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III./4.5.: Treatment
III./4.5.1.: General knowledge
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Before the penicillin era 80% of patients suffering from meningitis died. Nowadays mortality is around 20%. Further prevention of lethal cases came to a halt since the average lifespan has increased and the disease of elderly is more severe. In case of a suspicion of meningitis treatment should be immediate. The following advice can help in the correct evaluation of symptoms: when treating a patient with fever it has to be decided whether the fever is caused by an inflammation of the central nervous system, or the fever is not of neurological origin. Tumours of the diencephalon, subarachnoideal and intraventricular bleeding all cause a central fever. If the patient has fever with altered consciousness and neurological focal signs then the diagnosis of meningoencephalitis and cerebral abscess should emerge and an urgent CT scan should be performed. In case of symptoms of increased intracranial pressure dehydration is necessary.
III./4.5.2.: Medication
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Broad-spectrum antibiotics should be administered intravenously. Previously cephalosporine and ampicillin were recommended. In case of meningitises of nosocomial or traumatic origin vancomycin was effective. In young people when Meningococcus infection is the most common cause of meningitis, a high dose penicillin-G can be administered. Treatment continuation should be based upon the antibiotic susceptibility of pathogens. Recent guidelines recommend the intramuscular administration of ceftriaxone (Rocephin) or penicillin. The normal dose of ceftriaxone is 80 mg per kilogram body weight, with a maximal daily dose of 2 grams. The advantage of ceftriaxone is that is not only effective in case of meningococci, but also if Gram-negative pathogens (S. pneumonia, H. influenzae) are present. Penicillin should be administered in the dose of 2 million units for adults and children older than 10; 1 million units when treating children of 1-9 years, and 400 000 units in case of infants younger than 1 years old.
III./4.5.3.: A meningococcal sepsis and treatment
Ear, nose, and throat related conditions causing meningitis should be removed surgically. As an effect of Meningococcus endotoxines, a consequence of sepsis 70-75% of patients develops pinpoint petechias on the skin which do not get paler upon pressure. Endotoxins can result in disseminated intravascular coagulopathy (DIC). Abnormal bleeding occurs from the parenchymal organs, the epicardium, the pleura, the abdomen, the intestines and the bladder, etc. Consumption coagulopathy leads to thrombosis is certain organs. Infectious emboli can be released from the heart.
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The consequence of an endotoxin-shock is a haemorrhage of the adrenal cortex (Waterhouse—Friderichsen syndrome), in which mortality is over 80% regardless of intensive therapy. Abnormal bleeding can be cured with fresh frozen plasma; increased coagulation can be treated with heparin. The symptoms of acute adrenal gland failure include weariness, malaise, sleepiness, psychomotor retardation, low blood pressure, weak pulse, dry skin, fever, vomiting and visceral pain. Laboratory findings show ion depletion, hypoglycaemia, metabolic acidosis, and extrarenal azotemia. Bleeding into the adrenal glands can be confirmed by an abdominal ultrasound and CT scan. The treatment is based on the administration of glucocorticoids, but mineralocorticoids have to be substituted as well. Fluid and electrolyte replacement, support of circulation are necessary because of the septic state. In severe cases parenteral feeding and ICU monitoring is required.
III./4.5.4.: Prognosis
Prognostic signs of unfavourable purulent meningitis are:
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1) Sudden appearance of symptoms.
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2) Altered consciousness within 24 hours from the first symptoms.
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3) Permanent unconsciousness.
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4) Disturbed immune reactions, (characterized by the missing cellular reaction, purulence).
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5) Old age.
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6) Complications: hydrocephalus, ventricular empyema, vasculitis.
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7) Liquor protein level exceeds 1 g/l. Deafness, facial paresis, epilepsy and dementia can occur as residual symptoms.
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