Purulent meningitis

The main pathogens of purulent meningitis in newborns and children are streptococci of group B or D, Escherichia coli, Listeria monocytogenes, Haemophilus influenzae, pneumococcus, staphylococcus, etc. Risk factors include immunodeficient conditions, craniocerebral trauma, 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 develops acute nasopharyngitis with a high body temperature (up to 39-40.5 ° C), chills, intense headache, gradually intensifying and accompanied by nausea and vomiting. Pathognomonic signs of meningitis appear after 12-24 hours. Pain and stiff neck muscles are expressed. There are symptoms of Kernig and Brudzinsky, photophobia and general hyperesthesia. Sometimes note strabismus, ptosis, uneven pupils, a change in the psyche. In some cases, the patient is excited, restless, refuses to eat and drink; sleep disturbed. Sometimes mental disorders are more coarse (confusion, hallucinations and severe hyperactivity) or develop a sopor, coma.

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

Treatment of purulent meningitis

Treatment for purulent meningitis should be timely and targeted. The patient is hospitalized. Prescribe a specific and symptomatic therapy. Care for the patient is the same as with other acute infections. Antibiotics begin immediately after lumbar puncture and collection of material for bacteriological examination and determination of microflora sensitivity. The antibiotics used for empiric 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 the 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 path of infection	S. Agalactiae, E. Coli, K . pneumoniae, K . enterococus, 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	Polyresistant pneumococcus	Cefotaxime or ceftriaxone + vancomycin

The starting therapy of purulent meningitis of unknown etiology is the intramuscular injection of antibiotics of the aminoglycoside group (kanamycin, gentamicin) at a dose of 2 to 4 mg / kg per day or ampicillin in combination with kanamycin. The use of benzylpenicillin along with antibiotics-synergists of bactericidal action (gentamicin and kanamycin) is shown.

Dehydration therapy is used to reduce intracranial pressure. Raise the head end of the bed at an angle of 30 °, the head of the patient is given a medial position - this achieves a decrease in intracranial pressure by 5-10 mm Hg. Decrease in intracranial pressure in the first days of the disease can be achieved by limiting the volume of the injected liquid to 75% of the physiological requirement, until the syndrome of inadequate secretion of the antidiuretic hormone (can occur within 48-72 hours from the onset of the disease) is excluded. Limitations are gradually canceled as the condition improves and the intracranial pressure decreases. Preference is given to an isotonic solution of sodium chloride, it also introduces all medicines. You can use forced diuresis of dehydration type. The starting solution is mannitol (20% solution) from the calculation of 0.25-1.0 g / kg, it is administered intravenously for 10-30 minutes, then after 60-90 min it is recommended to administer furosemide in a dose of 1-2 mg / kg of body weight body. There are different schemes of dehydration when lifting intracranial pressure.

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

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

If the patient is restless or has insomnia, tranquilizers should be prescribed. With a headache, analgesics are used. Diazepam is used to prevent seizures.

The use of dexamethasone is indicated in severe forms of meningitis in a dose of 0.5-1 mg / kg. It is important to monitor the adequate water balance, bowel and bladder functions, and prevent the formation of pressure sores. Hyponatremia can predispose both to convulsions, and to a weakened response to treatment.

With hypovolemia, drip intravenous administration of isotonic solutions is necessary [sodium chloride, sodium chloride solution, complex (potassium chloride + calcium chloride + sodium chloride)]. To correct the acid-base state in order to combat acidosis intravenously injected 4-5% solution of sodium bicarbonate (up to 800 ml). In order to detoxify intravenously, plasma-substitution solutions are added drastically, which bind toxins circulating in the blood.

For intravenous injection of diazepam (4-6 ml of a 0.5% solution), intramuscular injection of lytic mixtures (2 ml of a 2.5% solution of chlorpromazine, 1 ml of a 1% solution of trimiperidine, 1 ml of a 1% solution of diphenhydramine) is used to arrest seizures and psychomotor excitation. Up to 3-4 times a day, valproic acid intravenously at 20-60 mg / kg per day.

In infectious-toxic shock with the phenomena of acute adrenal insufficiency, intravenous fluids are also administered. In the first portion of the liquid (500-1000 ml) add 125-500 mg of hydrocortisone or 30-50 mg of prednisolone, as well as 500-1000 mg of ascorbic acid.

After the acute phase of meningitis passes, multivitamins, nootropic, neuroprotective drugs, including pyracetam, cortex brain polypeptides, choline alfoscerate, etc. Are shown. Such treatment is prescribed for asthenic syndrome.

Forecast

Mortality from meningitis in recent decades has decreased significantly, it is about 14%. Many patients remain disabled, because diagnosis and treatment are delayed. Lethal outcome often occurs with pneumococcal infection, so timely diagnosis with urgent lumbar puncture and intensive therapy are necessary. In determining the prognosis, the following factors are important: the etiology, age, timing of hospitalization, the severity of the disease, the time of year, the presence of predisposing and concomitant diseases.

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