Links To Dr. Josh Farkas’ Outstanding IBNCC Chapter “Meningitis & Encephalitis”

In this post, I link to Dr. Josh Farkas‘ outstanding Internet Book of Neurocritical Care [Link is to the IBNCC TOC] chapter, Meningitis & Encephalitis, July 3, 2022.

All that follows is from the above resource.

Severe CNS infections are a bit of an orphan disease in critical care.  Unlike more common neurologic disorders (e.g. stroke), CNS infections are too rare to recruit lots of patients into RCTs.  Consequently, conventional treatment of these disorders lags decades behind other neurologic disorders (e.g. in terms of optimizing cerebral perfusion pressure).  Principles of neurocritical care can be applied to these patients, but it requires a leap of faith.  Meanwhile, getting the basics right is the most important aspect – prompt diagnosis, appropriate empiric antibiotics, and definitive neuroimaging.

CONTENTS

• Rapid Reference 
• Clinical manifestations
  • Background:  meningitis vs. encephalitis
  • When to suspect CNS infection
  • Infectious disease history
  • Neurological sequelae of bacterial meningitis
• Labs
  • Blood tests to consider
  • Lumbar puncture
• Imaging
  • Imaging findings in meningitis
  • Imaging to evaluate for complications of meningitis
  • Imaging to evaluate for HSV encephalitis
• Management
  • Antibiotic selection
    • Empiric regimen for undifferentiated CNS infection
    • Empiric regimen for bacterial meningitis
    • Empiric regimen for viral-pattern CSF results
    • Definitive therapy based on culture & sensitivity
  • Intubation
  • Avoidance of fever
  • Seizure prophylaxis & management
  • Management of ICP & CPP
  • Treatment failure & repeat lumbar puncture
• Podcast
• Questions & discussion
• Pitfalls

PITFALLS

• Failure to give steroid along with antibiotic.  Steroid is recommended by both US and European guidelines, based on prospective RCTs proving reduction in long-term neurologic disability.
• Under-utilization of ultrasound-guided lumbar puncture for morbidly obese patients (if you’re sending patients for IR-guided lumbar puncture, consider ultrasound). [See Two YouTube Videos On The Use of Ultrasound For Lumbar Puncture
  Posted on August 28, 2022 by Tom Wade MD]
• Delaying steroid/antibiotic therapy (e.g., for lumbar puncture).
• Failing to check VZV PCR (this is seen occasionally, so if you’re going to get HSV PCR it’s worth getting VZV also).(23566589)
• Keep in mind that antibiotics often require higher doses to penetrate the meninges (“meningeal dose”).  Thus, simply because the patient is on an antibiotic doesn’t mean that meningitis is necessarily covered adequately.
• Recognize that a patient with meningitis/encephalitis and obtundation is critically ill, and should usually receive care in an ICU.

Acknowledgement:  Thanks to Dr. Richard Choi (@rkchoi) for thoughtful comments on this chapter.

Going further

• Neurocritical care of the comatose meningitis patient (PulmCrit)
• Severe CNS infections (EMCrit)
• Meningitis Pearls & Pitfalls (Aaron Tiffee and Marc Zosky, emDocs)
• Bacterial Meningitis, Encephalitis, anti-NMDA receptor encephalitis, HSV encephalitis (Chris Nickson, LITFL)
• Neurocritical care intubation (EMCrit)