eMedicine Specialties > Infectious Diseases > CNS Infections

Meningitis: Follow-up

Author: Raymund R Razonable, MD, Consultant, Division of Infectious Diseases, Mayo Clinic of Rochester; Associate Professor of Medicine, Mayo Clinic College of Medicine
Coauthor(s): Michael R Keating, MD, Consultant, Assistant Professor of Medicine, Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine
Contributor Information and Disclosures

Updated: Aug 26, 2009

Follow-up

Further Inpatient Care

  • Vigilant surveillance for the development of complications is required.
  • Seizure precautions are indicated, especially for patients with impaired mental function.
  • Proper isolation precautions are indicated in cases of invasive meningococcal disease.
  • Monitor patients for potential adverse effects of medications, such as hypersensitivity reactions, cytopenia, or liver dysfunction.
  • Drug-level monitoring may be needed for some antibiotics such as vancomycin and the aminoglycosides.

Deterrence/Prevention

  • Vaccination
    • The use of the HIB vaccination is strongly recommended in susceptible individuals.
    • Vaccination against S pneumoniae is strongly encouraged in susceptible individuals, including individuals older than 65 years and those with chronic cardiopulmonary illnesses.
    • Vaccinations against encapsulated bacterial organisms (eg, S pneumoniae, N meningitidis) are encouraged for those with functional or structural asplenia. Always administer vaccinations expediently to individuals who undergo splenectomy.
    • Offer vaccination with quadrivalent meningococcal polysaccharide vaccine to all high-risk populations, including those with underlying immune deficiencies, those who travel to hyperendemic areas and epidemic areas, and those involved with laboratory work that deals with routine exposure to N meningitidis. College students who live in dormitories or residence halls are at modest risk; inform them about the risk and offer vaccination.
    • Vaccination against N meningitidis is recommended for all adolescents aged 11-18 years. 
    • Vaccination against measles and mumps effectively eliminates aseptic meningitis syndrome caused by these pathogens.
  • Chemoprophylaxis
    • Following exposure to an index case, temporary nasopharyngeal carriage is characteristic for H influenzae, N meningitidis, and S pneumoniae. An association between carriage and the risk of disease has been described, especially for N meningitidis and H influenzae. This is the basis for the following recommendations on chemoprophylaxis. However, this prophylaxis does not treat incubating invasive disease, and closely monitor individuals at highest risk.
    • H influenzae type b
      • To eliminate nasopharyngeal carriage and to decrease invasion of colonized susceptible individuals, use rifampin (20 mg/kg/d) for 4 days.
      • The index patient may need chemoprophylaxis if the administered treatment does not eliminate carriage.
    • N meningitidis
      • Prophylaxis is suggested for contacts of persons with meningococcal meningitis.
      • These contacts include household contacts, daycare center members who eat and sleep in the same dwelling, close contacts in military barracks or boarding schools, and medical personnel performing mouth-to-mouth resuscitation. Rifampin (600 mg PO q12h) for 2 days has been shown to rapidly eradicate the carrier stage, and the prophylaxis persists for as long as 10 weeks following treatment.
      • Alternative agents include ceftriaxone (250 mg IM) as a single dose in adults. It also is the safest choice in pregnant patients. It has been shown to eradicate the carrier state for 14 days. Ciprofloxacin (500-750 mg) as a single dose also is efficacious.

Complications

  • Even with effective antimicrobial therapy, significant neurologic complications have been reported to occur in as many as 30% of survivors following an episode of bacterial meningitis. Closely monitor for the development of these complications.
  • Cranial nerve palsies and the effects of impaired cerebral blood flow, such as cerebral infarction, are caused by increased ICP.
  • Other early complications include the development of venous sinus thrombosis, obstruction of CSF flow, or the formation of subdural empyema and brain abscess.
  • The long-term neurologic sequelae can be grouped into 3 categories as follows:
    • Hearing impairment
    • Obstructive hydrocephalus
    • Brain parenchymal damage: This is the most important feared complication of bacterial meningitis. It could lead to sensory and motor deficits, cerebral palsy, learning disabilities, mental retardation, cortical blindness, and seizures.

Prognosis

  • Patients with viral meningitis usually have a good prognosis for recovery.
  • The prognosis is worse for patients at the extremes of age (ie, <2 y, >60 y) and those with significant comorbidities and underlying immunodeficiency.
  • Patients presenting with an impaired level of consciousness are at increased risk for developing neurologic sequelae or dying.
  • A seizure during an episode of meningitis also is a risk factor for mortality or neurologic sequelae.
  • Acute bacterial meningitis is a medical emergency and delays in instituting effective antimicrobial therapy result in increased morbidity and mortality.
  • The presence of low-level pleocytosis (<20 cells) in patients with bacterial meningitis suggests a poorer outcome.
  • Meningitis caused by S pneumoniae, L monocytogenes, and gram-negative bacilli has a higher case-fatality rate compared to meningitis caused by other bacterial agents.
  • The prognosis of meningitis caused by opportunistic pathogens also depends on the underlying immune function of the host. Many of the survivors require lifelong suppressive therapy (eg, long-term fluconazole for suppression in patients with HIV-associated cryptococcal meningitis).

Patient Education

For excellent patient education resources, visit eMedicine's Brain and Nervous System Center and Children's Health Center. Also, see eMedicine's patient education articles Meningitis in Adults, Meningitis in Children, Brain Infection, and Spinal Tap.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize and entertain the diagnosis in a patient with fever, meningismus, and headache
  • Failure to expediently initiate antibacterial therapy because of delays associated with unnecessary radiographic studies
  • Failure to implement prophylactic treatment in exposed individuals (eg, health care workers and family members in close contact with a patient who has invasive meningococcus disease)
 


More on Meningitis

Overview: Meningitis
Differential Diagnoses & Workup: Meningitis
Treatment & Medication: Meningitis
Follow-up: Meningitis
Multimedia: Meningitis
References
Further Reading
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References

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Keywords

bacterial meningitis, aseptic meningitis, viral meningitis, tuberculous meningitis, syphilitic meningitis, Lyme meningitis, cryptococcal meningitis, fungal meningitis, parasitic meningitis, inflammation of the meninges, headache, nuchal rigidity, photophobia, pleocytosis, acute meningitis, chronic meningitis, Streptococcus pneumoniae meningitis, meningococcal meningitis, Haemophilus influenzae meningitis, Histoplasma meningitis, amebic meningoencephalitis

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Contributor Information and Disclosures

Author

Raymund R Razonable, MD, Consultant, Division of Infectious Diseases, Mayo Clinic of Rochester; Associate Professor of Medicine, Mayo Clinic College of Medicine
Raymund R Razonable, MD is a member of the following medical societies: American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and International Immunocompromised Host Society
Disclosure: Nothing to disclose.

Coauthor(s)

Michael R Keating, MD, Consultant, Assistant Professor of Medicine, Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine
Michael R Keating, MD is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, American Society of Transplantation, Infectious Diseases Society of America, and International Immunocompromised Host Society
Disclosure: Nothing to disclose.

Medical Editor

Joseph Richard Masci, MD, Chief of Infectious Diseases, Associate Director, Associate Professor, Department of Internal Medicine, Division of Infectious Diseases, Elmhurst Hospital Center, Mount Sinai School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

John W King, MD, Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center
John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi
Disclosure: emedicine $50.00 author of chapter

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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