Drugs used in purulent meningitis

Major antibacterial drugs used in purulent meningitis to reduce intracranial pressure with clinically significant intracranial hypertension shows the introduction of mannitol (0.25 - 0.5 g / kg / drip for 15 - 20 minutes) or glycerol. The head should be elevated at an angle of 30 °. Excessive administration of furosemide and fluid restriction, causing dehydration and lowering of blood pressure, reduces cerebral blood flow and increases the risk of thrombosis of cerebral vessels. And severe cases, resorting to artificial ventilation in hyperventilation mode.

2) Corticosteroids are used to reduce edema and the prevention of inflammatory complications. Dexamethasone was administered 20 minutes prior to the first dose of antibiotics at a dose of 4 mg / in, and then repeated every 6 hours for 4 days. Provided early administration of the drug reduces the chance of developing sensorineural hearing loss in children. In the treatment of dexamethasone should take care of the protection of the stomach (antacids block tori H2-receptor). Corticosteroids are not recommended to be administered in cases where it is impossible to eliminate fungal or tubercular meningitis etiology (in subacute or gradual predominance of CSF lymphocytes, eosinophils present in it or atypical lymphocytes, a normal level of glucose).

3) Maintenance of fluid and electrolyte balance. It should be carefully measure the amount of fluid introduced and highlighted, in severe cases - on a regular basis to determine the sodium content in the blood and serum osmolarity. Avoid dehydration as a timely and fully offsetting fluid deficit (especially when persistent vomiting), as well as hydration, maintaining normovolaemia. If hyponatremia (sodium content of less than 135 mEq / L) should be limited to a quarter of the volume of fluids - up to 1000-1200 ml / day, and increasing sodium levels gradually increase the daily volume of up to 1500 - 1700 mL. Preferably administered saline, Ringer's solution, with the addition of potassium (40 meq / l). It is necessary to avoid infusion solutions that contain a lot of free water (eg 5% glucose solution), contributing to swelling of the brain.

4) In view of the violations of cerebral autoregulation is necessary to monitor the stability of blood pressure. When hypovolemia is necessary replenishment bcc crystalloid and colloid solutions, at an arterial hypotension - the appointment of vasopressors (dopamine).

5) It is important to promptly recognize and carry out targeted treatment of systemic complications: shock, DIC, myocardial infarction, cardiac arrhythmias, pneumonia, pulmonary embolism. When DIC is used heparin, fresh frozen plasma, fibrinolysis inhibitors (trasilol, contrycal).

6) When seizures injected intravenously 5 -10 mg of diazepam (Relanium) - Watch for respiratory depression and decreased blood pressure. At the same time care should be taken to maintain airway patency and assign oxygen. It is necessary to exclude metabolic disorders (hypoglycemia or hyponatremia), which can cause seizures and require correction.

7) Patients with suspected meningkokkovy meningitis, must be isolated for 24 hours after initiation of antibiotic therapy. Patients with meningitis different etiology not require insulation.

Residual neurological symptoms persists in about one third of patients, most commonly observed sensorineural hearing loss, often marked paresis, seizures in children - a violation of psychological development.

Chemoprevention. Prevention of meningococcal meningitis is recommended to all who were in close contact with the patient. The hospital staff, unless they perform mouth-to-mouth in chemoprevention is not needed. Use rifampicin: 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. Pregnant women and children under 2 years of use ceftriaxone (single injection of 250 mg / m or 125 mg for adults - children). Chemoprevention is shown in mothers who have, in addition to the sick, a child up to 4 years. When meningitis caused by Haemophilus influenzae, if a family has a child up to 2 years, as recommended chemoprophylaxis (rifamppitsin, 20 mg / kg / day - 600 mg / day for 4 days).

Acute serous meningitis is more often the result of a viral infection. For serous meningitis is characterized by lymphocytic pleocytosis, a moderate increase in protein content, the normal glucose level, a negative result of bacteriological research, benign course with spontaneous recovery. Oppression of consciousness is usually shallow. For uncomplicated viral meningitis are not typical: stupor or coma , seizures, cranial nerves and other focal symptoms.

