11/8/2017 Bacterial Meningitis 2016 LLSA Articles Post-PCV7: Declining Review Incidence and Treatment Payal Shah, M.D. Kowalsky RH, Jaffe DM. Pediatric Emergency Care. 2013; 11/13/17 29(6):758-766 Beaumont Health System 2 11/8/2017 Bacterial Meningitis Learning Objectives Overview Identify current epidemiology of bacterial meningitis in various age groups Definition: Infection-mediated inflammation of the Implement an evidence based approach to empiric pia, arachnoid, and subarachnoid space therapy in suspected bacterial meningitis Aseptic versus bacterial 4% mortality in children Neurologic sequelae in survivors 3 4 11/8/2017 11/8/2017 Impact of PCV7 on Historical Background Pneumococcal Disease Epidemiology has changed in the last 20 years 97% efficacy in preventing one of 7 serotypes Before 1988 Hib accounted for 70% of bacterial 89% efficacy in preventing any of the remaining 90 meningitis in children younger than 5 serotypes Now most common, Streptococcus pneumoniae Prevention of other pneumococcal disease PCV7 developed Most positively impacted group was children less Routinely administered to children younger than 23 than 2 years old months, and children 24-59 months if high risk 5 6 11/8/2017 11/8/2017 1
11/8/2017 Epidemiology of Bacterial Emerging Serotypes Meningitis Streptococcus pneumoniae is the most common cause of bacterial meningitis in children Nonvaccine serotypes 19A and 22F have been on 1-3 months: Strep agalactiae, gram neg rods, strep the increase pneumoniae 3m-3years: S. pneumoniae, N. Meningitidis, S. PCV13 was licensed in 2010 agalactiae 3-10 yo: S. pneumoniae, N. Meningitidis 10-19 yo: N. Meningitidis, S. pneumoniae 7 8 11/8/2017 11/8/2017 History and Physical Laboratory Evaluation Examination Obtain CSF and blood cultures early Findings in older versus younger children White blood cell count Physical examination for shock, neurologic deficits, CSF glucose, protein, cell count and differential, cutaneous findings, bulging fontanelle gram stain, viral testing 73% had been febrile within 72 hours of presentation BMP , glucose, coagulation factors 9 10 11/8/2017 11/8/2017 Effect of Pre-treatment on CSF Lumbar Puncture Findings Sterilization of CSF was most rapid in children with Herniation meningococcal meningitis unlikely WBC count and neutrophil count are the least likely CT scan before LP to normalize indications 11 12 11/8/2017 11/8/2017 2
11/8/2017 Bacterial versus Aseptic Empiric Therapy Meningitis BMS Monitoring and stabilization Positive CSF Gram stain Obtain CSF culture but do not wait to treat in shock CSF Protein 80mg/dL or greater state CSF neutrophils 1000cells/uL or greater IV antibiotics Peripheral ANC 10,000 cells/uL or greater Seizure before or at time of presentation Rapid detection of enterovirus by PCR Procalcitonin 13 14 11/8/2017 11/8/2017 Empiric Therapy Empiric Therapy Younger than 1 month: A word on steroids… Coverage for S. agalactiae, E. Coli, Listeria Ampicillin plus cefotaxime or aminoglycoside Empiric Acyclovir Older than 1 month: Coverage for S. pneumoniae and N. meningitidis Vancomycin plus ceftriaxone or cefotaxime 15 16 11/8/2017 11/8/2017 Summary S. pneumoniae is still the most common agent of bacterial meningitis in children outside of the neonatal period Hyperglycemic Crisis PCV7 vaccine has caused a decline in pneumococcal meningitis, but there is an increase in non-PCV7- Van Ness-Otunnu R, Hack JB. Hyperglycemic crisis. J serotype meningitis Emerg Med. 2013; 45(5):797-805 No single test is diagnostic BMS can be used to identify patients at low risk for bacterial meningitis 1 The role of corticosteroids in unclear 8 17 11/8/2017 11/8/2017 3
