A 40-year-old man is brought to the emergency department by his wife for progressive lethargy, fever, and headache over the last 24-hours. He underwent craniotomy for meningioma resection 1 week ago. Since yesterday evening, the patient has had confusion, headaches, and a few episodes of vomiting. His wife denies any sick contacts, recent travel, flu-like symptoms, or skin rashes.
His temperature is 39.6 C (103.3 F), blood pressure is 140/90 mm Hg, pulse is 110/min and regular, and respirations are 16/min. There is no skin rash. The craniotomy incision is healing normally. On neurological examination, he is obtunded and does not follow commands. There is prominent neck stiffness. He is able to localize to noxious stimuli in the upper extremities and withdraw in the lower extremities.
Stat CT scan of the head shows no bleeding or masses. Lumbar puncture (LP) shows elevated opening pressure, white blood cell count of 1,200 cells/µL with 90% neutrophils, protein of 200 mg/dL, and glucose of 20 mg/dL.
Which of the following is the best next step in this patient's management?

Question

A 40-year-old man is brought to the emergency department by his wife for progressive lethargy, fever, and headache over the last 24-hours.  He underwent craniotomy for meningioma resection 1 week ago.  Since yesterday evening, the patient has had confusion, headaches, and a few episodes of vomiting.  His wife denies any sick contacts, recent travel, flu-like symptoms, or skin rashes.
His temperature is 39.6 C (103.3 F), blood pressure is 140/90 mm Hg, pulse is 110/min and regular, and respirations are 16/min.  There is no skin rash.  The craniotomy incision is healing normally.  On neurological examination, he is obtunded and does not follow commands.  There is prominent neck stiffness.  He is able to localize to noxious stimuli in the upper extremities and withdraw in the lower extremities.
Stat CT scan of the head shows no bleeding or masses.  Lumbar puncture (LP) shows elevated opening pressure, white blood cell count of 1,200 cells/µL with 90% neutrophils, protein of 200 mg/dL, and glucose of 20 mg/dL.
Which of the following is the best next step in this patient's management?

Quizplus · Accepted Answer

11ec193a_962c_0ebf_853d_ab4e943265da_MD0002_00 This patient presents with acute hospital-acquired (healthcare-associated) bacterial meningitis after recent brain surgery. The lumbar puncture findings of neutrophilic pleocytosis, elevated protein, and low CSF glucose strongly suggest a bacterial etiology. Following brain surgery, the most likely organisms to cause meningitis include gram-negative bacilli (e.g., Pseudomonas aeruginosa) and gram-positive cocci (e.g., methicillin resistant Staphylococcus aureus). Both cefepime and ceftazidime have good CNS penetration as well as broad coverage against gram-negative organisms, especially Pseudomonas aeruginosa, and some coverage against gram-positive organisms (e.g., Streptococcus pneumoniae). Vancomycin is effective against MRSA. (Choices B and C) Ceftriaxone and vancomycin are appropriate for empiric treatment of community-acquired meningitis in patients aged 2-50 years, as this combination retains good coverage against S. pneumoniae. However, ceftriaxone does not adequately cover Pseudomonas. Acyclovir is not needed as HSV meningitis is unlikely. (Choice D) Ampicillin is usually added in suspected bacterial meningitis to cover for Listeria monocytogenes in patients > age 50 or the immunocompromised. (Choice E) Piperacillin/tazobactam has good coverage against Pseudomonas and other gram-negative organisms, but does not have good CNS penetration. Educational objective: Patients with hospital-acquired meningitis should be empirically treated with an antipseudomonal cephalosporin and vancomycin. Cefepime, ceftazidime, and meropenem are all highly effective against gram-negative organisms (e.g., Pseudomonas) and have good CNS penetration. __________ References: Cephalosporins in the treatment of meningitis. (http://www.ncbi.nlm.nih.gov/pubmed/3319497) Healthcare-associated bacterial meningitis. (http://www.ncbi.nlm.nih.gov/pubmed/21526350)

A 40-Year-Old Man Is Brought to the Emergency Department by His