Meningitis

Introduction:

Meningitis is the inflammation of the meningeal coverings of the brain and spinal
cord, most commonly due to bacteria or viral cause, although it can also be caused
by fungus, protozoa, or toxic exposure. Bacterial meningitis is the most common
and is typically due to Streptococcus pneumoniae (pneumococcal), Neisseria menin-
gitides (meningococcal), or Haemophilus influenzae. The incidence of H. influenzae
meningitis infections has decreased since the vaccine against H. influenzae began
to be used routinely in infants in the early 1990s. Other organisms that can cause
bacterial meningitis include Staphylococcus aureus, Escherichia coli, and Pseudo-
monas. Organisms typically travel either through the bloodstream to the central
nervous system or enter by direct contamination (skull fracture or extension from
sinus infections). Bacterial meningitis is more common in colder months when
upper respiratory tract infections are more common. People in close living con-
ditions, such as prisons, military barracks, or college dorms are at greater risk for
outbreaks of bacterial meningitis due to likelihood of transmission.
Viral meningitis may follow other viral infections, such as mumps, herpes sim-
plex or zoster, enterovirus, and measles. Viral meningitis is often a self-limiting
illness.
Patients who are immunocompromised have an increased risk for contracting a
fungal meningitis. This may travel from the bloodstream to the central nervous
system or by direct contamination. Cryptococcus neoformans may be the causative
organism in these patients.

PROGNOSIS

Identification of meningitis and the causative organism is important in order to
adequately treat the patient. Bacterial meningitis still has a significant mortality rate
and these patients need to be managed in the hospital. Some patients will have per-
manent neurologic effects following the acute episode. Viral meningitis is typically
self-limiting. Fungal meningitis often occurs in patients who are immunocompro-
mised. Patients who have comorbidities or are elderly have greater difficulty with
the symptoms of meningitis.

SIGNS AND SYMPTOMS

• Stiff neck due to meningeal irritation and irritation of the spinal nerves
• Nuchal rigidity (pain when flexing chin toward chest) due to meningeal irri-
tation and irritation of the spinal nerves
• Headache due to increased intracranial pressure
• Nausea and vomiting due to increased intracranial pressure
• Photophobia (sensitivity to light) due to irritation of the cranial nerves
• Fever due to infection
• Malaise and fatigue due to infection
• Myalgia (muscle aches) due to viral infection
• Petechial rash on skin and mucous membranes with meningococcal infection
• Seizures due to irritation of brain from increased intracranial pressure

TREATMENT

• Administer antibiotics as soon as possible to improve outcome for bacterial
meningitis:
• penicillin G
• ceftriaxone
• cefotaxime
• vancomycin plus ceftriaxone or cefotaxime
• ceftazidime
• Fungal infections are typically treated with:
• amphotericin B
• fluconazole
• flucytosine
• Administer corticosteroid to decrease inflammation in pneumococcal
infection:
• dexamethasone
• Administer osmotic diuretic for cerebral edema:
• mannitol
• Administer analgesics for headache if needed:
• acetaminophen
• Administer anticonvulsant if necessary:
• phenytoin, phenobarbital
• Bed rest until neurologic irritation improves.

NURSING DIAGNOSES

• Risk for injury
• Powerlessness

NURSING INTERVENTION

• Monitor intake and output to check fluid balance.
• Keep room darkened due to photophobia.
• Monitor neurologic function at least every 2 to 4 hours, changes in mental
status, level of consciousness, pupil reactions, speech, facial movement sym-
metry, and signs of increased intracranial pressure.
• Seizure precautions per institution policy.
• Isolation per policy depending on organism.
• Explain to the patient:
• Why restrictions (bed rest) are necessary.
• Vaccine available for meningococcal meningitis—the 2 different types
are meningococcal polysaccharide vaccine (MPSV4) and conjugate vac-
cine (MCV4).