Bacterial Infection in CNS

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Bacterial Infection in CNS

• Li-Ming Lien, M.D.
• Department of Neurology
• Shin Kong WHS Memorial Hospital

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CNS infection
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CSF Formula
_at_ sudural empyema, brain abscess, sinus
thrombosis _at_sinusitis, mastoiditis R
resolving PT partially treated P protein G
glucose N normal F fungal
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CSF findings in CNS infection
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Acute Purulent Meningitis
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Symptom/Sign - APM

• URI prodrome
• Triad
• Fever, headache meningeal sign
• Seizure, focal sign, SIADH, hearing loss
  petechiae
• Associated systemic infectious s/s
• Joint, heart, lung.

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D/D with APM

• Brain abscess
• Subdural empyema
• Epidural abscess
• Viral meningoencephalitis
• Lyme disease
• Rickettsial disease

• Non-infectious disorders
• SAH
• Neuroleptic malignant syndrome
• Posterior fossa tumor

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S. Pneumonia Meningitis

• Most common pathogen
• Altered mental status on admission (5 alert)
• Rapid progression
• Seizure focal signs in early stage
• Highest mortality rate
• Coexistent pneumonia (25-50), AOM (33)

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S.Pneumonia Meningitis in elderly

• Most severe abnormalities of mental status
• Higher incidence of concurrent pneumonia,
  sinusitis, otitis media (58)
• Meningismus (57) Headache (21)
• Classic s/s may be subtle at initial presentation

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Treatment of APM

• Antibiotics
• Adjunctive therapy
• Steroid (Dexa 12 mg q12h 3D for hearing loss)
• Passive immunization with monoclonal antibody
• Anticytokines against TNF and IL-1
• Plasmapheresis
• IICP therapy
• Seizure management

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Ability of an antibiotic to penetrate the BBB

• Degree of lipid solubility
• Degree of ionization at physiologic pH
• Protein binding in serum
• Molecular size and structure
• Status of BBB

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Penetration of drug into CSF
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Treatment - APM

• 3rd generation Cephalosporin
• Penicillin
• Meningococcus
• Pneumococcus
• Chloroamphenicol H. influenza
• Duration 7-14 days
• BT decrement within 4-6 days after Tx

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Pathogens in various settings of APM
S Streptococcus (pneumonia, aureus, epidermidis,
group-B) HI Hemophilus influenza, NM
meningococcus, LM L. monocytogenes
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Acute bacterial meningitis in adultsSigurdardotti
r B et al Arch Intern Med 1997157425-30

• 127 pt (59M/73F)
• 1975-1994
• Pathogen
• N meningitidis 56
• S pneumonia 20
• Negative 8
• Underlying Dz 39
• Mortality 20

• Recurrent cases
• Rare 5/127 (4)
• 4 relapse within 1y
• 1 relapse 24 y later
• Only 1 patient had the same organism isolated in
  the first and second episodes.

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Empirical antibiotics in APM
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Normalization of CSF after TxConly et al Am J
Med 198375102-7

• Culture 1D
• Glucose 3D (80)
• Protein 10D
• WBC count gt10D

Diagnosis Culture 80 Gram stain 60-90
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Complications of APM

• Hydrocephalus
• Subdural effusion / empyema
• Cerebritis / brain abscess
• Cortical infarction

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Permanent deafness after APM
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Purulent meningitis 55F

• 12/4 Headache
• 12/5 Polyarthralgia
• 12/8 Fever
• 12/9 Delirium
• E3M5V3
• Babinski sign /

• Delirium 1 day
• Drowsiness 5 days
• Fever 5 days
• Complications
• Deafness (au) vestibulopathy
• 5 days after onset

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Purulent meningitis 55F

• CSF pressure 440 mmH2O
• Culture (CSF blood) Strept. acidominimus
• WBC (12/7) 14500 (seg83) ESR 27/1st hr
• EEG mild diffuse slow

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Brain Abscess
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Brain abscess

• Etiology
• Streptococcus (70), Bacteroid Gr (-)
• Pathogenesis
• Local infection ENT, tooth face
• Hematogenous Heart Lung
• Grey-white matter junction
• MCA territory
• Poor encapsulation

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S/S of brain abscess ()
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Diagnosis -BA

• S/S less than 50 with focal s/s
• CSF
• Culture () in 10 only
• Nonspecific profile data
• CBC 40 normal
• Image study

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Predisposing condition, site, pathogen in BA
SA Staphylococcus aureus, EB Enterobacteriaceae,
T temporal, CB cerebellum
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Histologic staging of BA
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??????

• ??? ??
• M5??, ?????,????????
• ?? N/S 2L/?
• ???
• Nafcillin or ?3? Cerhalosporin
• Metronidazole
• ??Penicillin??, ??Vancomycin
• ????
• Phenytoin 300mg/?
• ???????? ???, Mannitol, ??

