# data[].attributes.body
Patient LA is experiencing symptoms (reduced hearing, drowsiness, agitation, confusion, not cooperative, sore throat, cough, headache ) of meningitis requiring initiation of appropriate treatment.

Patient LA is experiencing signs (fever, culture positive for streptococcus pneumoniae) of meningitis requiring initiation of appropriate treatment.

Patient LA is experiencing progression of infection secondary to being treated with inappropriate medication requiring reassessment of therapy.

The patient is at risk of losing her hearing due to meningitis requiring initiation of treatment

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1. eradicate infection  via sterilization of CSF within 24hrs

2. Improve the signs like fever, culture positive for streptococcus pneumoniae, … within 24hrs

3. Improve symptoms like reduced hearing, drowsiness, agitation, confusion, not cooperative, sore throat, cough, headache within 24-48 hrs

4. Prevent mortality

5. Minimize complications like involvement of brain parenchymal, seizures, coma, complete hearing loss, cognitive impairment

# data[].attributes.body
Vancomycin
Vancomycin + rifampin

Vancomycin + moxifloxacin( 400 mg once daily for 10-14 days)

Linezolid

Give medication for 10-14 days

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1. hypokalemia give IV pottasium 20 - 40 meq of pottasium over 4 hrs
2. vancomycin (sensative in qatar so only this)
Choice:

Vancomycin: 15 mg/kg/dose every 8 to 12 hours initially

L.A’s dose: 750mg every 8 hrs

Give medication for 10-14 days

+

Dexamethasone  10mg IV q6H for 4 days started before the antibiotics or with the antibiotics

# data[].attributes.body
LA is experiencing symptoms of meningitis (reduced hearing, drowsiness, agitation, confusion, not cooperative, sore throat, cough, headache ) requiring initiation of therapy

# data[].attributes.body
1- cure infection, CSF sterilization within 24hr
2- prevent mortality
3- minimize complications (seizure, focal neurological defects, cognitive impairment, hearing loss, coma)
4- normalize signs and symptoms (fever, sore throat, hearing lose, CSF chemistry)
5- minimize ADRs within the course of therapy

# data[].attributes.body
Patient L.A is experiencing symptoms of meningitis such as hearing loss, agitation, photo phobia and neck stiffness  requiring immediate initiation of empiric therapy

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Vancomycin:

infusion reaction characterized by erythematous rash, generalized flushing, and pruritus

Cardiovascular: Decreased blood pressure, facial edema), flushing, hypersensitivity angiitis , peripheral edema, shock

Dermatologic: Acute generalized exanthematous pustulosis, cutaneous lupus erythematosus, erythema multiforme, lichenoid eruption , pemphigoid reaction, pruritus, psoriasiform eruption, skin rash, Stevens-Johnson syndrome , toxic epidermal necrolysis , urticaria

Endocrine & metabolic: Adrenocortical insufficiency, increased uric acid, menstrual disease

Gastrointestinal: Abdominal cramps, anorexia, cholestasis, Clostridioides difficile-associated diarrhea, Clostridioides difficile colitis, diarrhea, epigastric discomfort, flatulence, glossalgia, heartburn, nausea, staining of tooth, vomiting

Genitourinary: Hematuria,hemoglobinuria

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1. Studies suggest the combination of vancomycin and rifampicin, although not synergic, proved to be equally effective. Using this combination in the clinical setting may allow rifampicin administration without the emergence of resistance, and possibly concomitant dexamethasone administration without significant interference with CSF vancomycin levels.
2. We used combination instead of vancomycin monotherapy since according to clinical trials, Vancomycin is erratic in its penetration into the CSF and may be ineffective as monotherapy in pneumococcal meningitis.

