Meningitis: Difference between revisions
 
(111 intermediate revisions by 17 users not shown)
Line 1: Line 1:
==Adult==
''This page is for <u>adult</u> meningitis. See [[Meningitis (peds)]] for the pediatric page.''
=== Background ===
==Background==
*Microbiology
[[File:Meningitis-Epidemics-World-Map.png|thumb|Epidemic meningitis geographic distribution showing "meningitis belt."]]
**Bacterial meningitis:  
===Microbiology===
***Pneumococcus (60%), meningococcus (15%), GBS (15%), H flu (7%), listeria (2%)  
*Bacterial meningitis:  
**Viral meningitis
**[[Pneumococcus]] (60%), [[meningococcus]] (15%), [[group B streptococcus]] (15%), [[H flu]] (7%), [[listeria]] (2%)  
***Echo, coxsackie, entero (85%)
*Viral meningitis
***HSV, CMV
**Echovirus, [[Coxsackie_virus|coxsackies]], enterovirus (85%)
*Pathophysiology
**[[HSV]], [[CMV]], [[Herpes B virus]]
**Hematogenous spread via respiratory tract
**Contiguous spread (otitis media, sinusitis, brain abscess)


=== Risk Factors ===
===Pathophysiology===
#Otitis media  
*Hematogenous spread via respiratory tract
#Sinusitis
*Contiguous spread ([[otitis media]], [[sinusitis]], [[brain abscess]])
#Immunosuppression/splenectomy
#Alcoholism
#Pneumonia
#DM
#CSF leak
#Endocarditis
#Neurosurgical procedure / head injury
#Indwelling neurosurgical device / cochlear implant
#Malignancy


=== Clinical Features ===
===Risk Factors===
*Almost all patients present w/ at least 2 of the following:
{{Meningitis risk factors}}
**Headache
**Fever
**Neck stiffness
**Altered mental status
*Also may have:
**Photophobia
**Vomiting
**Prodromal URI
**Focal neuro sx (e.g. CN deficit)
**Seizure (25%)
*Jolt Test (~100% Sn)
**Have pt rapidly shake head L and R; if does not bother pt unlikely to have meningitis


=== Classification ===
===Classification===
#Acute (<24hr)  
*Acute (<24hr)  
##Usually bacterial in origin (25%)  
**Usually bacterial in origin (25%)  
#Subacute (1-7d)  
*Subacute (1-7d)  
##Viral or bacterial  
**Viral or bacterial  
#Chronic (>7d)  
*Chronic (>7d)  
##Viral, TB, syphilis, fungi, carcinomatous
**Viral, [[TB]], [[syphilis]], [[fungi]], carcinomatous


===Diagnosis===
==Clinical Features==
{| style="width: 500px" border="1" cellpadding="1" cellspacing="1"
Almost all adults present with at least 2 of the following:<ref>van de Beek D. et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med. 2004 Oct 28. 351(18):1849-59.</ref>
|-
*[[Headache]]
| '''Measure'''<br>  
*[[Fever]]
| '''Bacterial'''<br>  
*Neck stiffness
| '''Viral'''<br>  
*[[Altered Mental Status]]
| '''Fungal'''<br>  
 
| '''Neoplastic'''<br>
Other nonspecific symptoms include:
|-
*Photophobia
| Opening Pressure<br>
*[[Vomiting]]
| &gt;30
*Prodromal [[URI]]
| &lt;30
*[[Focal neuro|Focal neuro symptoms]] (e.g. [[cranial nerve palsies|CN deficit]])
| ~30
*[[Seizures]]
| ~20
*Rash
|-
**Approximately 2/3 of patients with [[meningococcemia]] develop rash.<ref>Sara Bode; Contagious Exanthematous Diseases. ''Quick References 2022''; 10.1542/aap.ppcqr.396150</ref>
| WBC Count<br>
**Can include erythematous, morbilliform, or urticarial macules and papules<ref>Sara Bode; Contagious Exanthematous Diseases. ''Quick References 2022''; 10.1542/aap.ppcqr.396150</ref>
| &gt;1000<br>
**Most common hallmark is purpuric lesions with jagged edges. <ref>Sara Bode; Contagious Exanthematous Diseases. ''Quick References 2022''; 10.1542/aap.ppcqr.396150</ref>
| &lt;1000<br>
 
| &lt;500<br>
==Differential Diagnosis==
| &lt;500<br>
{{Headache DDX}}
{{AMS and fever DDX}}
 