11/8/2017 Introduction Introduction Hyperglycemic crisis: Prevalence of DKA at initial diagnosis was greater than 25% Includes DKA and HHS Extreme metabolic derrangements Average duration of hospital stay is 3.6 days Involves ICU care, significant morbidity, and mortality Diabetes since 2010 effects 285 million adults worldwide and estimates health expenditures of Mortality in both adults and children $376 billion Improved understanding, prevention, and advances Incidence of Type 1 diabetes is increasing globally in management has resulted in declining death in children <5 years old rates There is an earlier age of onset of type 2 diabetes 19 20 11/8/2017 11/8/2017 Diagnostic Criteria for DKA and Pathophysiology of DM HHS DKA Insufficient endogenous insulin resulting in Blood glucose>250mg/dL hyperglycemia Moderate ketonuria Type 1 DM=autoimmune destruction of pancreatic Arterial pH of <7.3 and bicarbonate<15mEq/L beta cells=absolute insulin deficiency HHS Type 2 DM=progressive insulin resistance and Diabetic patient with altered mental status defects in insulin secretion=relative insulin Glucose>600 mg/dL deficiency=requires exogenous insulin No ketonuria pH typically >7.3 and bicarbonate>15 mEq/L Serum osmolality >320 mOsm/kg 21 22 11/8/2017 11/8/2017 Risk Factors for Hyperglycemic Clinical Presentation Crisis Young patients without health insurance History Age<2 years ROS Ethnic minority status Physical examination Infection Inadequate exogenous insulin Low BMI Cardiac, psychological, GI, Neurologic, Toxicologic, Pharmacologic, Other 23 24 11/8/2017 11/8/2017 4
11/8/2017 Goals of Management of Diagnostic Testing Hyperglycemic Crisis in Adults First critical step: bedside glucose Uncover and manage the underlying cause Screening ECG Replace fluids Urine ketones, BMP , lactic acid, venous pH, serum Correct acidosis osmolality, beta-hydroxybutyrate Improve mental status Other tests based on clinical circumstance Optimize renal perfusion Replete electrolytes 25 26 11/8/2017 11/8/2017 Fluids and Sodium Management Insulin in Treatment Volume resuscitation: focus on hydration status, Bedside glucose checks hourly initially, every 1-2 sodium correction(factor), urine output hours while on insulin drip Special considerations for pediatric and elderly Turn off any subcutaneous insulin pumps populations IV insulin infusion of 0.14 units/kg/h Consider bolus if glucose does not decrease in the first hour by 10% Rate of glucose decrease should be 50-75 mg/dL/hr Switch fluids/insulin overtime 27 28 11/8/2017 11/8/2017 Resolution of Electrolytes to Consider Hyperglycemic Crisis Potassium For DKA: Dehydration and Insulin therapy can cause a total Blood glucose<200 mg/dL + 2 of the following: body depletion of potassium serum bicarbonate>15 mEq/L, venous pH>7.3, calculated anion gap <12mEq/L Maintain a serum potassium between 4-5 mEq/L If K<3.3 then add 20mEq K to normal saline bolus For HHS: Bicarbonate Normalized serum osmolality, resolution of vital sign abnormalities, restored mentation No sustained benefit Phosphate Not recommended 29 30 11/8/2017 11/8/2017 5
11/8/2017 Conclusion Hyperglycemic crisis demands early recognition Fever in the We in the ED are at the forefront of treatment Postoperative Patient An organized approach to hyperglycemia, fluid balance, electrolyte abnormalities, and normalizing Narayan M, Medinilla SP . Fever in the postoperative acid-base status favors improved outcomes patient. Emerg Med Clin North Am. 2013; 31(4):1045-58 3 2 31 11/8/2017 11/8/2017 Introduction Inflammation and Healing Definition of Fever: Temperature greater than 38 Immediate postoperative fever =during the degrees C or 100.4 F procedure or up to 1 hour following it Early post-operative fever is usually noninfectious Caused by release of inflammatory mediators which increase capillary permeability and are healing Classic W’s of postoperative fever has fallen out of favor responders Timing of the fever after a procedure is important: Severity of the procedure in terms of extent of soft immediate, acute, subacute, and delayed tissue trauma leads to release of IL-6 which results in 90% of fevers occurring by the 5 th day post op have an fever identifiable source Usually a benign course with resolution of fever Most common source at 5 days postop: wound infection>UTI>pneumonia 33 34 11/8/2017 11/8/2017 Emergent Causes of Early Emergent Causes of Early Postoperative Fever Postoperative Fever Necrotizing Soft-Tissue Infections: Pulmonary embolism: Invasive: necrotizing fasciitis, clostridial gas Associated with a low grade temp<38.3C gangrene, fournier gangrene, streptococcal cellulitis Short lived fever Present within hours to days of initial procedure Prior to surgery risk factors Broad spectrum antibiotics and early surgical debridement is the key to lower morbidity and mortality 35 36 11/8/2017 11/8/2017 6
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