Médecine et maladies infectieuses
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The potential severity of meningitis in infants and children requires an optimized initial empirical therapy, mainly based on direct cerebro spinal fluid (CSF) examination, and rapid therapeutic adaptation according to bacterial identification and susceptibility. Combination treatment including cefotaxim (300 mg/kg per day) or ceftriaxone (100mg/kg per day) and vancomycine (60 mg/kg per day) remains the standard first line if pneumococcal meningitis cannot be ruled out. A simple treatment with third generation cephalosporin can be used for Neisseria meningitidis or Haemophilus influenzae meningitis, aminoglycosides must be added in case of Enterobacteriacae, mainly before 3 months of age. ⋯ When the minimal inhibitory concentration (MIC) of pneumococcal strain is less than 0.5mg/L, third generation cephalosporin should be continued alone for a total of 10 days. In other cases, a second lumbar puncture is necessary and the initial regimen, with or without rifampicin combination, should be used for 14 days. Amoxicillin during 3 weeks, associated with gentamycin or cotrimoxazole is recommended for listeriosis.
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The epidemiology of acute community-acquired bacterial meningitis in children in industrialized nations was greatly modified because of recommended vaccination against Haemophilus influenzae b, Streptococcus pneumoniae (SP) and in some countries against Neisseria meningitidis (Nm) group C. However, most cases of bacterial meningitis are caused by SP and Nm most frequently group B, which validates the first intention use of cefotaxime or ceftriaxone combined or not with vancomycin according to the probability of pneumococcal resistance.
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Despite breakthroughs in the diagnosis and treatment of infectious diseases, meningitis still remains an important cause of mortality and morbidity. An accurate and rapid diagnosis of acute bacterial meningitis is essential for a good outcome. The gold-standard test for diagnosis is CSF analysis. ⋯ Furthermore, in the early phases of acute bacterial and viral meningitis, signs and symptoms are often non specific and it is not always possible to make a differential diagnosis. Markers like CRP, procalcitonin, or sTREM-1 may be very useful for the diagnosis and to differentiate between viral and bacterial meningitis. Bacterial meningitis diagnosis and management require various biological tests and a multidisciplinary approach.
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Bacterial meningitis in adults is a severe disease, with high fatality and morbidity rates. Experimental studies showed that the inflammatory response in the subarachnoid space is associated with unfavorable outcome. In these experiments, corticosteroids, and in particular dexamethasone, were able to reduce the inflammatory cascades in the subarachnoid space. ⋯ A quantitative review showed a consistent beneficial effect of dexamethasone on mortality and a borderline statistical beneficial effect on neurologic sequels. On the basis of available evidence, adjunctive dexamethasone therapy should be initiated before or with the first dose of antibiotics and continued for four days in all adults with suspected or proven community bacterial meningitis in high-income countries, regardless of bacterial etiology. Since prompt use of dexamethasone and appropriate antibiotics improves the prognosis of adults with bacterial meningitis, hospitals will need protocols to include dexamethasone with the initial antibiotic therapy.
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The annual incidence of community acquired meningitis ranges between 0.6 and four per 100,000 adults in industrialized countries. The most common causative bacteria are Streptococcus pneumoniae, Neisseria meningitidis, Listeria monocytogenes. The emergence of resistance to antibiotics, especially for S. pneumoniae, could explain the clinical failure of third generation cephalosporins used to treat adults with S. pneumoniae meningitis. The present therapeutic suggestions are more based on the extrapolation of an experimental model than on relevant clinical trials.