==Evaluation==
===Physical Exam===
{| class="wikitable"
|+Clinical Tests for Meningitis
| align="center" style="background:#f0f0f0;"|'''Finding'''
| align="center" style="background:#f0f0f0;"|'''Description'''
| align="center" style="background:#f0f0f0;"|'''Sensitivity'''
| align="center" style="background:#f0f0f0;"|'''Specificity'''
|-
|-
| &nbsp;% PMNs<br>
| Nuchal rigidity||
| &gt;80%<br>  
*Rigidity of neck muscles with flexion
| 1-50%<br>  
||13%<ref name="Nakao">Nakao JH, et al. Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014;32(1):24-28.</ref>||80% <ref name="Nakao" />
| 1-50%<br>
| 1-50%<br>
|-
|-
| Glucose<br>
| Kernig's sign||
| &lt;40<br>
*With flexed hip at 90°, extension of knee produces pain
| &gt;40<br>  
||2%<ref name="Nakao" />||97%<ref name="Nakao" />
| &lt;40<br>
| &lt;40<br>
|-
|-
| Protein<br>
| Brudzinski's sign||
| &gt;200<br>
*Involuntary lifting of legs with passive flexion of the neck
| &lt;200<br>  
||2%<ref name="Nakao" />||98%<ref name="Nakao" />
| &gt;200<br>
| &gt;200<br>
|-
|-
| Gram Stain<br>
| [[EBQ:Jolt Test|Jolt Test]]||
| Pos
*Horizontal rotation of the head at frequency of 2 rotations/second
| neg<br>
*Exacerbation of pre-existing headache is positive test.
| India ink<br>
||100%?^||
| <br>
|}
|}
^Although a 1991 study<ref>Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache. 1991 Mar;31(3):167-71.</ref> showed high sensitivity with this test, multiple newer studies have cast doubt on its sensitivity.<ref>Absence of jolt accentuation of headache cannot accurately rule out meningitis in adults. Am J Emerg Med. 2013 Nov;31(11):1601-4</ref><ref>Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014 Jan;32(1):24-8</ref> Although it may be clinically useful in the right subset of patients, it should not be considered to be 100% sensitive.


^For bloody tap, subtract 1 WBC for every 250 RBC
===Work-Up===
 
=== DDX  ===
#Encephalitis
#Brain mass
#Brain abscess
#SAH
#Migraine
 
=== Work-Up ===
#CBC
#CBC
#Chem
#Chem
#Blood cx
#Blood culture
#?CT head: See [[CT Before Lumbar Puncture]]
#?CT head: See [[CT Before Lumbar Puncture]]
#CXR (50% of pts w/ pneumoccocal meningitis have e/o pna on CXR)  
#[[CXR]] (50% of patients with pneumoccocal meningitis have evidence of pneumonia on CXR)  
#CSF studies
#[[Lumbar Puncture]]
##Glucose and protein (Tube 1)
 
##Gram stain and culture (Tube 2)
===[[Lumbar Puncture]] Diagnosis===
##Cell count and differential (Tube 3)
{{Lumbar Puncture Diagnosis}}
##Special studies if indicated (HSV PCR, india ink) - Tube 2
##Hold (Tube 4)


