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ID Case Conference 1-2-08 #2

ID Case Conference 1-2-08 #2. Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases. CC: AMS.

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ID Case Conference 1-2-08 #2

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  1. ID Case Conference 1-2-08 #2 Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases

  2. CC: AMS • 26 year old gentleman who presents with headache, fever, and AMS. He starting complaining of an earache on Thursday, 12/27/07. He had a refill of flonase from a prior bout of sinusitis so his wife filled the prescription and he took flonase around lunchtime. By dinner he said he was feeling better. On Friday the patient woke up with what he described as a "sinus headache." He took tylenol and benadryl on Friday and went to bed. At 6pm on Friday when his wife went to check on him he was altered and "seemed like he was trying to say something but couldn't talk." She called 911 who took him to a local hospital.

  3. HPI • At ED the patient was found to be febrile to 102.7F, tachycardic to 119, received Rocephin at 2125pm, LP done 2310pm Vancomycin dosed at 2310pm. The patient was also started empirically on acyclovir in the ED. Blood cultures were done in the ED prior to Rocephin dose. Steroids were not given prior to or with antibiotics. • The patient has not had any sick contacts or been around any daycare centers. He did see his 5 year old nephew and 8 month old niece on Christmas eve and Christmas day but both children were healthy. They have two outdoor dogs, no recent travel. 12 point review of systems is negative as described above.

  4. PMH • h/o adenotonsillectomy • h/o bilaterally eustasian tube placment at age 9 or 10 • Otherwise unremarkable

  5. Medications • Flonase • Allergies - NKDA

  6. Social History / Family History • Social History: denies tobacco or drugs. No h/o STDs, the patient's wife denies any HIV risk factors. Rare alcohol (1 beer every month or so) • Family History: father and mother both alive and healthy, no diseases run in the family

  7. ROS • The patient has not had any sick contacts or been around any daycare centers. He did see his 5 year old nephew and 8 month old niece on Christmas eve and Christmas day but both children were healthy. • They have two outdoor dogs, no recent travel. 12 point review of systems is negative as described above

  8. Physical Exam • 37.2 - 120/70 - 90 - 16 - 98% on RA • General obtunded, not answering questions. • Eyes EOMI, PERRLA, nonicteric • ENT no e/e on OP. dry mucous membranes. vesicle on R upper lip • Neck no JVD • Lymph Nodes no LAD appreciated in cervical, supraclavicular, or inguinal regions • Cardiovascular tachycardic, no murmurs • Lungs CTAB • Skin no rash or lesions • Abdomen soft NT nabs, no HSM • Extremeties no c/c/e • Musculo Skeletal nl tone, full ROM present • Neurological obtunded. hyperreflexic in BLE with 2 beats of clonus bilaterally. reflexes in BUE are 2+, no clonus. normal cerebellar function, strength is intact in BU and LE

  9. 15.0 15 134 102 23.6 176 21 0.9 3.5 43.4 166 Labs 8.9 46 16 1.0 37 TProt 6.9 Albumin 3.8 N-92.9 L-2.1 M-5.0 E-0.0 B-0.0 Head CT - WNL

  10. Discussion

  11. “A Diagnostic test was performed…” • The patient was admitted to the ICU and CSF showed gram positive diplococci. Bacterial antigen detection was negative for strep B, H flu, N men, and positive for strep pneumo. Blood cultures grew strepcocci in 2/2 cultures, CSF culture grew strep pneumo that was resistant to cefotaxime, intermediate to PCN and CTX, and sensitive to vancomycin. The patient was admitted to the ICU, when the sensitivities were discovered he was transferred to UNC MICU for further management. ID was consulted regarding the questions of steroid administration and whether the current antibiotic regimen was sufficient.

  12. Bacterial Meningitis • Review of 493 pts with acute bacterial meningitis published in 1993 • 40% nosocomial • Of the 296 cases of cases of community acquried meningitis, most common pathogens were • Strep pneumo 37% • Neisseria meningitis 13% • Listeria monocytogenes 10% • H. flu 4%

  13. Bacterial Meningitis • Risk factors for death among community acquired bacterial meningitis • Age >60 • Obtunded mental state at admission • Seizures within the first 24 hours • Mortality Rate • 25% for community acquired strains

  14. Streptococcus pneumoniae meningitis • Case fatality rate for meningitis-related strep pneumo meningitis was 25%, compared to 10% for N. meningitidis. • Review of 109 cases of pneumococcal meningitis from 1994-96 • 9% of cases were resistant to cefotaxime • 11% had intermediate suseptibility

