Appropriate antimicrobials should be given promptly if bacterial meningitis is suspected, even if the evaluation is ongoing. More Information. One large cohort study found a 4.5% mortality rate and a 30.9% rate of complications, such as developmental delay, seizure disorder, or hearing loss, for childhood encephalitis and meningitis combined.50 Tuberculous meningitis also has a higher mortality rate (19.3%) with a higher risk of neurologic disease in survivors (53.9%).51 A recent prospective cohort study also found that males had a higher risk of unfavorable outcomes (odds ratio = 1.34) and death (odds ratio = 1.47).52, Complications from bacterial meningitis also vary by age (Table 71,11,12,46,5356 ). It is associated with a variety of complications including disseminated disease as well as neurologic complications . Pilot studies that have investigated fluconazole with flucytosine as initial therapy yielded unsatisfactory outcomes [7]. In contrast to non-CNS disease, several studies have been performed that specifically evaluate outcomes among HIV-negative patients with cryptococcal meningitis. In cases where fluconazole is not an option, an acceptable alternative regimen is itraconazole, 200400 mg/d, for 612 months [9] (BIII). Cryptococcal Meningitis: Diagnosis and Management Update Salmonella meningitis is a kind of bacterial meningitis that can be dangerous if not treated. All Rights Reserved. Airborne Precautions if pulmonary infiltrate, Airborne Precautions plus Contact Precautions, if potentially infectious draining body fluid present, Petechial/ecchymotic with fever (general). Delayed initiation of antibiotics can worsen mortality. People with advanced HIV should be tested early for cryptococcal infection. In the most recent large comparative study of this disease, the overall mortality was 6%; in contrast, previous treatment studies experienced mortality rates of 14%25% [11, 13]. Use eye/face protection if aerosol-generating procedure performed or contact with respiratory secretions anticipated. This fungus is found in soil all over the world. The cause determines if it is contagious. Meningitis can also be caused by a variety of other organisms, including bacteria, viruses, and other fungi. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. The desired outcome is resolution of symptoms, such as cough, shortness of breath, sputum production, chest pain, fever, and resolution or stabilization of abnormalities (infiltrates, nodules, masses, etc.) The serum cryptococcal antigen is positive in >99% of subjects with cryptococcal meningitis, usually at titers >1 : 2048 [11, 13]. Drug acquisition costs are high for antifungal therapies administered for life. These tissues are called meninges. . HILLARY R. MOUNT, MD, AND SEAN D. BOYLE, DO. An alternative to this regimen is amphotericin B (0.71 mg/kg/d) plus 5-flucytosine (100 mg/kg/d) for 2 weeks, followed by fluconazole (400 mg/day) for a minimum of 10 weeks. Antifungal medicine treats meningitis in those who have it, and can prevent meningitis in those who do not. CM is more common in people who have compromised immune systems, such as people who have AIDS. Practice Guidelines for the Management of Cryptococcal Disease Specific recommendations for the treatment of non-HIV-associated cryptococcal meningitis are summarized in table 1. Cryptococcus neoformans: Treatment of meningoencephalitis and Copyright 2023 American Academy of Family Physicians. In conjunction with antiretroviral therapy, long-term maintenance antifungal therapy should be administered. Most of the illness and deaths are estimated to occur in resource-limited countries, among people living with HIV. Specific recommendations for the treatment of non-HIV-associated cryptococcal meningitis are summarized in table 1. This guideline is part of a series of updated or new guidelines from the IDSA that will appear in CID. CDC twenty four seven. This specific species is an emerging pathogen and is best known for the 2013 outbreak in the U.S. Pacific Northwest. Abstract. Most common causes are bacterial or viral. These guidelines update the recommendations that were first released in 2018 on diagnosing, preventing, and managing cryptococcal disease. Diagnosis is clinical and microscopic, confirmed by culture or fixed . There are a number of clinical decision tools that have been developed for use in children to help differentiate between aseptic and bacterial meningitis in the setting of pleocytosis. Flucytosine dosage must be adjusted on the basis of hematologic toxicities or, preferably, based on measurement of flucytosine levels. This recommendation is extrapolated from the treatment experience of patients with HIV-associated cryptococcal meningitis [11, 13]. On the basis of experience of treating cryptococcal meningitis in HIV disease, it is reasonable to follow a similar induction, consolidation, and suppression strategy, since previous strategies reported failure rates of 15%20% with 6 weeks of treatment with combination amphotericin B/5-flucytosine [3]. Other laboratory testing and clinical decision rules, such as the Bacterial Meningitis Score, may be useful adjuncts. Therefore, the specific treatment of choice and the optimal duration of treatment have not been fully elucidated for HIV-negative patients. Recommendations. Youll probably switch to taking only fluconazole for about eight