if resistance is suspected.

50 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 3 Regarding pneumococcal meningitis. Which of the following statements is incorrect? A.Delays in antibiotic therapy lead to poorer outcomes B.Low Glasgow coma score at admission is a predictor of poor outcome.Low Glasgow coma score at admission is a predictor of poor outcome. C.Most patients make a full recovery.Most patients make a full recovery. D.Vancomycin and or rifampicin can be added if resistance is suspected.Vancomycin and or rifampicin can be added if resistance is suspected. Regarding pneumococcal meningitis. Which of the following statements is incorrect? A.Delays in antibiotic therapy lead to poorer outcomes B.Low Glasgow coma score at admission is a predictor of poor outcome.Low Glasgow coma score at admission is a predictor of poor outcome. C.Most patients make a full recovery.Most patients make a full recovery. D.Vancomycin and or rifampicin can be added if resistance is suspected.Vancomycin and or rifampicin can be added if resistance is suspected. A)Sorry INCORRECT answer. Delays of 3 or more hours in receiving antibiotic therapy from admission to hospital result in poorer outcomes. Please choose another option A)Sorry INCORRECT answer. Delays of 3 or more hours in receiving antibiotic therapy from admission to hospital result in poorer outcomes. Please choose another option

51 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 3 Regarding pneumococcal meningitis. Which of the following statements is incorrect? A.Delays in antibiotic therapy lead to poorer outcomesDelays in antibiotic therapy lead to poorer outcomes B.Low Glasgow coma score at admission is a predictor of poor outcome. C.Most patients make a full recovery.Most patients make a full recovery D.Vancomycin and or rifampicin can be added if resistance is suspected.Vancomycin and or rifampicin can be added if resistance is suspected. Regarding pneumococcal meningitis. Which of the following statements is incorrect? A.Delays in antibiotic therapy lead to poorer outcomesDelays in antibiotic therapy lead to poorer outcomes B.Low Glasgow coma score at admission is a predictor of poor outcome. C.Most patients make a full recovery.Most patients make a full recovery D.Vancomycin and or rifampicin can be added if resistance is suspected.Vancomycin and or rifampicin can be added if resistance is suspected. B)Sorry INCORRECT answer. Low Glasgow coma score at admission is a predictor of poor outcome. Please choose another option B)Sorry INCORRECT answer. Low Glasgow coma score at admission is a predictor of poor outcome. Please choose another option

52 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 3 Regarding pneumococcal meningitis. Which of the following statements is incorrect? A.Delays in antibiotic therapy lead to poorer outcomes B.Low Glasgow coma score at admission is a predictor of poor outcome. C.Most patients make a full recovery. D.Vancomycin and or rifampicin can be added if resistance is suspected. Regarding pneumococcal meningitis. Which of the following statements is incorrect? A.Delays in antibiotic therapy lead to poorer outcomes B.Low Glasgow coma score at admission is a predictor of poor outcome. C.Most patients make a full recovery. D.Vancomycin and or rifampicin can be added if resistance is suspected. C)CORRECT answer. Up to 50% of survivors have some form neurological sequelae, including deafness, focal neurological deficits, epilepsy and cognitive impairment. Click here to finish the session.. C)CORRECT answer. Up to 50% of survivors have some form neurological sequelae, including deafness, focal neurological deficits, epilepsy and cognitive impairment. Click here to finish the session..

53 ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS Learning Objectives Introduction Epidemiology History and PresentationHistory and Presentation Examination FindingsExamination Findings Clinical Diagnosis Diagnosis and treatment of Acute MeningitisDiagnosis and treatment of Acute Meningitis Diagnostic Tests Treatment Notification Outcomes Key Points Session summary and References and further readingSession summary and References and further reading Self Assessment Question 3 Regarding pneumococcal meningitis. Which of the following statements is incorrect? A.Delays in antibiotic therapy lead to poorer outcomesDelays in antibiotic therapy lead to poorer outcomes B.Low Glasgow coma score at admission is a predictor of poor outcome.Low Glasgow coma score at admission is a predictor of poor outcome. C.Most patients make a full recovery.Most patients make a full recovery. D.Vancomycin and or rifampicin can be added if resistance is suspected. Regarding pneumococcal meningitis. Which of the following statements is incorrect? A.Delays in antibiotic therapy lead to poorer outcomesDelays in antibiotic therapy lead to poorer outcomes B.Low Glasgow coma score at admission is a predictor of poor outcome.Low Glasgow coma score at admission is a predictor of poor outcome. C.Most patients make a full recovery.Most patients make a full recovery. D.Vancomycin and or rifampicin can be added if resistance is suspected. D)Sorry INCORRECT answer. Vancomycin and or rifampicin can be added if resistance is suspected. Please choose another option D)Sorry INCORRECT answer. Vancomycin and or rifampicin can be added if resistance is suspected. Please choose another option

54 Congratulations on completing this module and thank you for using NeuroID: elearning. We hope to see you at a NeuroID: Liverpool Neurological Infectious Diseases Course soon. Download a certificateDownload a certificate and then to finish the session CLICK HERE.CLICK HERE

55 Liverpool Medical Institution, UK Provisional date: May 2013 NeuroID 2013: Liverpool Neurological Infectious Diseases Course Ever struggled with a patient with meningitis or encephalitis, and not known quite what to do? Then the Liverpool Neurological infectious Diseases Course is for you! For Trainees and Consultants in Adult and Paediatric Neurology, Infectious Diseases, Acute Medicine, Emergency Medicine and Medical Microbiology who want to update their knowledge, and improve their skills. For more information and to REGISTER NOW VISIT: Presented by Leaders in the Field Commonly Encountered Clinical Problems Practical Management Approaches Rarities for Reference Interactive Case Presentations State of the Art Updates Pitfalls to Avoid Controversies in Neurological Infections To learn more about neurological infectious diseases… Convenors: Prof Tom Solomon, Dr Enitan Carrol, Dr Rachel Kneen, Dr Nick Beeching, Dr Benedict Michael Feedback from previous course: “Would unreservedly recommend to others” “An excellent 2 days!! The best course for a long time”


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