  15. Strep Pneumo and Steroids • Randomized, placebo-controlled trial involving 301 adults with suspected meningitis • Dexamethasone before or with the first dose of ABX reduced the risk of unfavorable outcome from 25 percent to 15 percent (number needed to treat, 10 patients). • Mortality was reduced from 15 percent to 7 percent. • The benefit was greatest in patients with intermediate disease severity • In those with pneumococcal meningitis • Unfavorable outcomes declined from 52 percent to 26 percent (number needed to treat, four). • Mortality was reduced from 34 percent to 14 percent. Benefit was a result of reduced mortality from systemic causes

  16. Steroids and Vanc? • Prospective Multicenter Observational Study of 14 patients (13 with proven pneumococcal meningitis) • All patients started empiric treatment with CTX, vancomycin, and dexamethasone • Vancomycin levels measured in CSF on day 2 or 3 of therapy and correlated with protein in CSF and vanc in serum • Mean levels of vancomycin in serum and CSF were 25.2 and 7.2 respectively, and positively coorelated

  17. Penicillin-nonsusceptible Strep pneumoniae meningitis • Retrospective, nested case-control study comparing cases with PNSP meningitis with controls with PSSP meningitis obtained from the Immunization Monitoring Program, Active (IMPACT) cross-Canada surveillance study of invasive infections • No difference in outcomes between PNSP and PSSP – pediatric literature

  18. References • Stucki A, Cottagnoud M, Winkelmann V, Schaffner T, Cottagnoud P.Daptomycin produces an enhanced bactericidal activity compared to ceftriaxone, measured by [3H]choline release in the cerebrospinal fluid, in experimental meningitis due to a penicillin-resistant pneumococcal strain without lysing its cell wall. Antimicrob Agents Chemother. 2007 Jun;51(6):2249-52. Epub 2007 Mar 19. • Ricard JD, Wolff M, Lacherade JC, Mourvillier B, Hidri N, Barnaud G, Chevrel G, Bouadma L, Dreyfuss D. Levels of vancomycin in cerebrospinal fluid of adult patients receiving adjunctive corticosteroids to treat pneumococcal meningitis: a prospective multicenter observational study.Clin Infect Dis. 2007 Jan 15;44(2):250-5. Epub 2006 Dec 15. • Lee H, Song JH, Kim SW, Oh WS, Jung SI, Kiem S, Peck KR, Lee NY.Evaluation of a triple-drug combination for treatment of experimental multidrug-resistant pneumococcal meningitis. Int J Antimicrob Agents. 2004 Mar;23(3):307-10. • Fiore AE, Schuchat A, et al.Clinical outcomes of meningitis caused by Streptococcus pneumoniae in the era of antibiotic resistance.Clin Infect Dis. 2000 Jan;30(1):71-7. • Kellner JD, Vaudry W, et al. Outcome of penicillin-nonsusceptible Streptococcus pneumoniae meningitis: a nested case-control study.Pediatr Infect Dis J. 2002 Oct;21(10):903-10 • *Ribes S, Gudiol F, et al. Evaluation of ceftriaxone, vancomycin and rifampicin alone and combined in an experimental model of meningitis caused by highly cephalosporin-resistant Streptococcus pneumoniae ATCC 51916.J Antimicrob Chemother. 2005 Nov;56(5):979-82. Epub 2005 Sep 20. • *Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS Jr, Swartz MN.Acute bacterial meningitis in adults. A review of 493 episodes.N Engl J Med. 1993 Jan 7;328(1):21-8. • *Nguyen TH, Farrar JJ, et al.  Dexamethasone in Vietnamese adolescents and adults with bacterial meningitis.N Engl J Med. 2007 Dec 13;357(24):2431-40. *Scarborough M, Zijlstra EE, et al. Corticosteroids for bacterial meningitis in adults in sub-Saharan Africa.N Engl J Med. 2007 Dec 13;357(24):2441-50. • *Peltola H, Sarna S, et al. Adjuvant glycerol and/or dexamethasone to improve the outcomes of childhood bacterial meningitis: a prospective, randomized, double-blind, placebo-controlled trial.Clin Infect Dis. 2007 Nov 15;45(10):1277-86. Epub 2007 Oct 15. • *de Gans J, van de Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators.Dexamethasone in adults with bacterial meningitis.N Engl J Med. 2002 Nov 14;347(20):1549-56. • *van de Beek D, de Gans J, McIntyre P, Prasad K.Steroids in adults with acute bacterial meningitis: a systematic review.Lancet Infect Dis. 2004 Mar;4(3):139-43.

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