DRG Category: 75
Mean LOS: 6.1 days
Description: Medical: Viral Meningitis With Complication or Comorbidity or Major Complication or Comorbidity
DRG Category: 98
Mean LOS: 7.1 days
Description: Medical: Non-Bacterial Infection of Nervous System Except Viral Meningitis With Complication or Comorbidity
Meningitis is an acute or subacute inflammation of the meninges (lining of the brain and spinal cord). The bacterial or viral pathogens responsible for meningitis usually come from another site, such as those that lead to an upper respiratory infection, sinusitis, or mumps. The organisms can also enter the meninges through open wounds. Bacterial meningitis is considered a medical emergency because the outcome depends on the interval between the onset of disease and the initiation of antimicrobial therapy. In the United States, approximately 4,000 people contract bacterial meningitis each year, and approximately 500 deaths occur. In contrast, the viral form of meningitis is sometimes called aseptic or serous meningitis. It is usually self-limiting and, in contrast to the bacterial form, is often described as benign.
In the bacterial form, bacteria enter the meningeal space and elicit an inflammatory response. This process includes the release of a purulent exudate that is spread to other areas of the brain by the cerebrospinal fluid (CSF). If it is left untreated, the CSF becomes thick and blocks the normal circulation of the CSF, which may lead to increased intracranial pressure (ICP) and hydrocephalus. Long-term effects of the illness are predominantly caused by a decreased cerebral blood flow because of increased ICP or toxins related to the infectious exudate. If the infection invades the brain tissue itself, the disease is then classified as encephalitis. Other complications include visual impairment, cranial nerve palsies, deafness, chronic headaches, paralysis, and even coma. Treatment complications include hypotension, cardiac dysrhythmias, shock, hyponatremia, syndrome of inappropriate antidiuretic hormone, and stroke.
Of the bacteria that cause meningitis, pneumococcal meningitis has the highest rates of mortality between 20% and 30% in adults and 10% in children. If severe neurological impairment is seen at the time of initial assessment or very early in the clinical course, the mortality rate is 50% to 90%, even when therapy is instituted immediately.
Meningitis is most frequently caused by bacterial or viral agents. In newborns, Streptococcus pneumoniae is the most frequent bacterial organism; in other age groups, it is S pneumoniae and Neisseria meningitidis. Haemophilus influenzae is the most common organism in unvaccinated children and adults who contract meningitis. Viral meningitis is caused by many viruses such as West Nile and human immunodeficiency virus. Depending on the cause, isolation precautions may be indicated early in treatment. There has been a decrease in viral meningitis in locations where immunizations have become routine. Risk factors include being immunocompromised (HIV disease, tissue transplantation recipients, autoimmune conditions, and prematurity), alcohol abuse, and cirrhosis.
Heritable immune responses could be protective or increase susceptibility. Deficiency of complement factor I (CFI) causes susceptibility to meningitis.
Meningitis occurs most frequently in young children, older people, and persons in a debilitated state. Infants and the very old are at the most risk for pneumococcal meningitis, whereas children from 2 months to 3 years most frequently have haemophilus meningitis. Male infants have higher rates of infection than female infants. The Centers for Disease Control and Prevention (CDC, 2021) recommend haemophilus vaccine type b conjugate vaccine for infants 2 to 6 months and pneumococcal conjugate vaccine for children under age 2 years. Meningococcal meningitis is most common during childhood after age 3 years and during adolescence. Recommendations are that children receive a meningococcal conjugate vaccine at 11 to 12 years, with a booster dose at age 16 years (CDC, 2021). Now that vaccinations are routine in the United States, bacterial meningitis in children is uncommon. Prognosis is poorest for patients at the extremes of age—the very young and the very old of both sexes.
Black persons are at slightly greater risk than other races and ethnicities for bacterial and viral meningitis, although at this time there is no explanation for those differences in risk. CDC reported in 2018 that 69% of new HIV diagnoses in the United States were in gay and bisexual men. In young people ages 13 to 24 years, young gay and bisexual men account for 83% of all new HIV diagnoses. Persons with HIV are more at risk for meningitis than the general population. These infections may be community-acquired bacterial or viral meningitis, and most commonly are cryptococcal, tuberculous, syphilitic, or lymphomatous meningitis.
Meningitis is more prevalent in developing than in developed countries because of lower rates of vaccination and less attention to other disease prevention strategies. Experts estimate that the incidence is 10 times higher in developing countries as compared to developed countries because of the lack of preventive services. Causes of viral meningitis around the world include enteroviruses, Japanese B encephalitis virus, mumps or measles virus, and HIV. Many people with these viral infections do not develop symptoms. While it can be found in many countries, meningococcal meningitis is endemic to Africa and India, particularly during hot and dry weather. The area in Northern Africa between Ethiopia to Senegal is considered the “meningitis belt” because of the high prevalence in this area.
