DRUGS USED FOR PURULENT Meningitis
BASIC ANTIBACTERIAL DRUGS USED FOR PURULENT MENINGITES To reduce intracranial pressure with clinically significant intracranial hypertension, administration of mannitol (0.25-0.5 g / kg iv in the course of 15-20 minutes) or glycerol is indicated. The head should be raised at an angle of 30 °. Excessive administration of furosemide and restriction of fluid, causing dehydration and lowering blood pressure, reduces cerebral blood flow and increases the risk of cerebral thrombosis. And severe cases resort to mechanical ventilation in hyperventilation mode.
2) Corticosteroids are used to reduce edema and prevent inflammatory complications. Dexamethasone is administered 20 minutes before the first dose of antibiotics at a dose of 4 mg iv, then again every 6 hours for 4 days. Under the condition of early use, the drug reduces the likelihood of developing sensorineural hearing loss in children. When treating dexamethasone, care should be taken to protect the stomach (antacids, H2-receptor blockers). Corticosteroids are not recommended in cases where the fungal or tuberculous etiology of meningitis cannot be ruled out (with subacute or gradual prevalence of lymphocytes in the CSF, the presence of eosinophils or atypical lymphocytes in it, and normal glucose levels).
3) Maintaining water-electrolyte balance. It is necessary to carefully measure the volume of injected and released fluid, in severe cases - regularly determine the sodium content in the blood and the serum osmolarity. Both dehydration should be avoided, promptly and completely compensating for fluid deficiency (especially with persistent vomiting), and hyperhydration, supporting normovolemia. In case of hyponatremia (sodium content below 135 meq / l), the volume of injected fluid should be limited by a quarter to 1000–1200 ml / day, and as the sodium level increases, the daily volume should be gradually increased to 1500–1700 ml. It is preferable to introduce saline, Ringer's solution with the addition of potassium (40 meq / l). Infusion solutions containing a lot of free water (e.g. 5% glucose solution) that aggravate cerebral edema should be avoided.
4) Due to impaired autoregulation of cerebral blood flow, it is necessary to monitor the stability of blood pressure. With hypovolemia, it is necessary to replenish bcc with crystalloid and colloidal solutions, with arterial hypotension, the appointment of vasopressors (dopamine).
5) It is important to timely recognize and conduct targeted treatment of systemic complications: shock, DIC, myocardial infarction, cardiac arrhythmias, pneumonia, pulmonary embolism. In case of DIC, heparin , freshly frozen plasma, fibrinolysis inhibitors (trasilol, contracal) are used.
6) In case of epileptic seizures, 5-10 mg of diazepam (relanium) is administered intravenously - watching for possible respiratory depression and a decrease in blood pressure. At the same time, care should be taken to maintain airway and prescribe oxygen. Metabolic disorders (hypoglycemia or hyponatremia), which can cause seizures and require correction, should be excluded.
7) Patients with suspected meningococcal meningitis should be isolated at 24 hours after the start of antibiotic therapy. Patients with meningitis of a different etiology do not require isolation.
Residual neurological symptoms persist in about a third of patients, sensorineural hearing loss is most often observed, paresis, epileptic seizures are often noted, in children - a violation of mental development.
Chemoprophylaxis. Prevention of meningococcal meningitis is recommended to everyone who is in close contact with the patient. Hospital staff, if not breathing mouth to mouth, do not need chemoprophylaxis. Rifampicin is used: in adults, 600 mg every 12 hours for 2 days (or a single dose of ciprofloxacin, 750 mg), in children, 10 mg / kg every 12 hours for 2 days. In pregnant women and children under 2 years of age, ceftriaxone is used (a single injection of 250 mg IM for adults or 125 mg for children). Chemoprophylaxis is indicated in mothers who, in addition to the diseased, have a child under 4 years old. With meningitis caused by hemophilic bacillus, if the family has a child under 2 years old, chemoprophylaxis is also recommended (rifamppicin, 20 mg / kg / day - up to 600 mg / day for 4 days).
Acute serous meningitis is more often the result of a viral infection. Serous meningitis is characterized by lymphocytic pleocytosis, a moderate increase in protein, normal glucose, a negative bacteriological test, a benign course with spontaneous recovery. Oppression of consciousness is usually shallow. Uncomplicated viral meningitis is not characteristic: stupor or coma , epileptic seizures, damage to the cranial nerves and other focal symptoms.
