ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d 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.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d 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.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d 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)

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Epidemiology I

Acute bacterial meningitis has an incidence of 0.6-4 per 100 000 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 BChildhood immunization against Haemophilus influenza B has dramatically reduced the incidence of this infection

Meningococcal vaccineSimilarly, increasing use of the meningococcal vaccine against serogroups A & C have reduced the incidence acute bacterial meningitis from these serogroups.

Quadrivalent vaccineMore widespread use of the quadrivalent vaccine against serogroups A,C Y and W135 may further decrease the incidence from these other serogroups.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d 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.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d 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

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d 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 historyThis should include “over the counter” and herbal remedies.

• Occupational historyThis is important for exposure risk, e.g. students. Teacher, care worker and also for contact tracing if Meningococcal meningitis is confirmed.

ACUTE ANEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d 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.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Physical Examination Findings in Acute Bacterial Meningitis IIOther 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.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d 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.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d 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).

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Clinical Diagnosis II

A list of possible alternative diagnosis to acute bacterial meningitis:

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d 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.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Diagnosis and Treatment of Acute Bacterial Meningitis II

Reproduced with permission of the British Infection Association (BIA)

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Diagnosis and Treatment of Acute Bacterial Meningitis IIIDiagnostic 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.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Diagnosis and Treatment of Acute Bacterial Meningitis IV

LP exclusion criteria:

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Diagnostic Tests in Acute Bacterial Meningitis LP ILumbar 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 glucosePlasma 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 stainGives a rapid answer if organisms are seen.

Culture and sensitivityCulture and sensitivity provides further information about the organisms identity and resistance profile.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Diagnostic Tests in Acute Bacterial Meningitis LP IIPneumococcal and meningococcal PCR

Further PCRsFurther 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.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Treatment of Acute Bacterial Meningitis I

Urgent treatment with IV antibiotics should be instigatedonce 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.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Treatment of Acute Bacterial Meningitis IIMeningococcal meningitisMeningococcal 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 meningitisCefotaxime 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 meningitisIn the elderly or pregnant additional cover with ampicillin is recommended to treat Listeria monocytogenes.

For further information, refer to the Listeria meningitis session.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d 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 diseases.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Outcomes IPrevention 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

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Outcomes IIPrimary 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.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Outcomes IIIOutcomes: 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 arthritisTypically develops from day 5 of the illness or during recovery from the infection and generally involving the large joints.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d 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 mm3.

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.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Outcomes VPneumococcal 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

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.

.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d 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

.

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

Session SummaryHaving 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. 3.

2. Brouwer MC et al, Corticosteroids for acute bacterial meningitis (Review) Cochrane collaboration 2010.

3. 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: 649–659.

4. Fitch, MT et al, Emergency diagnosis and treatment of adult meningitis Lancet Infect Dis 2007;7:191–200.

5. 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, 2010.

6. 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. View8. The Scottish Government, Guidance on Notifiable Diseases, Notifiable Organisms and

Health Risk States. View

ACUTE PNEUMOCOCCAL AND MENINGOCOCCAL MENINGITIS

• Learning Objectives• Introduction• Epidemiology• History and Presenta

tion• Examination Finding

s• Clinical Diagnosis• Diagnosis

and treatment of Acute Meningitis

• Diagnostic Tests• Treatment• Notification• Outcomes• Key Points• Session summary an

d References and further reading

• Self Assessment

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 featureB. Kernig’s sign is always presentC. Lumbar puncture must be delayed until after CT brain.D. Dexamethasone is still of benefit after 24 hours of antibiotic t

herapy.