Patient Care and Monitoring

1. Assess the patient's signs, symptoms, and risk factors for meningitis. Do these offer any clues to the offending pathogen?

2. Determine if the patient can undergo an immediate LP or if the LP should be delayed until a CNS mass lesion can be ruled out. If the LP is delayed, blood cultures should be drawn and appropriate empirical antimicrobial therapy initiated immediately.

3. Based on patient-specific data, local resistance patterns, and other relevant data, design an appropriate empirical antimicrobial regimen directed at the most likely pathogens; empirical regimens should consist of high-dose IV cidal therapy.

4. Determine if adjunctive dexamethasone therapy is indicated; if so, start steroid therapy 15-20 minutes before the first dose of antimicrobial therapy.

5. Provide supportive care for patients with CNS infections, including hydration, electrolyte replacement, antipyretics, analgesics, and antiepileptic drugs.

6. Monitor culture and sensitivity data from the microbiology laboratory to determine whether any refinements are needed in the patient's treatment regimen. Design a therapeutic plan to finish out the patient's course of therapy for acute meningitis.

7. Monitor the patient's response to therapy (i.e., clinical signs/symptoms and laboratory data), as well as the development of complications, including seizures and hearing loss. Dexamethasone therapy may reduce antibiotic penetration, so antimicrobial drug dosing may have to be increased (especially vancomycin) to achieve dequate CSF levels. Serum levels of vancomycin should be measured and doses titrated to ensure adequate CNS concentrations. Evaluate whether intraventricular or intrathecal antibiotics are indicated.

8. Perform ongoing surveillance for adverse drug reactions, drug allergies, and drug interactions.

9. Determine whether prophylaxis is indicated for close contacts of patients with CNS infections. Close contacts should be located for patients with suspected meningococcal or Hib meningitis. After consultation with the local health department, antibiotic prophylaxis should be provided promptly to these individuals to avoid secondary disease.

10. Evaluate whether the patient is a candidate for finishing out his or her course of parenteral treatment on an outpatient basis. If so, the importance of close medical follow-up and medication compliance should be stressed to the patient and his or her family.

11. Consider how to minimize the patient's risk of contracting the current (and other) CNS infections in the future; administer appropriate vaccines after recovery from the acute infection.

12. Arrange for patient follow-up after discharge from the hospital. Continue to monitor for neurologic sequelae for several months after completion of treatment, and educate the patient and family in this regard. Serious complications that may occur include, among others, hearing loss, hemiparesis, quadriparesis, muscular hypertonia, ataxia, seizure disorders, mental retardation, learning disabilities, and obstructive hydrocephalus.

Evaluate antimicrobial dosing regimens to ensure efficacy of the treatment regimen. Trough vancomycin concentrations of 15 to 20 mg/L are recommended for the

treatment of CNS infections. Monitor patients for drug adverse effects, drug allergies, and drug interactions. The specific safety monitoring plan will depend on the antibiotic(s) used (Table 70-3). Pay close attention to concomitant medications in patients on rifampin for treatment or prophylaxis. Rifampin is a potent inducer of hepatic metabolism and may reduce the efficacy of other drugs metabolized by the cytochrome P-450 3A enzyme pathway.

Abbreviations Introduced in This Chapter

CDC Centers for Disease Control and Prevention CLSI Clinical and Laboratory Standards Institute

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