Pharm: CNS Infections
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- Bacterial Meningitis: Highest Mortality
- 1. S. Pneumoniae 2.H. influenza type B 3.N. meningitidis Neonates: Group B/D Streptococci
- Bacterial Meningitis: Triad of Symptoms
- fever, severe neck stiffness (meningismus), & change in mental status (all can be absent though)
- Bacterial Meningitis: Treatments
- vancomycin + ceftriaxone/or cefotaxime +/- ampicillin * ampicillin if Listeria or > 50yo and immunocomprimised * dexamethasone w/ S. pneumonia and H influenza [to ↓inflammation] * sometimes rifampin to ↑vancomycin [b/c steroids interfere w/ this]
- Brain Abscess: Causes
- Polymicrobial (Strep, enteric gram (-) rods, &/or anaerobes). * S. aureus w/ drug users.
- Brain Abscess: Treatments
- Penicillin G + Metronidazole (or Clindamycin) * If suspect Staph—add cloxacillin or nafcillin * If suspect MRSA—vancomycin * If suspect gram (-) rods—3rd/4th gen cephalosporin like cefotaxime, ceftriaxone, cefepime, ceftazidime * If suspect DRSP [drug resistant strep]—substitute Pen G for Vancomycin
- Neurosyphilis: Causes
- T. pallidum in ppl 10-20 laters w/ untreated syphilis...esp in HIV patients
- Neurosyphilis: Treatment
- Pen G (iv, im, or sc for 10-14 days) + oral probenecid (4x a day) * If not pregnant and allergic to penicillin—oral tetracycline or doxycycline * Alternative therapy is ceftrizxone * Blood test & LP 3, 6, 9, 12, and 24 months after
- Viral/Aseptic Meningitis: Causes
- 85% Enteroviruses; of those 4% Herpes family, esp HSV-2 * Usually self-limited and recover in 7-10 days * Biphasic symptoms of fever, headache, stiff neck, irritable, nausea, etc.
- Viral/Aseptic Meningitis: Treatment
- * mostly supportive (rest,hydration, antipyretics, pain meds) * Sx meningoencephalitis: empiric Acyclovir** [I.V.] d/t HSV encephalitis * seizures w/ IV anticonvulsants ** doesn't affect human cells b/c they don't perform the 3rd phosphorylation step that the virus does. ** ↓ renal toxicity risk w/ adequate hydration. * Relapse can occur w/in 3 months so after initial course of IV for 10-14 days, give prolonged oral course
- Rabies: Treatment
- * post-exposure prophylaxis 1. wash wound for 5 min 2. 1 dose of human rabies immunoglobulin (HRIG) [1/2 around wound site, 1/2 IM] 3. 4 doses of rabies vaccine over a 14 days period [1st dose ASAP, then at 3, 7, and 14 days]
- Brain and Spine TB: Causes
- M.tuberculosis * CSF = ↑protein, ↓glucose, ↑lymphocytes ; takes 2 weeks, often comes back (-)
- Brain and Spine TB: Treatment
- 4 drug regimen = isoniazid, rifampicin, pyrazinamide, ethambutol (or streptomycin b/c btr CSF penetration) for 2 months * isoniazid & rifampicin for at least 10 more months. ** Secondline drugs-ethionamid, cycloserine, ofoxacin, para-aminosalicyclic acid (PAS). ** Corticosteroids (Dexamethasone) during the 1st 6 weeks if there is cerebral edema or subarachnoid block
- Neuro-Cryptococcosis: Causes
- Cryptococcal meningitis Sx: unbearable headache w/ or w/o fever. [mimics SAH]; poss. seizurs, neck stiffness, PE is unremarkable except of papilledema, 1/3 get disseminated infection to lungs, kidney, skin
- Nocardiosis: Treatment
- Meropenem + Amikacin * Sulfonamides (Sulfadiazine b/c penetrates the CNS and CSF) used to be the 1st line therapy * Alternative = parenteral meropenem, 3rd generation cephalosporins (cefotaxime/ceftriaxone)
- Nocardiosis: Causes
- bacteria Nocardia, [esp. N. asteroides or N. brasiliensis]
- Listeriosis: Causes
- Gram (+) Listeria monocytogene * infections = pregnancy, neonatal, CNS, or Gastroenteritis
- Listeriosis: Treatment
- V Ampicillin + aminoglycoside (gentamicin, tobramycin, amikacin) * treat bacteremia for 2 wks, meningitis for 3 wks, brain absecess for at least 6 wks
- Neurocysticercosis: Cause
- T. Solium (cysticercus) - uncooked pork
- Neurocysticercosis: Treatment
- Antihelminthic drugs (Albendazole or praziquantel) + corticosteroids +/or surgery * seizures = phenytoin, phenobarbital, benzodiazepam, etc. if needed
- Toxoplasmosis: Cause
- T. gondii - litter box * Dx w/ indirect fluorescent Ab test measuring IgG Ab. [PCR for blood samples but less common]
- Toxoplasmosis: Treatment
- * Acute = Sulfadizine + antimalarial pyrimethamine for 4-6 wks (clindamycin is an alternative as well as cotrimoxazole or spiramycin for pregnant women to protect the fetus) * Latent = Clindamycin + atovaquone (Use Atovaquone to kill cysts in AIDS pts). Antibiotics don't work at this stage
- Tetanus: Causes
- C. Tetani—prolonged contraction of skeletal muscle fibers caused by the neurotoxin, tetanospasmin
- Tetanus: Treatment
- Mild = tetanus immunoglobulin IV or IM + metronidazole IV for 10 days, diazepam, tetanus vaccine Severe = Mild Treatment + tetanus immunoglobulin, magnesium, continuous IV diazepam, tx cardiac fluctuations, maintain airway, breathing and proper nutrition, need intensive care
- Botulism: Cause
- C. botulinum's neurotoxins --> Flaccid paralysis [from food-borne, wound, or infant botulism and interferes w/ Ach release]
- Botulism: Treatment
- trivalent antitoxin (effective against toxins A, B and E) * infant botulism = immune globulins (GG) IV