Purulent meningitis

The main causative agents of purulent meningitis in newborns and children are group B or D streptococci, Escherichia coli, Listeria monocitogenes, Haemophilus influenzae, pneumococci, staphylococci, etc. Risk factors include immunodeficiency states, traumatic brain injury, and surgical interventions on the head and neck.

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Symptoms of purulent meningitis

The incubation period of purulent meningitis is from 2 to 12 days. Then, within 1-3 days, acute nasopharyngitis develops with high body temperature (up to 39-40.5 °C), chills, intense headache, gradually increasing and accompanied by nausea and vomiting. Pathognomonic signs of meningitis appear after 12-24 hours. Pain and rigidity of the neck muscles are expressed. Symptoms according to Kernig and Brudzinsky, photophobia and general hyperesthesia appear. Sometimes strabismus, ptosis, uneven pupils, mental changes are noted. In some cases, the patient is excitable, restless, refuses to eat and drink; sleep is disturbed. Sometimes mental disorders are more severe (confusion, hallucinations and severe hyperactivity) or stupor and coma develop.

In case of septicemia and involvement of not only the membranes of the brain, but also the substance of the central nervous system and its roots, disorders of the functions of the cranial nerves, hydrocephalus, paresis of the limbs, aphasia, visual agnosia, etc. appear. Such symptoms can develop at any stage of the disease, even after visible recovery.

Treatment of purulent meningitis

Treatment for purulent meningitis should be timely and targeted. The patient is hospitalized. Specific and symptomatic therapy is prescribed. Patient care is the same as for other acute infections. Antibiotics are started immediately after lumbar puncture and collection of material for bacteriological examination and determination of microflora sensitivity. Antibiotics used for empirical therapy depend on the age of the patient and the pathogen. After identification of the pathogen, first- or second-line antibiotics are used.

Antibiotics used in empirical therapy of patients with meningitis depending on age and pathogen (Saez-Liorens X., McCracken G., 1999)

Group of patients	Microorganisms	Empirical antibiotics
Newborns:
Vertical route of infection	S. agalactiae, E. coli, K. pneumoniae, K. enterococcus, I. monocytocgenes	Ampicillin + cefotaxime
Nosocomial infection	Staphylococci, Gram-negative bacteria, P. aeruginosa	Vancomycin + ceftazidime
Immunosuppressive conditions	L monocytogenes, gram-negative bacteria, P. aeruginosa	Ampicillin + ceftazidime
Neurosurgical operations, shunts	Staphylococci, gram-negative bacteria	Vancomycin + ceftazidime
With the prevalence of penicillin-resistant S. pneumoniae	Multidrug-resistant pneumococcus	Cefotaxime or ceftriaxone + vancomycin

Initial therapy for purulent meningitis of unknown etiology is intramuscular administration of aminoglycoside antibiotics (kanamycin, gentamicin) at a dose of 2 to 4 mg/kg per day or ampicillin in combination with kanamycin. The use of benzylpenicillin together with synergist antibiotics of bactericidal action (gentamicin and kanamycin) is indicated.

Dehydration therapy is used to reduce intracranial pressure. The head of the bed is raised at an angle of 30°, the patient's head is placed in a mid-position - this reduces intracranial pressure by 5-10 mm Hg. Intracranial pressure can be reduced in the first days of the disease by limiting the volume of administered fluid to 75% of the physiological need until the syndrome of inappropriate secretion of antidiuretic hormone is excluded (it can occur within 48-72 hours from the onset of the disease). Restrictions are gradually lifted as the condition improves and intracranial pressure decreases. Preference is given to isotonic sodium chloride solution, which is also used to administer all medications. Forced diuresis of the dehydration type can be used. The starting solution is mannitol (20% solution) at a rate of 0.25-1.0 g/kg, it is administered intravenously for 10-30 minutes, then after 60-90 minutes it is recommended to administer furosemide at a dose of 1-2 mg/kg of body weight. There are different dehydration schemes for increased intracranial pressure.

Initial pathogenetic therapy for any bacterial purulent meningitis includes the administration of dexamethasone. At stages II and III of intracranial hypertension, glucocorticoids are administered in an initial dose of up to 1-2 mg/kg of body weight, and from the 2nd day - 0.5-0.6 mg/kg per day in 4 doses for 2-3 days, depending on the rate at which cerebral edema regresses.

When choosing an antibiotic used to treat purulent meningitis, the degree of drug penetration through the blood-brain barrier is taken into account. Parenteral administration of antibiotics is combined with endolymphatic and intrathecal administration if necessary.

If the patient is restless or suffers from insomnia, tranquilizers should be prescribed. For headaches, analgesics are used. Diazepam is used to prevent seizures.

Dexamethasone is indicated for severe forms of meningitis at a dose of 0.5-1 mg/kg. It is important to monitor adequate water balance, bowel and bladder functions, and prevent the formation of bedsores. Hyponatremia may predispose to both seizures and a weakened response to treatment.

In case of hypovolemia, intravenous drip administration of isotonic solutions is necessary [sodium chloride, sodium chloride complex solution (potassium chloride + calcium chloride + sodium chloride)]. To correct the acid-base balance in order to combat acidosis, a 4-5% sodium bicarbonate solution (up to 800 ml) is administered intravenously. For the purpose of detoxification, plasma-substituting solutions are administered intravenously by drip, which bind toxins circulating in the blood.

To stop seizures and psychomotor agitation, intravenous administration of diazepam (4-6 ml of 0.5% solution), intramuscular administration of lytic mixtures (2 ml of 2.5% chlorpromazine solution, 1 ml of 1% trimeperidine solution, 1 ml of 1% diphenhydramine solution) up to 3-4 times a day, and intravenous valproic acid at 20-60 mg/kg per day are used.

In infectious toxic shock with acute adrenal insufficiency, intravenous fluid infusion is also performed. 125-500 mg of hydrocortisone or 30-50 mg of prednisolone, as well as 500-1000 mg of ascorbic acid are added to the first portion of fluid (500-1000 ml).

After the acute phase of meningitis has passed, multivitamins, nootropics, neuroprotective drugs are indicated, including piracetam, cattle cerebral cortex polypeptides, choline alfoscerate, etc. Such treatment is also prescribed for asthenic syndrome.

Forecast

Mortality from meningitis has decreased significantly in recent decades, it is about 14%. Many patients remain disabled, since diagnosis and treatment are delayed. A fatal outcome occurs more often with pneumococcal infection, so timely diagnosis with urgent lumbar puncture and intensive care are necessary. The following factors are important in determining the prognosis: etiology, age, duration of hospitalization, severity of the disease, season, presence of predisposing and concomitant diseases.

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