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Excision
Well-defined
Mature lesion
Accessible
Solitary lesion
Inaccessible
Antibiotics
Ill-defined
Aspiration
CT F-U
RESOLUTION
Multiple lesions
CT Followup
Trial of medical Tx
CT F-U
Progression to mature lesions
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Treatment - BA

• Penicillin Strepto anaerobes
• CM metronidazole anaerobes
• 3rd generation cephalosporin Gr(-)
• Nafcillin Staphylococcus
• Vancomycin MRSA
• Duration 4-6 wk (iv) ? 2-6 m (po)

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Treatment - BA

• Medical Tx only
• Poor physical condition
• Multiple, deep dominant
• Meningitis/ependymitis ()
• Good repsonse to Tx, size lt4 cm
• Medical Surgical Tx
• Encapsulation
• Acute deteriorating

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53M Mr. Su 5128007-97

• 2/13 Fever, seizure, delirium
• 2/14 UGI bleeding, shock, Status E.
• 2/16 Occasional delirium, no seizure
• 2/18 Diabetes insipitus
• 2/19 Stereotaxic operation
• 2/26 Extubation
• PH HT, DM, Alcoholic liver cirrhosis

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53 M Alcoholic cirrhosis, HT, DM, Brain abscess
(Klebsiella P.)
GM
Amikin
GM
Rocephin
Fortum
Shiomarin
Fortum
Fever
Intubation
DI
CVP-sepsis
Operation
Presenting s/s Acute onset of fever, seizure
delirium Complications GI bleeding, DI, Status,
Septic shock
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97/2/14
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97/2/14
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97/2/14
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97/3/11
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97/3/18
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97/4/1
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97/4/12
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97/2/24
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97/5/16
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97/6/19
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2/14
3/11
4/1
4/24
5/16
6/19
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5128007 53M 98/3/30
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Subdural Empyema
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Subdural empyema

• 15-25 of pyogenic intracranial infection
• Complication of otorhinologic infection
• M/F 3/1 Age 20-30 y/o (70)
• Diagnosis
• MRI / CT
• CSF culture stain almost negative
• Subdural pus 1/3 sterile
• Otorhinogenic Streptococcus
• Head injury/surgery Staphylococcus

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Clinical signs of SDE
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Brain abscess vs. subdural empyema
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Predisposing causes of SDE
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Microbiology of adult SDE
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Empirical antibiotics for SDE
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Tx of subdural empyema

• Empical antibiotics
• PCN 3rd CEP Metronidazole
• Duration 3-4 wk after drainage
• Seizure prophylaxis
• Steroid in selective case
• Mannitol in selective case

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Complications of SDE
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Mr. Chen 55M 1996

• 11/29 Cough for 1 wk, drowsiness for 2 days
• Diplopia, headache, vomiting, GTCC
• E2M5V2, 38.2oC, no meningeal signs
• 12/4 Severe left temporal headache vomiting
• 12/7 Afebrile but still headache
• 12/11 Discharge under anti-TB 4 combined Tx
• 12/14 Fever flare-up with right hemiparesis
  
  

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Laboratory tests SDE

• CRP (12/2)7.9 Pus culture E. Coli
• EEG 3-7 Hz slows with left emphasis

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Head CT without contrast 96/11/29
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Head CT - 1 96/12/20
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Head CT - 2 96/12/20
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Head CT - 3 96/12/20
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Head CT
12/20
11/29
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URI
Cons
Cons
Headache
Fever
Fever
Seizure
PN
CG
Glycerol
IRE
Dilantin
Admission
1W
-1W
2W
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Epidural Abscess
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Epidural abscess - Cranial EA

• Cranial EA can cross the cranial dura along
  emissary veins, so sudural empyema often is also
  present.
• Identical etiology, pathogenesis, and pathogen to
  those described for subdural empyema
• The onset of symptoms may be insidious and
  overshadowed by the primary focus of infection.
  (cf rapidly progressive life-threatening
  condition in subdural empyema)

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Cranial SDE vs. Spinal EDA
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Epidural abscess - Spinal EA

• Etiology
• Hematogenous dissemination (skin, UTI, lung)
• Extension of vertebral osteomyelitis
• Extension of decubitus ulcer or paraspinal
  abscess
• Back surgery, lumbar puncture, epidural
  anesthesia
• Microorganisms
• Staphylococci 50-95
• Gram(-) bacilli 18
• Streptococci 8

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Clinical course of Spinal EA

• Clinical course
• Within hours to days (hematogenous seeding)
• Over months (vertebral osteomyelitis)
• Clinical features
• Local pain and tenderness
• Radicular pain
• Cord s/s
• Constitutional s/s (fever, stiff neck, headache)

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Treatment of spinal EA

• Combined medical-surgical approach
• Empirical antibiotics
• Nafcillin 1.5 g q4h
• Metronidazole 7.5 mg/kg q6h
• Third-generation cephalosporin (cefotamime,
  ceftriaxone)
• Parenteral antibiotics should be continued for
  3-6 weeks