CICM SAQ 2015.1 Q11

Question

With respect to community-acquired bacterial meningitis in Australia and New Zealand:

a) List two common pathogens encountered AND the empirical antimicrobial therapy of choice in EACH the following contexts: (70% marks)

  • i)  Neonate aged < 1month
  • ii)  Immunocompetent adult aged 35 years
  • iii) Adult aged 48years on steroids
  • iv) Immunocompetent adult aged 85 years

b) Briefly discuss the role of adjunctive corticosteroids in the management of meningitis. (30% marks)

Answer

Answer and interpretation

a) List two common pathogens encountered AND the empirical antimicrobial therapy of choice in EACH the following contexts:

Pathogens

Neonate aged < 1 month

  • Gp B Strep (agalactiae)
  • E. coli
  • Listeria

Immunocompetent adult aged 35 years

  • Strep. pneumoniae
  • N. meningitidis

Adult aged 48 years on steroids

  • Listeria
  • Gram negative bacilli
  • [TB]

Immunocompetent adult aged 85 years

  • Strep pneumoniae
  • N meningitides
  • Listeria
  • Aerobic GNB

Antimicrobial Therapy

  • Neonate aged < 1month
    Amoxycillin/Ampicillin + 3rd generation cephalosporin (OR Amox/Amp + aminoglycoside)
  • Immunocompetent adult aged 35 years
    3rd generation cephalosporin + Vancomycin
  • Adult aged 48 years on steroids
    Vancomycin + Ampicillin + either Cefepime or Meropenem
  • Immunocompetent adult aged 85 years
    3rd generation cephalosporin + Vancomycin + Ampicillin NB Some protocols substitute Rifampicin for Vancomycin.

b) Briefly discuss the role of adjunctive corticosteroids in the management of meningitis. (30% marks)

Multiple studies and meta-analyses conflicting results with mortality and neurological sequelae. Neurological sequelae seen in up to 50% of survivors of community-acquired meningitis.

Cochrane review 2013: Overall –

  • Trend to reduction in mortality
  • Reduced rate of hearing loss
  • Reduced rate of short-term neurological sequelae 
subgroup analyses –
  • Reduced hearing loss in children with h influenza only
  • Favourable effect on mortality with s pneumonia only
  • No effect in low income countries, except possibly for tb meningitis

Approach to use of adjunctive steroids

  • Adults in developed world – suspected or proven pneumococcus. Therefore commence steroids in all and discontinue if proven to not be pneumococcus.
  • Children – suspected or proven H influenza, although many recommendations do include steroids for suspected pneumococcal or meningococcal as well. 
Given prior to, or with first dose of antibiotics. Continued for 4 days.
  • Potential side-effects of steroids
 – Concern that steroids may reduce antibiotic penetration into CSF (esp Vancomycin) – controversial. Generic SEs – e.g. hyperglycaemia, GI bleed, immunosuppression etc.
  • Pass rate: 9%
  • Highest mark: 5.9

Additional comments:

  • Overall candidates had poor knowledge about the causative organisms and appropriate antimicrobial agents in the setting of bacterial meningitis
Exams LITFL ACEM 700

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CICM

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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