weeks. As a result, most clinicians are uncertain about which agents to use for which underlying disease state, in what combination, and for what duration. One-fourth of the patients had opening pressures >350 mm H2O [22]. Most people who develop CM already have severely compromised immune systems. Studies evaluating the effectiveness of amphotericin B, with or without flucytosine, have elucidated the optimal length of therapy for HIV-negative, immunocompromised and immunocompetent hosts. The most troublesome toxic side effect is renal injury, including elevation of the serum creatinine, hypokalemia, hypomagnesemia, and renal tubular acidosis. Options. Amphotericin B, flucytosine, and fluconazole are antifungal medications shown to improve survival in patients with cryptococcal infections. This approach has been shown to reduce the chance of a patient developing cryptococcal meningitis. Your doctor will clean an area over your spine, and then theyll inject numbing medication. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. Thus, itraconazole should be used in cases where the patient is intolerant of fluconazole or has failed fluconazole therapy (BI). Beginning in the 1980s, orally bioavailable azole antifungal agents with activity against C. neoformans were introduced, in particular, itraconazole and fluconazole. Most patients with cryptococcal meningoencephalitis are immunocompromised. Benefits and harms. Thank you for submitting a comment on this article. The goal of treatment is cure of the infection (CSF sterilization) and prevention of long-term CNS system sequelae, such as cranial nerve palsies, hearing loss, and blind-ness. Few studies have been conducted that specifically evaluate outcomes among HIV-negative patients with pulmonary or non-CNS disease. Centers for Disease Control and Prevention. There are two meningitis vaccines available in the US, and both are proven safe. Among patients with AIDS- associated cryptococcal meningitis who are treated successfully, there is a high risk of relapse in the absence of maintenance therapy. Preferred treatment options for cryptococcal disease in HIV-negative patients. You can review and change the way we collect information below. Transmission Precautions | Appendix A | Isolation Precautions These agents can be used alone or in combination with other agents with varying degrees of success. Youll receive antifungal drugs if you have CM. A 2015 Cochrane review found a nonsignificant reduction in overall mortality (relative risk [RR] = 0.90), as well as a significant reduction in severe hearing loss (RR = 0.51), any hearing loss (RR = 0.58), and short-term neurologic sequelae (RR = 0.64) with the use of dexamethasone in high-income countries.41 The number needed to treat to decrease mortality in the S. pneumoniae subgroup was 18 and the number needed to treat to prevent hearing loss was 21.38,41 There was a small increase in recurrent fever in patients given corticosteroids (number needed to harm = 16) with no worse outcome.38,41, The best evidence supports the use of dexamethasone 10 to 20 minutes before or concomitantly with antibiotic administration in the following groups: infants and children with H. influenzae type B, adults with S. pneumoniae, or patients with Mycobacterium tuberculosis without concomitant human immunodeficiency virus infection.7,8,42,45 Some evidence also shows a benefit with corticosteroids in children older than six weeks with pneumococcal meningitis.45, Because the etiology is not known at presentation, dexamethasone should be given before or at the time of initial antibiotics while awaiting the final culture results in all patients older than six weeks with suspected bacterial meningitis. Airborne plus Contact Precautions plus eye protection. Mortality remains high despite the introduction of vaccinations for common pathogens that have reduced the incidence of meningitis worldwide. Recommendations. The differential . Cookies used to make website functionality more relevant to you. In each case, careful assessment of the CNS is required to rule out occult meningitis. Because CSF enterovirus polymerase chain reaction testing is more rapid than bacterial cultures, a positive test result can prompt discontinuation of antibiotic treatment, thus reducing antibiotic exposure and cost in patients admitted for suspected meningitis.34 Similarly, polymerase chain reaction testing can be used to detect West Nile virus when seasonally appropriate in areas of higher incidence. There are 2 key elements in preventing relapse of cryptococcal meningitis: (1) control of HIV replication by means of potent HAART and (2) the use of chronic antifungal therapy to prevent microbial relapse. Drug-related toxicities and development of adverse drug-drug interactions are the principal potential harms of therapeutic intervention. Last medically reviewed on December 11, 2017, Meningitis is an inflammation of the fluid and membranes surrounding the brain and spinal cord. Viral meningitis (non-HSV) management is focused on supportive care. When flucytosine was added to amphotericin B as combination therapy, overall outcome of therapy was improved and the duration of treatment could be reduced from 10 weeks to 46 weeks, depending on the status of the host [1, 3]. This helps to ensure recovery and reduce the risk of complications, such as brain swelling and seizures.