Enteroviruses are the most common cause of viral meningitis, and the disease is especially common in the summer months in children under 15 years of age. On examination, maculopapular, vesicular or petechial rash, herpangina, hemorrhagic conjunctivitis can be detected. Meningitis caused by the mumps virus often occurs in late autumn or early spring, and occurs 3 times more often in males. The presence of orchitis, oophoritis, mumps, pancreatitis with increased activity in the blood of lipase and amylase is characteristic. Lymphocytic choriomeningitis often occurs in late autumn and winter. Infection occurs as a result of contact with objects contaminated with feces or nasal mucus of domestic mice. Some patients develop a rash, lung infiltration, alopecia , mumps, orchitis , myopericarditis. Leukopenia , thrombocytopenia, pathological liver tests are characteristic. In CSF, high pleocytosis (above 1000 in 1 μl) and low glucose are sometimes detected. Meningitis caused by the herpes simplex virus type II often occurs against the background of the first exacerbation of genital herpes. Meningitis caused by the herpes zoster virus can be suspected in the presence of a characteristic rash. Epstein-Barr virus can cause meningitis , which is accompanied or not accompanied by clinical manifestations of infectious mononucleosis. The diagnosis is confirmed in the presence of atypical leukocytes in the blood and CSF. Meningitis can also be caused by tick-borne encephalitis virus.
Diagnostics. The causative agent can sometimes be isolated from CSF, feces (enteroviruses), blood (lymphocytic choriomeningitis virus), urine (mumps virus), nasopharyngeal rinse (enteroviruses and adenoviruses). Some viruses, in particular herpes simplex or herpes zoster viruses, can be identified in the CSF by polymerase chain reaction. More often, the pathogen is determined retrospectively by increasing the titer of specific antibodies in the study of paired sera. The pathogen can be determined more quickly by the ratio of specific antibodies in CSF and serum.
Symptomatic treatment : rest, bed rest, analgesics, non-steroidal anti-inflammatory drugs. Repeated lumbar puncture is necessary only if the fever and meningeal symptoms do not decrease within a few days or there is suspicion in favor of a different diagnosis. If bacterial meningitis cannot be ruled out, empirical antibiotic therapy should be prescribed. In severe meningitis caused by herpes viruses or herpes zoster, intravenous use of acyclovir is possible. In adults, a complete recovery usually occurs. Occasionally, headaches, general weakness, discoordination, impaired attention and memory persist from several weeks to several months.
Chronic meningitis Chronic meningitis is usually diagnosed in cases where symptoms persist for more than 4 weeks against persistent inflammatory changes in CSF. The clinical picture is characterized by persistent headache, meningeal symptoms, damage to the cranial nerves and roots of the spinal nerves, mental disorders that occur against the background of fever, general malaise, anorexia. The cause of chronic meningitis can be brain carcinomatosis, neuroleukemia, Lyme disease, tuberculosis, a fungal infection or parasitic infestation, granulomatous diseases (sarcoidosis, hypereosinophilic syndrome), drug meningitis (when taking ibuprofen, ciprofloxacin). It is important to exclude the presence of such sources of infection as otitis media , sinusitis , heart disease with a discharge of blood from right to left, chronic pulmonary infection.
Tuberculous meningitis is more often a manifestation of hematogenously disseminated tuberculosis. The primary focus may be in the lungs, retroperitoneal lymph nodes, bones. Often it is not possible to find him. The disease is more common in children and the elderly, as well as in patients with immunodeficiency (including AIDS, alcoholism and drug addiction, malnutrition). The initial manifestations are nonspecific: malaise, apathy, anorexia , subfebrile condition, inconsistent headaches, night sweats, weight loss, then the headache becomes constant, vomiting , drowsiness, meningeal signs appear. Symptoms gradually increase, confusion, signs of damage to the cranial nerves (oculomotor, facial, auditory, visual), epileptic seizures appear. Untreated tuberculous meningitis leads to death within 4 to 8 weeks. In the cerebrospinal fluid, pleocytosis from 10 to 500 / μl is detected, at first neutrophils may dominate, but after about a week, pleocytosis becomes lymphocytic. The protein content often rises to 5 - 10 g / l, the glucose level drops. The diagnosis is confirmed by staining the smear for acid-resistant bacteria, as well as by seeding cerebrospinal fluid (according to indications - sputum, urine, gastric contents). Mandatory chest x-ray, tuberculin test.
Treatment begins with three drugs (isoniazid, rifampicin , pyrazinamide). Additionally, vitamin B6 is prescribed to prevent isoniazid polyneuropathy. With a good effect, after 2 to 3 months, pyrazinamide is canceled, and isoniazid and rifampicin are retained for at least another 10 months. In severe cases, streptomycin is additionally prescribed.