=== Treatment  ===
====Delay in LP====
#Abx
*CSF cultures become sterile in '''2 hrs''' after parenteral antibiotics in meningococcal meningitis and '''6 hrs''' in pneumococcal meningitis<ref>Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibotic pretreatment. Pediatrics2001;108:1169–74</ref><ref>Michael B1, Menezes BF, Cunniffe J, Miller A, Kneen R, Francis G, Beeching NJ, Solomon T. Effect of delayed lumbar punctures on the diagnosis of acute bacterial meningitis in adults. Emerg Med J 2010;27:6 433-438. PMID 20360497</ref>
##Give as soon as possible (if LP performed w/in 2hr of abx CSF culture will not be affected)
*12 hrs after antibiotics: CSF glucose levels increase and protein levels decrease. CSF WBC and neutrophils are not affected<ref>Lise E. Nigrovic, Richard Malley, Charles G. Macias, John T. Kanegaye, Donna M. Moro-Sutherland, Robert D. Schremmer, Sandra H. Schwab, Dewesh Agrawal, Karim M. Mansour, Jonathan E. Bennett, Yiannis L. Katsogridakis, Michael M. Mohseni, Blake Bulloch, Dale W. Steele, Ron L. Kaplan, Martin I. Herman, Subhankar Bandyopadhyay, Peter Dayan, Uyen T. Truong, Vince J. Wang, Bema K. Bonsu, Jennifer L. Chapman, Nathan Kuppermann. Effect of Antibiotic Pretreatment on Cerebrospinal Fluid Profiles of Children With Bacterial Meningitis. Pediatrics Oct 2008, 122 (4) 726-730. PMID 18829794</ref>
##Guidelines
###Age 18-50y
####Ceftriaxone 2gm IV q12hr + vancomycin 15mg/kg q8-12hr
#####(vancomycin is for resistant pneumococcus)
###Age >50y
####Ceftriaxone 2gm IV q12hr + vancomycin 15mg/kg q8-12hr + ampicillin 2gm IV q4h
#####Amp is for listeria)
###CSF leak w/ history of closed head trauma
####Ceftriaxone 2gm IV q12hr + vancomycin 15mg/kg q8-12hr
###History of recent penetrating head injury, neurosurgery, CSF shunt
####(Ceftazidime 2gm IV q8hr or cefepime or meropenem) + vanco 25 milligrams/kg load
###Meningitis due to sinusitis
####Ceftriaxone + metronidazole
#Dexamethasone
##Only give prior to or w/ first dose of abx
##10mg IV q6hr x4d
#Mannitol
##For marked cerebral edema
#Acyclovir
##Consider for pts w/ suspected viral menengitis who present w/ neuro deficits
##10mg/kg IV q8hr


=== Prophylaxis  ===
==[[Antibiotics]]==
*For meningococcus exposure
*''Give as soon as possible (if [[LP]] performed within 2hr of antibiotics, [[CSF]] culture will not be affected)''
**Indications:
{{Meningitis Antibiotics}}
***Household contacts
***School or day care contacts in previous 7d
***Direct exposure to pt's secretions (kissing, shared utensils or toothbrush)
***Intubation without facemask
**Meds
***Rifampin 600mg PO BID x2d OR CTX 250mg IM x1 OR ciprofloxacin 500mg PO x1


===Disposition===
#Bacterial meningitis
##Admit w/ droplet precautions
#Viral meningitis
##Admit for empiric abx until culture results return OR
##Discharge w/ 24hr f/u


==Pediatric==
If patient has a cephalosporin allergy, you can replace the third generation cephalosporin with Meropenem or chloramphenicol.
===Background===
*Meningismus is difficult to discern if <6mo, (esp if <2mo)
*<3months old
**1% incidence of bacterial meningitis
**E. coli, Group B strep, listeria
*>3months old
**S. pneumo, meningococcus, staph


===Diagnosis===
==[[EBQ:De_Gans_-_Steroids_for_Bacterial_Meningitis|Steroids]]==
Bacterial Meningitis Score for >2mo and well-appearing
*[[Dexamethasone]] in adults
*Risk Factor
**Only give 15 min prior to or with first dose of [[antibiotics]]
**Peripheral blood ANC >10K
**10mg IV q6hr x4d
**Seizure
*Overall, steroids only decreased mortality in patients with meningitis caused by [[Streptococcus pneumoniae]]<ref>Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D. Corticosteroids for Acute Bacterial Meningitis. Cochrane Database of Systematic Reviews 2010, Issue 9.</ref>
**CSF
*Steroids did decrease rates of any hearing loss, severe hearing loss, and any neurological sequelae in meningitis caused by all species
***CSF ANC >1000
**This benefit was present in high-income countries but not in low-income countries
***CSF protein >80
*[[Dexamethasone]] in children and infants
***CSF Gram stain (if + 61% Sn, 99% Sp)
**There has been no mortality benefit found with steroid use in children<ref>Mongelluzzo J, Mohamad Z, Ten Have TR, et al. Corticosteroids and mortality in children with bacterial meningitis. JAMA. 2008. 299(17):2048-2055.</ref>
**Steroids decreased the rate of hearing loss in children with meningitis caused by [[Haemophilus influenzae]]<ref>Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D. Corticosteroids for Acute Bacterial Meningitis. Cochrane Database of Systematic Reviews 2010, Issue 9.</ref>
*[[Hydrocortisone]] for [[adrenal insufficiency|adrenal failure]] (Waterhouse–Friderichsen syndrome, bilateral adrenal hemorrhage causing adrenal failure, seen in meningococcemia)


