Complications

complications:

Cerebral edema (swelling of the brain) with increase in intracranial pressure
Waterhouse-Friedrichsen syndrome (10-15% of meningococcal sepsis cases)
Hydrocephalus (= hydrocephalus, i.e. the water in the nerves cannot flow off and accumulates) due to inflammatory adhesions of the meninges
Pus accumulation in the cavities of the brain where brain fluid is normally found (brain ventricle; ventricular lymph nodes)

Therapy

The therapy of purulent meningitis is mainly based on the: If the pathogen has not yet been identified, an intravenous antibiotic treatment combined with several antibiotics is started as soon as possible, depending on the suspected pathogen. This is based on the suspected pathogen. If the pathogen is detected, the antibiotic treatment is specifically adapted to the pathogen.

Thus, there are various recommended therapy shamas that depend on the pathogen and its resistance behavior (ineffectiveness of certain antibiotics due to resistance formation). The sensitivity of the pathogens to various antibiotics is tested in a so-called antibioogram. Penicillins interfere with the cell wall structure of the bacteria and thus prevent them from growing.

They are particularly effective against Gram-positive bacteria such as pneumococci and Gram-negative cocci such as meningococci, which are treated with high doses of penicillin G for 10 to 14 days. In principle, cephalosporins can be used for penicillin allergy. If a purulent meningitis has developed due to a corresponding focus of inflammation, this focus (paranasal sinuses, mastoid, middle ear; brain abscess; visible on CT) must be surgically removed immediately.

The treatment of brain edema is a particular difficulty. Conventional therapy involves elevating the upper body to an angle of about 30°, administering sufficient painkillers and normalizing body temperature. In rare cases, the patient is put under an anaesthetic (thiopental anaesthesia).

If there are still signs of cerebral pressure (vomiting, clouding of consciousness), an attempt is made to draw the water “from the brain tissue into the blood vessels” (osmotherapy) with the intravenous administration of hyperosmolar solutions, such as glycerol, mannitol or dextrose solutions. The water molecules flow from the site of low concentration to the site of higher concentration, i.e. from the tissue into the blood. The administration of steroids such as cortisone, which have an anti-inflammatory effect, was and is controversial for a long time, but has ultimately proved ineffective in treating brain edema.

Only dexamethasone (Fortecortin) has been shown to have a certain beneficial effect. It is recommended to administer 10 mg of dexamethasone immediately before the administration of the antibiotic and to continue with this every 6 hours for 4 days. Recent studies have shown that this has reduced mortality and the frequency of unfavorable courses as well as hearing disorders, but this is more likely to be due to a general positive influence on the course of the disease rather than a reduction in intracranial pressure (German Society of Neurology).

If the cerebral pressure persists or if hydrocephalus is present, consideration must be given to the application of a ventricular drainage. For this purpose, a tube (shunt) is inserted directly into the cerebrospinal fluid spaces of the brain so that the cerebrospinal fluid can drain off to the outside and the cerebral pressure is reduced. In the case of an infection with meningococcus, the severe course of a meningococcal sepsis (blood poisoning by meningococcus and meningococcal toxins) can lead to the complication of the so-called meningococcal meningitis.Waterhouse-Friedrichsen Syndrome, in which activation of the body’s own coagulation system with the consumption of coagulation factors dissolved in the blood is the main focus, resulting in numerous smaller and larger bleedings into the skin and other organs.

These clotting factors must be replaced under constant laboratory control. For this reason, blood plasma (Fresh Frozen Plasma = FFP) is given additionally, because it contains coagulation factors. From puberty onwards, inhibition of blood clot formation (thrombosis) with anticoagulants (heparins) is also recommended as a prophylaxis against thrombosis.

Treatment with antibiotics
Surgical removal of inflammatory foci, if present
Brain Pressure Therapy
Therapy of complications
In previously healthy adults, but also in immunocompromised and alcoholics, a broad-spectrum antibiotic that crosses the blood-brain barrier well (3rd generation cephalosporins, e.g. cefotaxime or ceftriaxone, 2 g 3x/day) is initially combined with ampicillin (5 g 3x/day).
In patients who probably acquired the germ in hospital (nosocomial infection), after surgery or trauma, vancomycin (2 gday every 6-12 hours) is combined with meropenem or ceftazidim (2 g three times/day).
In young patients with skin symptoms, meningococcus is relatively certain to be present. In these cases, treatment is with high-dose penicillin G. Nevertheless, the pathogen must still be detected.