What are the guideline sources, guidelines and references for Acute bacterial meningitis ?
Guideline sources The following summarized guidelines for the evaluation and management of acute bacterial meningitis (ABM) are prepared by our editorial team based on guidelines from the Center for Disease Control (CDC 2022; 2019), the European Society for Microbiology and Infectious Diseases (ESCMID 2016), the European Federation of Neurological Societies (EFNS 2008), and the Infectious Diseases Society of America (IDSA 2004). 1 2 3 4 5 7 7 7 Definition ABM is an acute inflammation of the meninges, particularly the arachnoid and the pia mater, associated with the invasion of bacteria into the subarachnoid space. 7 Epidemiology Bacterial meningitis is mostly caused by S. pneumoniae and Neisseria meningitides. [ 21180625]. Disease course https://web.pathway.md/diseases/reclISc8dymrnSrCz 1/7 6/23/23, 1:37 AM Acute bacterial meningitis Pathway Bacterial invasion to the CNS through the bloodstream or direct access leads to ABM, which causes clinical manifestations of fever, malaise, headache, meningismus, photophobia, phonophobia, vomiting, altered mental status, focal neurological signs (epileptic seizures, or paresis of a limb), and coma. 7 Prognosis and risk of recurrence Bacterial meningitis is associated with a 34% mortality rate. 7 Guidelines 1. Screening and diagnosis Diagnostic algorithms: consider the use of diagnostic algorithms to guide the management of patients with suspected ABM, but use clinical judgment in deciding whether to start empiric treatment. C 2. Diagnostic investigations Clinical history: avoid ruling out ABM solely based on the absence of classic symptoms, because such classic clinical characteristics may be absent in adults. D Blood cultures: obtain blood cultures before administering the first dose of antibiotics in patients with suspected ABM. A Cranial imaging: Obtain cranial imaging before lumbar puncture in patients with: focal neurologic deficits new-onset seizures severely altered mental status with a Glasgow Coma Score < 10 severely immunocompromised state. A Initiate empiric treatment immediately on clinical suspicion if lumbar puncture is delayed while awaiting cranial imaging. A LP and CSF analysis: As per ESCMID 2016 guidelines, obtain CSF leukocyte count, protein and glucose concentration, CSF culture, and Gram stain in patients with suspected ABM. A As per EFNS 2008 guidelines: Perform lumbar puncture and obtain CSF analysis as soon as safely possible in patients with suspected ABM. B Postpone diagnostic lumbar puncture in patients with symptoms and signs of raised ICP, or in patients judged to be at high risk of cerebral herniation following lumbar puncture (imaging evidence of intracranial mass lesion, obstructive hydrocephalus or midline shift). A https://web.pathway.md/diseases/reclISc8dymrnSrCz 2/7 6/23/23, 1:37 AM Acute bacterial meningitis Pathway As per IDSA 2004 guidelines, obtain a Gram stain examination of CSF in all patients with suspected meningitis. B CSF lactate: avoid measurement of CSF lactate concentrations for patients with suspected community-acquired bacterial meningitis. D CSF enterovirus PCR: consider enteroviral reverse transcription PCR to establish the diagnosis of enteroviral meningitis. C Serum C-reactive protein: consider obtaining serum CRP in patients with CSF findings consistent with meningitis, but for whom the Gram stain result is negative, and the physician is considering withholding antimicrobial therapy. A normal CRP has a high negative predictive value for the diagnosis of ABM. C Serum procalcitonin: insufficient evidence at the time of guideline writing to make recommendations regarding the use of serum procalcitonin. I 3. Medical management Setting of care: hospitalize all patients with suspected ABM on an emergent basis. B Time to antibiotics: insufficient evidence to set forth specific guidelines on the interval between the initial physician encounter and the administration of the first dose of antimicrobial therapy. I Prehospital antibiotics: initiate pre-hospital antibiotic treatment only for patients with strong suspicion of disseminated meningococcal infection, because of the unpredictable risk of early