*Any risk factor = high risk for bacterial meningitis
==Antivirals==
*Very low risk if infant lacks all risk factors
*[[Acyclovir]]
**Consider for patients with suspected viral meningitis who present with neurologic deficits
**10mg/kg IV q8hr (Obese patients should be dosed using [[ideal body weight estimation|ideal body weight]])


===Work-Up===
==Other Considerations==
#CBC
*Inpatient team may consider MRI with MRV for further diagnostic considerations
#CSF
*If there is concern for tick-borne illness, it may be prudent to add [[doxycycline]] before ID consult can occur


===DDx===
==Prophylaxis==
{{Neisseria meningitis post exposure prophylaxis}}


===Treatment===
==Disposition==
===Bacterial meningitis===
*Admit with [[droplet precautions]]


===Disposition===
===Viral meningitis===
*Admit despite negative meningitis score if:
*Admit for empiric [[antibiotics]] until culture results return '''OR'''
**Age <2mo w/ any degree of pleocytosis
*Discharge with 24hr follow up
**Appear ill
**Infants w/ aseptic meningitis
*If likely viral meningitis still give CTX x 1, f/u in 24hr


==See Also==
==See Also==
*[[Meningitis (peds)]]
*[[Neoplastic meningitis]]


== Source ==
==References==
Tintinalli
<references/>


[[Category:ID]]
[[Category:ID]]
[[Category:Neuro]]
[[Category:Neurology]]

Latest revision as of 20:30, 2 November 2022

This page is for adult meningitis. See Meningitis (peds) for the pediatric page.

Background

Epidemic meningitis geographic distribution showing "meningitis belt."

Microbiology

Pathophysiology

Risk Factors

Classification

  • Acute (<24hr)
    • Usually bacterial in origin (25%)
  • Subacute (1-7d)
    • Viral or bacterial
  • Chronic (>7d)

Clinical Features

Almost all adults present with at least 2 of the following:[1]

Other nonspecific symptoms include:

Differential Diagnosis

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Altered mental status and fever

Evaluation

Physical Exam

Clinical Tests for Meningitis
Finding Description Sensitivity Specificity
Nuchal rigidity
  • Rigidity of neck muscles with flexion
 13%[5] 80% [5]
Kernig's sign
  • With flexed hip at 90°, extension of knee produces pain
 2%[5] 97%[5]
Brudzinski's sign
  • Involuntary lifting of legs with passive flexion of the neck
 2%[5] 98%[5]
Jolt Test
  • Horizontal rotation of the head at frequency of 2 rotations/second
  • Exacerbation of pre-existing headache is positive test.
 100%?^

^Although a 1991 study[6] showed high sensitivity with this test, multiple newer studies have cast doubt on its sensitivity.[7][8] Although it may be clinically useful in the right subset of patients, it should not be considered to be 100% sensitive.

Work-Up

  1. CBC
  2. Chem
  3. Blood culture
  4. ?CT head: See CT Before Lumbar Puncture
  5. CXR (50% of patients with pneumoccocal meningitis have evidence of pneumonia on CXR)
  6. Lumbar Puncture

