GGC Medicines


Adult Therapeutics Handbook

Central nervous system infections

Central nervous system infections

Below are details of the management of bacterial meningitis, meningitis contact prophylaxis, brain abscess, viral encephalitis and viral meningitis.

Bacterial meningitis

  • Symptoms of acute meningitis include:
    • Fever
    • Headache
    • Neck stiffness
    • Photophobia

Always seek urgent advice from infectious diseases / microbiology. Discuss further management with infectious diseases on call at the Queen Elizabeth University Hospital (see Appendix 6 for contact details).

  • The investigation of suspected meningitis must include:
    • Cerebrospinal fluid for Gram stain, culture and polymerase chain reaction (PCR) for bacteria and viruses
    • CSF sample to biochemistry for protein / glucose, with a paired serum glucose sample
    • Blood cultures
    • Throat swab
    • Clotted and EDTA blood for bacterial PCR
    • See trakcare order set for meningitis
  • Administer IV antibiotic therapy urgently on arrival in hospital and after blood cultures.
  • Perform CT scan before lumbar puncture if: age ≥60 years; seizures; reduced GCS or abnormal level of consciousness; CNS signs; immunosuppression.

    N.B. Contraindications to CT scan e.g. coagulopathy - discuss with radiology

  • Duration of therapy dependent on aetiology:
    • N. meningitides 5 days
    • S. pneumoniae 10-14 days
    • L. monocytogenes 21 days

Bacterial meningitis

Meningitis Contact Prophylaxis

  • All suspected cases of meningococcal disease are notified to the NHSGGC Board, Public Health Protection Unit (see Appendix 6 for contact details).
  • Specialists in Communicable Disease will identify close family and friends of the patient who may require antibiotic prophylaxis.
  • This should be given as soon as possible (ideally within 24 hours) after diagnosis of the index case.

Brain Abscess

  • Perform blood cultures.
  • Discuss treatment and duration with neurosurgery and microbiology / infectious diseases unit.

Potential source:

  • Sinus (Streptococcus milleri, Pneumococcus, Haemophilus influenzae)
  • Middle ear (mixed aerobes and anaerobes)
  • Post traumatic (Staphylococcus aureus or mixed infections)
  • Blood stream, endocarditis (Staph and Strep species)

Viral encephalitis

  • Encephalitis is inflammation of the parenchyma of the brain. It is often associated with meningitis (meningoencephalitis).
  • Symptoms include fever and headache with signs of cerebral involvement - fits, altered level of consciousness, confusion, personality change, focal neurological changes e.g. cranial nerve deficits.
  • Herpes Simplex Virus (HSV) is the commonest cause of sporadic viral encephalitis, however in many cases no aetiological agent is identified.
  • Treatment should be started with IV aciclovir.
  • Perform CT scan before lumbar puncture (LP).
  • Send CSF for viral PCR as well as microbiology and biochemistry.
  • In the first 72 hours after the onset of HSV encephalitis, CSF PCR may be negative; repeat LP is advised if the diagnosis is suspected.

Duration of treatment for confirmed HSV encephalitis is at least 14 days with a second CSF sample for PCR advised after 14 days of treatment. If the HSV PCR remains positive continued treatment is recommended. Discuss with infectious diseases unit / virology.

Viral meningitis

In general no specific antiviral treatment is recommended. Viral meningitis does not require antiviral therapy unless the patient is immunocompromised. Discuss with infectious diseases / virology.

 

Content last updated December 2018