circulatory collapse from adrenocortical necrosis. Consider rapid pre-admission antibiotic therapy for other patients only if a delay in excess of 90 minutes in hospital transfer is anticipated. B Route of antibiotic administration: administer initial antibiotic therapy via the parenteral route in patients with ABM. A Empiric antibiotics: As per ESCMID 2016 guidelines, use an empiric antibiotic regimen based on patient age and local resistance rates. A As per EFNS 2008 guidelines, administer intravenous ceftriaxone or cefotaxime as part of initial empirical therapy for ABM. B Show 2 more Duration of treatment: complete 5-7 days of antibiotic therapy for meningococcal meningitis. B Show 5 more Definitive antibiotic therapy (cephalosporins): use a third-generation cephalosporin in patients with pneumococcal and meningococcal meningitis caused by strains that are not susceptible to penicillin. B Definitive antibiotic therapy (vancomycin): maintain serum vancomycin trough concentrations of approximately 15-20 mg/mL in patients in whom vancomycin is used for the treatment of meningitis. B https://web.pathway.md/diseases/reclISc8dymrnSrCz 3/7 6/23/23, 1:37 AM Acute bacterial meningitis Pathway Show 2 more Definitive antibiotic therapy (carbapenems): use meropenem as an alternative to cefotaxime or ceftriaxone that has been shown to have similar clinical and microbiologic outcomes. A Definitive antibiotic therapy (fluoroquinolones): use fluoroquinolones only for meningitis caused by multidrug-resistant gram-negative bacilli, or when patients have not responded to or cannot receive standard antimicrobial therapy. B Definitive antibiotic therapy (rifampin): add rifampin only if the organism is shown to be susceptible and there is a delay in the expected clinical or bacteriologic response. B Adjunctive dexamethasone: As per ESCMID 2016 guidelines, administer adjunctive dexamethasone (10 mg IV q6h, for 4 days) to all adults with ABM in high-income countries. A As per EFNS 2008 guidelines, administer adjunctive high-dose dexamethasone before or with the first dose of antibiotics in all patients with clinically suspected pneumococcal (or H. influenzae) meningitis, especially if focal neurological signs are present. B As per IDSA 2004 guidelines, avoid prescribing adjunctive dexamethasone to adult patients who have already received antimicrobial therapy, because administration of dexamethasone in this circumstance is unlikely to improve patient outcome. D Landmark trials: European Dexamethasone Study In adults with bacterial meningitis, dexamethasone was superior to placebo with respect to unfavorable outcome. de Gans J et al. N Engl J Med. 2002 Nov 14. Other adjunctive treatments: Avoid routine adjuvant therapy with mannitol, acetaminophen, antiepileptic drugs, or hypertonic saline. D Avoid hypothermia and glycerol in patients with ABM. D 4. Inpatient care Monitoring for complications: monitor patients with bacterial meningitis for neurologic and systemic complications, and initiate specific treatment when required. A 5. Therapeutic procedures Intrathecal antibiotics: consider intrathecal administration of vancomycin in patients who do not respond to parenteral antibiotics. C https://web.pathway.md/diseases/reclISc8dymrnSrCz 4/7 6/23/23, 1:37 AM Acute bacterial meningitis Pathway 6. Specific circumstances Patients with seizures: Initiate long-term antiepileptic drug therapy in patients with late-onset seizures. For patients with acute symptomatic seizures, consider withdrawing antiepileptic drug therapy after 1 year, in the absence of seizure recurrence and structural brain (cortical) injury as visualized in brain imaging. Consider driving restriction in adult patients if they had seizures, or have functional impairment such as visual field defect and limb weakness. CSF shunt infection: Remove CSF shunts in patients in whom shunt infection is present; administer appropriate antibiotic therapy, and insert an external drainage catheter to accelerate clearance of ventriculitis and facilitate the management of hydrocephalus. B Combine rifampin with vancomycin in patients with CSF shunt infections caused by staphylococci, especially in cases in which the shunt cannot be removed. B 7. Preventative measures