Lumbar Puncture Diagnosis

Measure Normal Bacterial Aseptic (Viral) Fungal Tuberculosis Subarachnoid hemorrhage Neoplastic
Appearance Clear Clear, cloudy, or purulent Clear Clear or opaque Clear or opaque Xanthochromia, bloody, or clear Clear or opaque
Opening Pressure (cm H2O) 10-20 >25 Normal or elevated >25 >25 >25 Normal or elevated
WBC Count^ (cells/µL) 0-5^ >100^ 5-1000 <500 50-500 0-5 (see correction section) <500
% PMNs >80-90% 1-50%^^ 1-50% Early PMN then lymph 1-50%
Glucose >60% of serum glucose Low Normal Low Low Normal Normal
Protein^^^ (mg/dL) < 45 Elevated Elevated Elevated Elevated Elevated >200
Gram Stain Neg Pos Neg India ink Tb stain Blood
  • ^Normal or lower WBC results may be found in immunocompromised, early, or partially treated (e.g. with oral antibiotics) bacterial menintigis, and those with tuberculosis meningitis
  • ^^Lymph predominance may be found in patients with early bacterial meningitis or those that have been partially treated (e.g. with oral antibiotics)
  • ^^^For unexplained elevations of protein, consider encephalitis, MS, Guillian Barre

Corrections

  • WBC correction (for bloody tap)
    • Simplified version (if peripheral WBC and RBC counts are within normal limits):
      • Subtract 1 WBC for every 750 RBC in CSF
    • Complex version (WBC and/or RBC not within normal limits):
      • "WBCs added" = WBC(blood) x [RBC(CSF) / RBC(blood)]
      • WBC counted/resulted - "WBCs added" = actual WBC
  • Protein correction (for bloody tap)
    • For each 1000 RBC decrease protein value by 1mg/dl

Delay in LP

  • CSF cultures become sterile in 2 hrs after parenteral antibiotics in meningococcal meningitis and 6 hrs in pneumococcal meningitis[9][10]
  • 12 hrs after antibiotics: CSF glucose levels increase and protein levels decrease. CSF WBC and neutrophils are not affected[11]

Antibiotics

  • Give as soon as possible (if LP performed within 2hr of antibiotics, CSF culture will not be affected)

Neonates (up to 1 month of age)[12]

MRSA is uncommon in the neonate

> 1 month old[14]

Adult < 50 yr[15]

Adult > 50 yr and Immunocompromised[16]

Post Procedural (or penetrating trauma)[18]

Cryptococcosis Meningitis

Options

  • Amphotericin B 1mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily
  • Amphotericin B 5mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily

Meningitis with severe PCN allergy

Meningitis with VP shunt

Neisseria meningitidis Prophylaxis

  • Ceftriaxone 250mg IM once (if less than 15yr then 125mg IM)
  • Ciprofloxacin 500mg PO once
  • Rifampin 600 mg PO BID x 2 days
    • if < 1 month old then 5mg/kg PO BID x 2 days
    • if ≥ 1 month old then 10mg/kg (max at 600mg) PO BID x 2 days


If patient has a cephalosporin allergy, you can replace the third generation cephalosporin with Meropenem or chloramphenicol.

Steroids

  • Dexamethasone in adults
    • Only give 15 min prior to or with first dose of antibiotics
    • 10mg IV q6hr x4d
  • Overall, steroids only decreased mortality in patients with meningitis caused by Streptococcus pneumoniae[19]
  • Steroids did decrease rates of any hearing loss, severe hearing loss, and any neurological sequelae in meningitis caused by all species
    • This benefit was present in high-income countries but not in low-income countries
  • Dexamethasone in children and infants
    • There has been no mortality benefit found with steroid use in children[20]
    • Steroids decreased the rate of hearing loss in children with meningitis caused by Haemophilus influenzae[21]
  • Hydrocortisone for adrenal failure (Waterhouse–Friderichsen syndrome, bilateral adrenal hemorrhage causing adrenal failure, seen in meningococcemia)

Antivirals

  • Acyclovir
    • Consider for patients with suspected viral meningitis who present with neurologic deficits
    • 10mg/kg IV q8hr (Obese patients should be dosed using ideal body weight)

Other Considerations

  • Inpatient team may consider MRI with MRV for further diagnostic considerations
  • If there is concern for tick-borne illness, it may be prudent to add doxycycline before ID consult can occur

Prophylaxis

Only for meningococcus exposure

Indications

  • Household contacts
  • School or day care contacts in previous 7 days
  • Direct exposure to patient's secretions (kissing, shared utensils or toothbrush)
  • Intubation without facemark

