Review Question - QID 105831

This patient has bacterial meningitis, likely secondary to Streptococcus pneumoniae. Appropriate empiric treatment would include vancomycin, ceftriaxone and ampicillin and dexamethasone.

Bacterial meningitis in individuals over the age of 50 is typically caused by S. pneumoniae, N. meningitidis, L. monocytogenes or gram negative bacilli. Treatment, hence, should include vancomycin (in case of S. aureus), ceftriaxone and ampicillin. The addition of dexamethasone in S. pneumonia meningitis has been shown to decrease mortality and reduce neurological sequelae. If a culture diagnosis of S. pneumoniae is confirmed, treatment can be narrowed to ceftriaxone for 10-14 days.

Bamberger discusses diagnosis, treatment and prevention of meningitis. A lumbar puncture is the only reliable method for distinguishing bacterial from aseptic meningitis. Empiric therapy for meningitis covers the the most likely organisms based on the age of the patient. S. pneumoniae infections are resistant to penicillins, so they should be treated with ceftriaxone. Chemoprophylaxis options for N. meningitidis include rifampin, ciprofloxacin or ceftriaxone; for H. influenzae chemoprophylaxis, rifampin is appropriate.

Brouwer et al. review the use of corticosteroids in bacterial meningitis. They found that corticosteroids reduced hearing loss and neurological sequelae in S. pneumoniae, N. meningitidis, H. influenzae. Corticosteroids only decreased mortality in those infected with S. pneumoniae. In children, the protective effects of corticosteroids against hearing loss were only demonstrated in H. influenzae infections. Finally, the results in this review were significant only for high-income countries.

Incorrect Answers:
Answer 1: Acyclovir would be an appropriate if the patient was infected with herpes encephalitis. The results of the lumbar puncture are consistent with bacterial meningitis.
Answer 2: Supportive treatment would be acceptable if it was confirmed that the cause was aseptic meningitis.
Answer 3: Ceftriaxone and dexamethasone would be appropriate if S. pneumoniae was the known microbe, as empiric therapy would not be required.
Answer 5: Vancomycin, ceftriaxone and ampicillin are the correct antibiotic options. However, if S. pneumonia is suspected, dexamethasone should be added.