Meningococcal and Hib immunization: As per ESCMID 2016 guidelines, provide pneumococcal immunization to patients who have had pneumococcal meningitis. B Show 2 more As per EFNS 2008 guidelines, provide primary immunization against N. meningitidis and H. influenzae type B infection to all groups at risk. B Pneumococcal immunization: Offer 1 dose of pneumococcal conjugate vaccine (either PCV20 or PCV15) in adults aged 19-64 years with certain underlying medical conditions or other risk factors not previously received pneumococcal conjugate vaccine or if previous vaccination history is unknown. E Show 5 more Offer 1 dose of PPSV23 in all adults aged 65. E Show 7 more Post-exposure prophylaxis: As per ESCMID 2016 guidelines, administer antibiotic prophylaxis consisting of ceftriaxone, ciprofloxacin, or rifampicin to household contacts and other close contacts of patients with meningitis due to N. meningitidis. A As per EFNS 2008 guidelines, administer post-exposure prophylaxis with either rifampicin, ciprofloxacin or ceftriaxone to household or close contacts of patients with suspected or proven meningitis due to N. meningitidis or H. influenzae. B https://web.pathway.md/diseases/reclISc8dymrnSrCz 5/7 6/23/23, 1:37 AM Acute bacterial meningitis Pathway 8. Follow-up and surveillance Indications for specialist referral: offer access to specialist neurology services for all survivors of ABM. Follow-up lumbar puncture: repeat CSF analysis in patients who have not responded clinically after 48 hours of appropriate antimicrobial therapy. B Surveillance for hearing loss, audiometry: As per EFNS 2008 guidelines, perform audiometry in patients recovering from bacterial meningitis in whom hearing impairment is suspected. As per EFNS 2008 guidelines, test for hearing loss during admission in children and adults with bacterial meningitis. In the case of hearing loss, refer patients to an ear-nose-throat specialist in a medical centre performing cochlear implants. A 9. Quality improvement Public health reporting: report all cases of suspected meningococcal or H. influenzae type B meningitis to the local public health authorities on an urgent basis. B Likelihood Ratios Pertinent positives The following findings increase the probability of acute bacterial meningitis in adults. -1 Finding LR+ Value Presence of jolt accentuation of headache 2.4 (1.4-4.2) History of nausea 1.3 (1.1-1.6) History of headache 1.1 (1.0-1.3) Pertinent negatives The following findings decrease the probability of acute bacterial meningitis in adults. -1 Finding LR- Value Absence of jolt accentuation of headache 0.05 (0.01-0.35) No history of headache 0.43 (0.19-0.96) No history of nausea 0.64 (0.44-0.92) References 1. 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. Open https://web.pathway.md/diseases/reclISc8dymrnSrCz 6/7 6/23/23, 1:37 AM Acute bacterial meningitis Pathway 2. Tunkel AR, Hartman BJ, Kaplan SL et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39 9 1267 84. Open 3. van de Beek D, Cabellos C, Dzupova O et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22 Suppl 3 S37 62. Open 4. Miwako Kobayashi, Jennifer L Farrar, Ryan Gierke et al. Use of 15 Valent Pneumococcal Conjugate Vaccine and 20 Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices United States, 2022. MMWR Morb Mortal Wkly Rep. 2022 Jan 28;71 4 109 117. Open 5. Almea Matanock, Grace Lee, Ryan Gierke et al. Use of 13 Valent Pneumococcal Conjugate Vaccine and 23 Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged 65 Years: Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019 Nov 22;68 46 1069 1075. Open 6. Lisa R Park, Amanda M Griffin, Douglas P Sladen et al. American Cochlear Implant Alliance Task Force Guidelines for Clinical Assessment and Management of Cochlear Implantation in Children With Single- Sided Deafness. Ear Hear. 2022 Mar/Apr;43 2 255 267. Open 7. Olaf Hoffman, R Joerg Weber. Pathophysiology and treatment of bacterial meningitis. 2009 Nov;2 6 1 7.2009 Nov;2 6 1 7. Open 8. Catherine Liu, Arnold Bayer, Sara E Cosgrove et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus aureus Infections in Adults and Children. Clin Infect Dis. 2011 Feb 1;52 3):e18 55. Open https://web.pathway.md/diseases/reclISc8dymrnSrCz 7/7