Prophylaxis regimen

Either of the options are acceptable

  • Rifampin 600mg PO BID x2d
    • 5mg/kg PO if < 1 month old
    • 10mg/kg PO ≥ 1 month old
  • Ceftriaxone 250mg IM x1
    • 125mg IM if ≤ 15 years old
    • Ceftriaxone should be used for pregnant patients
  • Azithromycin[22]
    • Pediatric: 10 mg/kg (maximum 500 mg), po x 1
    • Adult: 500 mg, po x 1
  • Ciprofloxacin 500mg PO x1
    • No longer recommended as an option in California[23]
    • Do not use in patients with recent travel to Saudi Arabia[24]

Disposition

Bacterial meningitis

Viral meningitis

  • Admit for empiric antibiotics until culture results return OR
  • Discharge with 24hr follow up

See Also

References

  1. ↑ van de Beek D. et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med. 2004 Oct 28. 351(18):1849-59.
  2. ↑ Sara Bode; Contagious Exanthematous Diseases. Quick References 2022; 10.1542/aap.ppcqr.396150
  3. ↑ Sara Bode; Contagious Exanthematous Diseases. Quick References 2022; 10.1542/aap.ppcqr.396150
  4. ↑ Sara Bode; Contagious Exanthematous Diseases. Quick References 2022; 10.1542/aap.ppcqr.396150
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Nakao JH, et al. Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014;32(1):24-28.
  6. ↑ Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache. 1991 Mar;31(3):167-71.
  7. ↑ Absence of jolt accentuation of headache cannot accurately rule out meningitis in adults. Am J Emerg Med. 2013 Nov;31(11):1601-4
  8. ↑ Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014 Jan;32(1):24-8
  9. ↑ Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibotic pretreatment. Pediatrics2001;108:1169–74
  10. ↑ Michael B1, Menezes BF, Cunniffe J, Miller A, Kneen R, Francis G, Beeching NJ, Solomon T. Effect of delayed lumbar punctures on the diagnosis of acute bacterial meningitis in adults. Emerg Med J 2010;27:6 433-438. PMID 20360497
  11. ↑ Lise E. Nigrovic, Richard Malley, Charles G. Macias, John T. Kanegaye, Donna M. Moro-Sutherland, Robert D. Schremmer, Sandra H. Schwab, Dewesh Agrawal, Karim M. Mansour, Jonathan E. Bennett, Yiannis L. Katsogridakis, Michael M. Mohseni, Blake Bulloch, Dale W. Steele, Ron L. Kaplan, Martin I. Herman, Subhankar Bandyopadhyay, Peter Dayan, Uyen T. Truong, Vince J. Wang, Bema K. Bonsu, Jennifer L. Chapman, Nathan Kuppermann. Effect of Antibiotic Pretreatment on Cerebrospinal Fluid Profiles of Children With Bacterial Meningitis. Pediatrics Oct 2008, 122 (4) 726-730. PMID 18829794
  12. ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
  13. ↑ https://www.aappublications.org/content/early/2015/02/25/aapnews.20150225-1
  14. ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
  15. ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
  16. ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
  17. ↑ [Guideline] Chaudhuri A, Martinez-Martin P, Kennedy PG, 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. Eur J Neurol. 2008 Jul. 15(7):649-59.
  18. ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
  19. ↑ Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D. Corticosteroids for Acute Bacterial Meningitis. Cochrane Database of Systematic Reviews 2010, Issue 9.
  20. ↑ Mongelluzzo J, Mohamad Z, Ten Have TR, et al. Corticosteroids and mortality in children with bacterial meningitis. JAMA. 2008. 299(17):2048-2055.
  21. ↑ Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D. Corticosteroids for Acute Bacterial Meningitis. Cochrane Database of Systematic Reviews 2010, Issue 9.
  22. ↑ https://www.cdph.ca.gov/Programs/OPA/Pages/CAHAN/ca-discontinuation-of-ciprofloxacin-for-invasive-meningococcal-disease-pep.aspx
  23. ↑ https://www.cdph.ca.gov/Programs/OPA/Pages/CAHAN/ca-discontinuation-of-ciprofloxacin-for-invasive-meningococcal-disease-pep.aspx
  24. ↑ https://www.cdc.gov/mmwr/volumes/73/wr/mm7322e1.htm
Retrieved from "https://www.wikem.org/w/index.php?title=Meningitis&oldid=367024"