Adult Medical-Surgical Adult Medical-Surgical NursingNursing

Neurology Module: Neurology Module:

MeningitisMeningitis

Meningitis: DefinitionMeningitis: Definition

Inflammation/ infection of the meningeal Inflammation/ infection of the meningeal coverings of the brain and spinal cordcoverings of the brain and spinal cord

Meningitis: Meningitis: Causative OrganismsCausative Organisms

Viral (aseptic) Viral (aseptic)

Bacterial (septic)Bacterial (septic)

FungalFungal

TBTB

Bacteria Causing MeningitisBacteria Causing Meningitis

Meningococcus/ Neirissia meningitidis* Meningococcus/ Neirissia meningitidis*

Haemophilus influenzae (HIB)*Haemophilus influenzae (HIB)*

Streptococcus pneumoniae Streptococcus pneumoniae (Pneumococcus)(Pneumococcus)

Staphylococcus pneumoniaeStaphylococcus pneumoniae

* gram negative* gram negative

Meningitis: Meningitis: Entry of PathogensEntry of Pathogens

Haemogenous (via blood circulation) Haemogenous (via blood circulation) following an infection usually of the upper following an infection usually of the upper respiratory tract (nasopharynx, mastoid, respiratory tract (nasopharynx, mastoid, otitis media) (original droplet infection)otitis media) (original droplet infection)

Trauma (head injury) or neurosurgeryTrauma (head injury) or neurosurgery

Opportunistic infection in an immuno-Opportunistic infection in an immuno-compromised patient (Pneumococcus and compromised patient (Pneumococcus and fungal mainly)fungal mainly)

Meningitis: Meningitis: Transmission of InfectionTransmission of Infection

Direct contactDirect contact

Droplet from “carriers”Droplet from “carriers”

Organisms are usually present in the Organisms are usually present in the nasopharynx. Most people are “carriers” nasopharynx. Most people are “carriers” but do not succumb to infection as have but do not succumb to infection as have adequate immune response adequate immune response

Meningitis: PathophysiologyMeningitis: Pathophysiology

Upper respiratory tract infection → Upper respiratory tract infection → septicaemia → meningeal and CSFsepticaemia → meningeal and CSF

Inflammation of underlying cortex → small Inflammation of underlying cortex → small thrombi and reduced cerebral blood flowthrombi and reduced cerebral blood flow

Generalised septicaemia vasculitis and Generalised septicaemia vasculitis and vascular necrosis (Meningococcal) vascular necrosis (Meningococcal)

Purulent meningeal exudate within CSF Purulent meningeal exudate within CSF and ventricles →and ventricles →

Meningitis: Pathophysiology (cont)Meningitis: Pathophysiology (cont)

Altered intra-cranial physiology:Altered intra-cranial physiology:

↑ ↑ permeability of blood-brain barrierpermeability of blood-brain barrier

Cerebral oedemaCerebral oedema

↑ ↑ intra-cranial pressureintra-cranial pressure

Possible blockage and lack of absorption Possible blockage and lack of absorption of CSF by villi → hydrocephalusof CSF by villi → hydrocephalus

Gram negative endotoxins can cause Gram negative endotoxins can cause septic shock and multi-system failureseptic shock and multi-system failure

Meningitis: Prognosis Meningitis: Prognosis

Prognosis depends on:Prognosis depends on:

How quickly treatedHow quickly treated

How severe the infectionHow severe the infection

Can lead to death within a few hoursCan lead to death within a few hours

Meningitis: ComplicationsMeningitis: Complications

DeafnessDeafness

Visual impairmentVisual impairment

SeizuresSeizures

ParalysisParalysis

Amputation of a limbAmputation of a limb

HydrocephalusHydrocephalus

Septic shockSeptic shock

DICDIC

Meningitis: Clinical Manifestations Meningitis: Clinical Manifestations (Meningeal Irritation)(Meningeal Irritation)

Severe headacheSevere headachePyrexia (high fever throughout illness)Pyrexia (high fever throughout illness)Altered level of consciousness (maybe Altered level of consciousness (maybe coma)coma)Nuchal rigidity (neck spasm)Nuchal rigidity (neck spasm)PhotophobiaPhotophobiaMay have focal seizuresMay have focal seizuresRash: purpura do not blanche on pressure Rash: purpura do not blanche on pressure

Meningitis: DiagnosisMeningitis: Diagnosis

History and clinical pictureHistory and clinical picturePositive Kernig’s and Brudzinski’s signsPositive Kernig’s and Brudzinski’s signsSkin purpura which do not blancheSkin purpura which do not blancheLumbar puncture: Lumbar puncture: CSF culture of micro-organismsCSF culture of micro-organismsCSF pressureCSF pressureBlood culture, CBC, ESR, CRP,throatswabBlood culture, CBC, ESR, CRP,throatswabBrain CT / MRI (exclude hydrocephalus)Brain CT / MRI (exclude hydrocephalus)

Meningitis: Acute ManagementMeningitis: Acute Management

Quiet darkened room, minimal handlingQuiet darkened room, minimal handlingIntrathecal antibiotics (via lumbar Intrathecal antibiotics (via lumbar puncture)puncture)IV antibioticsIV antibioticsDexamethasone (↓ cerebral oedema)Dexamethasone (↓ cerebral oedema)Anti-convulsantAnti-convulsantOsmotic diuretic (Mannitol)Osmotic diuretic (Mannitol)IV fluids and colloid volume expanders to IV fluids and colloid volume expanders to correct hypotension in septic shockcorrect hypotension in septic shock

Public Health ImplicationsPublic Health Implications

Since meningitis spreads by droplet Since meningitis spreads by droplet infection, protect the public:infection, protect the public:Isolate until antibiotics establishedIsolate until antibiotics establishedPrompt follow-up of contactsPrompt follow-up of contactsPassive immunisation and antibiotic Passive immunisation and antibiotic course (Rifampicin) to contactscourse (Rifampicin) to contactsCurrent active prevention: HIB vaccination Current active prevention: HIB vaccination in infancy; anti-pneumococcal vaccine for in infancy; anti-pneumococcal vaccine for immunocompromised (widely used now)immunocompromised (widely used now)

Meningitis: Nursing ConsiderationsMeningitis: Nursing Considerations

Respiratory isolation until 24 hours after Respiratory isolation until 24 hours after antibiotic therapyantibiotic therapy

Quiet, restful atmosphere (darkened if Quiet, restful atmosphere (darkened if photophobic)photophobic)

Monitoring: GCS, vital signs, fluid balanceMonitoring: GCS, vital signs, fluid balance

Cool clean bedclothesCool clean bedclothes

Control pyrexiaControl pyrexia

Support of family membersSupport of family members