Meningitis

Páginas: 6 (1287 palabras) Publicado: 14 de diciembre de 2012
The

n e w e ng l a n d j o u r na l

of

m e dic i n e

review article
current concepts

Community-Acquired Bacterial Meningitis
in Adults
Diederik van de Beek, M.D., Ph.D., Jan de Gans, M.D., Ph.D.,
Allan R. Tunkel, M.D., Ph.D., and Eelco F.M. Wijdicks, M.D., Ph.D.
From the Department of Neurology, Center of Infection and Immunity Amsterdam,
Academic Medical Center, Universityof
Amsterdam, Amsterdam (D.B., J.G.); the Department of Medicine, Monmouth Medical Center, Long Branch, N.J. (A.R.T.); and
the Department of Neurology, Division of
Critical Care Neurology, Mayo Clinic College
of Medicine, Rochester, Minn. (E.F.M.W.).
Address reprint requests to Dr. van de Beek
at the Department of Neurology H2, Academic Medical Center, University of Amsterdam, P.O. Box 22660,1100 DD Amsterdam, the Netherlands, or at d.vandebeek@
amc.uva.nl.

B

acterial meningitis is a medical, neurologic, and sometimes
neurosurgical emergency that requires a multidisciplinary approach. Bacterial
meningitis has an annual incidence of 4 to 6 cases per 100,000 adults (defined
as patients older than 16 years of age), and Streptococcus pneumoniae and Neisseria
meningitidis areresponsible for 80 percent of all cases.1,2 A diagnosis of bacterial
meningitis is often considered, but the disease can be difficult to recognize.1-8 Recommendations for antimicrobial therapy are changing as a result of the emergence
of antimicrobial resistance. In this review we summarize the current concepts of
the initial approach to the treatment of adults with bacterial meningitis,highlighting
adjunctive dexamethasone therapy and focusing on the management of neurologic
complications.

N Engl J Med 2006;354:44-53.

initial approach

Copyright © 2006 Massachusetts Medical Society.

In adults presenting with community-acquired acute bacterial meningitis, the sensitivity of the classic triad of fever, neck stiffness, and altered mental status is low
(44 percent), butalmost all such patients present with at least two of four symptoms
— headache, fever, neck stiffness, and altered mental status (as defined by a score
below 14 on the Glasgow Coma Scale).1 Lumbar puncture is mandatory in any patient in whom bacterial meningitis is suspected, although the procedure can be
hazardous (Fig. 1 in the Supplementary Appendix, available with the full text of this
articleat www.nejm.org). Reports have emphasized the risk of brain herniation as
a complication of diagnostic lumbar puncture in patients with meningitis.9-13 Patients with expanding masses (e.g., subdural empyema, brain abscess, or necrotic
temporal lobe in herpes simplex encephalitis) may present with symptoms that appear to be identical with those of bacterial meningitis, and in these patients aswell,
lumbar puncture may be complicated by brain herniation.5,9 The withdrawal of cerebrospinal fluid reduces counterpressure from below, thereby adding to the effect of
compression from above, increasing the brain shift that may already be present
(Fig. 1).9 Neuroimaging — either cranial computed tomography (CT) or magnetic
resonance imaging (MRI) — to detect brain shift is recommended as aprecaution
in selected patients before lumbar puncture.9,10 A prospective study involving 301
adults with suspected meningitis confirmed that clinical features can be used to
identify patients who are unlikely to have abnormal findings on cranial CT (41 percent of the patients in this study).10 Of 235 patients who underwent cranial CT, in
only 5 patients (2 percent) was bacterial meningitisconfirmed, reflecting the heterogeneity of the study group with clinically suspected bacterial meningitis. Cranial
imaging should precede lumbar puncture in patients who have new-onset seizures, an immunocompromised state, signs that are suspicious for space-occupying lesions, or moderate-to-severe impairment of consciousness.9,10,13 When these
44

n engl j med 354;1

www.nejm.org

january...
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