Enteroviruses - the most common cause of viral meningitis, the disease occurs most often in the summer months in children under 15 years. On examination, can be detected maculopapular, vesicular or petechial rash, gerpangina, hemorrhagic conjunctivitis . Meningitis caused by mumps virus, occurs more often in late autumn or early spring, it is 3 times more common in males. Characterized by orchitis, oophoritis, mumps pancreatitis with increased activity in the blood lipase and amylase. Lymphocytic choriomeningitis often occurs in late autumn and winter. Infection is through contact with objects contaminated with feces or nasal mucus house mice. Some patients appear rash, pulmonary infiltrates, alopecia , mumps, orchitis , mioperikardit. Characterized by leukopenia , thrombocytopenia, abnormal liver function tests. The CSF pleocytosis sometimes detected high (above 1000 per 1 L) and low glucose. Meningitis caused by herpes simplex virus type II, occurs frequently in the first acute genital herpes. Meningitis is caused by the herpes zoster virus, can be suspected in the presence of a characteristic rash. Epstein-Barr virus can cause meningitis , accompanied or not accompanied by clinical symptoms of infectious mononucleosis. The diagnosis is confirmed by the presence of abnormal white blood cells in the blood and cerebrospinal fluid. Meningitis can be caused by a virus and tick-borne encephalitis.

Diagnostics. Exciter can sometimes be isolated from the cerebrospinal fluid, feces (enteroviruses), the blood (lymphocytic choriomeningitis virus), urine (mumps virus), nasopharyngeal wash (enteroviruses and adenoviruses). Some viruses, particularly herpes simplex viruses or herpes may be identified in CSF using the polymerase chain reaction. The most common pathogen is determined retrospectively to increase the titer of specific antibodies in the study of paired sera. Pathogen can more quickly determine the ratio of specific antibodies in serum and CSF.

Treatment is symptomatic: rest, bed rest, analgesics, non-steroidal anti-inflammatory drugs. Repeated lumbar puncture is needed only when the fever and meningeal symptoms do not decrease within a few days or there are suspicions in favor of a diagnosis. If we can not exclude bacterial meningitis , it is necessary to appoint an empirical antibiotic therapy. In severe meningitis, caused by the herpes viruses or herpes zoster may intravenous acyclovir. In adults, usually a full recovery. Occasionally headaches, general weakness, discoordination, impaired attention and memory are saved from a few weeks to several months.

Chronic meningitis . Chronic Meningitis is usually diagnosed in cases where the symptoms persists for more than 4 weeks against persistent inflammatory changes in CSF. The clinical picture is characterized by persistent headache, meningeal signs, cranial nerves and spinal nerves, psychiatric disorders, occurring against the backdrop of fever, general malaise, anorexia. The cause of chronic meningitis may be meningeal carcinomatosis, neuroleukemia, Lyme disease, tuberculosis, fungal infection or parasitic infestation, granulomatous disease (sarcoidosis, hypereosinophilic syndrome), drug meningitis (with ibuprofen, ciprofloxacin). It is important to exclude the presence of sources of infection as otitis media , sinusitis , heart disease with blood discharge from right to left, chronic pulmonary infection.

TB meningitis is more often a manifestation of hematogenous-disseminated tuberculosis. It may be the primary focus in the lung, retroperitoneal lymph nodes, bones. Often, it can not be found. The disease is more common in children and the elderly, and immunocompromised patients (including AIDS, alcoholism and drug addiction, eating disorders). Initial symptoms are nonspecific: malaise, apathy, anorexia , low-grade fever, irregular headaches, night sweats, weight loss, then the headache becomes constant, there are vomiting , lethargy, meningeal signs. Symptoms gradually increasing, there are confusion, signs of cranial nerve (oculomotor, facial, auditory, visual), seizures. Untreated TB meningitis is fatal within 4 - 8 weeks. CSF pleocytosis detected in 10 to 500 / L, neutrophils can dominate initially, but after about a week lymphocytic pleocytosis becomes. The protein content is often increased to 5 - 10 g / l glucose level falls. The diagnosis is confirmed by staining of smear for acid bacteria and by seeding liquor (indication - sputum, urine, gastric contents). Required chest X-ray, tuberculin test.

Treatment starts with three drugs (isoniazid, rifampicin, pyrazinamide). Additionally prescribe vitamin B6, warning izoniazidovuyu polyneuropathy. With good effect after 2 - 3 months pyrazinamide cancel, and isoniazid and rifampicin remain for at least another 10 months. In severe cases, appoint more streptomycin.