PLANNING AND IMPLEMENTATION
Collaborative
Assessment and maintenance of airway, breathing, and circulation (ABCs) are essential. Treatment with intubation, mechanical ventilation, and hyperventilation may occur if the patient's airway and breathing are threatened, and fluid resuscitation may be needed if the patient is in shock or hypotensive. The most critical treatment is the rapid initiation of antibiotic therapy. Generally, people with viral meningitis will recover without antiviral medications, but if encephalitis occurs in conjunction with meningitis, antivirals may be used. Serial neurological assessments and vital signs not only monitor critical changes in the patient but also monitor the patient's response to therapy. Supportive measures such as bedrest and temperature control with antipyretics or hypothermia limit oxygen consumption. Gradual treatment of hyperthermia is required to prevent shivering.
Other strategies to manage increased ICP include osmotic diuretics, such as mannitol, or intraventricular CSF drainage and ICP pressure monitoring. Fluids are often restricted if signs of cerebral edema or excessive secretion of antidiuretic hormone are present. If the patient experiences seizures, the physician prescribes anticonvulsant medications. Surgical interventions or CSF drainage may be required to prevent permanent neurological deficits as a result of complications such as hydrocephalus or abscesses. The patient is likely to have a severe headache from increased ICP. Because large doses of narcotic analgesia mask important neurological changes, most physicians prescribe a mild analgesic to decrease discomfort. In children, pain relief decreases crying and fretting, which, if left untreated, have the potential to aggravate increased ICP.
Rehabilitation begins with the acute phase of the illness but becomes increasingly important as the infection subsides. If residual neurological dysfunction is present as a result of irritation, pressure, or brain and nerve damage, an individualized rehabilitation program with a multidisciplinary team is required. Vision and auditory testing should be done at discharge and at intervals during long-term recovery because early interventions for these deficits are needed to prevent developmental delays.
| Medication or Drug Class | Dosage | Description | Rationale |
|---|
| Antibiotics | High-dose parenteral therapy IV for 2 wk; dosage and drug vary by organism, age, and severity | Choice of antibiotic depends on Gram stain and culture and sensitivities; for suspected bacterial meningitis, a third-generation cephalosporin (ceftriaxone, cefotaxime) is often used while culture results are pending along with vancomycin; in people over age 50 years the therapy may be a combination of vancomycin plus ampicillin plus ceftriaxone or cefotaxime | Cause bacterial lysis and prevent continuation of infection; initial dosages are based on weight or body surface area and then are adjusted according to peak and trough results to maintain therapeutic levels |
| Antivirals (currently under investigation) | Varies with medication (acyclovir, ganciclovir, foscarnet) | Antiviral agent | Halts viral replication |
Other Drugs: Other drugs include analgesics, adjunct corticosteroid therapy (has been reported to decrease the inflammatory process and decrease incidence of hearing loss but is controversial), and anticonvulsants. Vaccinations exist for meningococcal, pneumococcal, and haemophilus meningitis, and the prophylaxis for persons exposed to meningococcal meningitis is rifampin.
Independent
Make sure the patient has adequate ABCs. In the acute phase, the primary goals are to preserve neurological function and to provide comfort. The head of the bed should be elevated 30 degrees to relieve ICP. Keep the patient's neck in good alignment with the rest of the body and avoid hip flexion. Control environmental stimuli such as light and noise and institute seizure precautions. Soothing conversation and touch and encouraging the family's participation are important; they are particularly calming with children who need the familiar touch and voices of parents. Children are also reassured by the presence of a security object.
Institute safety precautions to prevent injury, which may result from either seizure activity or confusion associated with increasing ICP. Take into account an increase in ICP if restraints are used and the patient fights them. Implement measures to limit the effects of immobility, such as skin care, range-of-motion exercises, and a turning and positioning schedule. Note the effect of position changes on ICP, and space activities as necessary.
Explain the disease process and treatments. Alterations can occur in thought processes when ICP begins to increase and the level of consciousness begins to decrease. Reorient the patient to time, place, and person as needed. Keep familiar objects or pictures around. Allow visitation of significant others. Establish alternative means of communication if the patient is unable to maintain verbal contact (e.g., the patient who needs intubation). As the patient moves into the rehabilitative phase, developmentally appropriate stimuli are needed to support normal growth and development. Determine the child's progress on developmental tasks. Make appropriate referrals if the child is not progressing or if the child or family evidence signs of inability to cope.
Evidence-Based Practice and Health Policy
Ellis, D., Zaoutis, T., Thibault, D., Crispo, J., Abraham, D., & Willis, A. (2020). Readmissions after hospital care for meningitis in the United States. American Journal of Infection Control, 48, 798–804.
- The authors' objectives were to describe the characteristics of adults hospitalized with meningitis; describe meningitis hospitalization outcomes, including 30- and 90-day readmissions; and determine whether clinical, patient, or hospitalization characteristics were associated with readmission and readmission outcomes. The authors performed a retrospective study of the 2014 National Readmissions Database and extracted data on hospitalized adults (N = 18,883) with a principal diagnosis of meningitis.
- Meningitis hospitalizations commonly involved adults 25 to 54 years of age who were insured by private carriers. The readmission rates were 7.0% at 30 days and 11.4% at 90 days. Readmission was associated with greater comorbidity burden, public insurance, and medical error. Readmissions were most often for meningitis, septicemia, or medical complications.