3. According to clinical trials, early intravenous administration of dexamethasone has been evaluated as adjunctive therapy in an attempt to diminish the rate of hearing loss and other neurologic complications as well as mortality in adult patients with pneumococcal meningitis in high-income countries.
4. According to a clinical trial, a total of 301 adults (age, ⩾17 years) were randomized to receive dexamethasone (10 mg q6h for 4 days) or placebo, the first dose being administered 15–20 min prior to the first antimicrobial dose. At 8 weeks after enrollment, the percentage of patients with an unfavorable outcome (15% vs. 25%; P = .03) and death (7% vs. 15%; P = .04) was significantly lower in the dexamethasone group

5. Since the patient had resistance to penicillins and has a cephalosporin allergy, rifampin was used as an adjunctive with vancomycin.
6. Vancomycin is 100 percent sensitive in Qatar and therefore should be used.

Reference:
1. J. Martínez-Lacasa, C. Cabellos, A. Martos, A. Fernández, F. Tubau, P. F. Viladrich, J. Liñares, F. Gudiol, Experimental study of the efficacy of vancomycin, rifampicin and dexamethasone in the therapy of pneumococcal meningitis, Journal of Antimicrobial Chemotherapy, Volume 49, Issue 3, March 2002, Pages 507–513, https://doi.org/10.1093/jac/49.3.507
2. https://academic.oup.com/cid/article/39/9/1267/402080

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-        Cefotaxime (cephalosporine allergy)

-        Ceftriaxone (cephalosporine allergy)

-        Ceftriaxone + vancomycin (cephalosporine allergy)

-        Cefotaxime + vancomycin (cephalosporine allergy)

-        Chloramphenicol

-        Moxifloxacin + vancomycin

-        Ceftriaxone + rifampicin (cephalosporine allergy)

-        Cefotaxime + rifampicin (cephalosporine allergy)

-        Dexamethasone 10mg IV q6hrs x 4 days

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- CSF analysis results ( Lumbar puncture) make sure it's negative checked by doctor, pharmacist, and lab technician.
- CDC make sure all labs are normal done by Dr, the pharmacist and lab tech
- CRP
- Serum creatinine
- WBc
- CT scan (only people with tumor, seizure or cant do lumbar puncture, follow up in those done in the begining)

# data[].attributes.body
Meningitis:

DRP:

Patient is suffering from symptoms of fever, headache, sore throat, vomiting, and new onset photophobia, suggestive of possible meningitis infection, requiring urgent initiation of empiric therapy followed by targeted therapy if confirmed.

* goals of therapy:

cure the infection (CSF steralized within 24 hr)

prevent mortality and minimize the complications (seizures, focal neurologic defecit, coma)

normalise signs and symptoms within 5 days

minimize the possible ADRs of drugs

pharmacological options of therapy:

Vamcomycin + dexamethasone +/- moxifloxacin

Recommendation:

Dexamethasone 10 mg IV every 6 hr for 4 days

Vancomycin 500 mg IV every 8 hr, target 15 mcg\ml

Moxifloxacin 400 mg IV  per day

Monitoring:

Safety:

Vancomycin: red man syndrome ( sx redness, rash, itching), infusion-related

Moxifloxacin: QT prolongation and arrhythmia ( ECG monitoring), GI sx (diarrhea, nausea, vomiting)

Dexamthazone:  hyperglycemia (glucose level)

Efficacy:

No deterioration in symptoms and patient stability

# data[].attributes.body
1- cure the meningitis infection within 24 hrs
2- normalize signs and symptoms within 24-48hrs (neck stiffness, photophobia, decreased hearing)
3- prevent mortality
4-  minimize and prevent complications such as seizures, focal neurological deficits, hearing loss and coma
5- minimize adverse drugs reactions

# data[].attributes.body
1- to cure the meningitis and achieve sterile CSF within 24 hours and resolution of signs (confusion, vomiting) and symptoms (neck stiffness, photophobia, headache, hearing loss) within 48 hours
2- minimize complication of meningitis such as seizures and coma within the course of treatment.

# data[].attributes.body
1- The most important initial issues are avoidance of delay in administering therapy and the choice of drug regimen. Intravenous antimicrobial therapy should be initiated immediately after the performance of the lumbar puncture (LP) or, if a computed tomography scan of the head is indicated to be performed before LP, immediately after blood cultures are obtained. Adjunctive dexamethasone should be given shortly before or at the same time as the first dose of antimicrobials, when indicated.

# data[].attributes.body
1- Vancomycin

2- Dexamethasone