How to treat a patient with meningial symptoms, cerebrospinal fluid (CSF) showing hypoglycorrhachia, hyperproteinorrachia, and high opening pressure?

From the Guidelines

A patient with meningeal symptoms and CSF findings of hypoglycorrhachia, hyperproteinorrachia, and high opening pressure should be treated promptly for bacterial meningitis while awaiting culture results, with empiric antibiotic therapy and management of increased intracranial pressure. The patient's CSF profile, which includes low glucose (35 mg/dL), high protein (230 mg/dL), and high opening pressure, is suggestive of bacterial meningitis, as bacteria consume glucose and trigger inflammation, leading to increased protein and pressure [ 1 ].

• The recommended empiric antibiotic therapy is ceftriaxone 2g IV every 12 hours plus vancomycin 15-20 mg/kg IV every 8-12 hours, with the addition of ampicillin 2g IV every 4 hours for patients over 50 years or immunocompromised individuals to cover Listeria [ 1 ].
• Dexamethasone 0.15 mg/kg IV every 6 hours for 2-4 days should be administered, ideally before or with the first antibiotic dose, to reduce inflammation and improve outcomes [ 1 ].
• Increased intracranial pressure should be managed by elevating the head of the bed to 30 degrees and considering mannitol 0.25-1 g/kg IV if severe [ 1 ].
• Supportive care, including seizure prophylaxis with levetiracetam 500-1000 mg IV twice daily if seizures occur, should be provided [ 1 ].
• Antibiotics should be adjusted based on culture results and continued for 7-21 days depending on the identified pathogen [ 1 ]. It is essential to note that the use of corticosteroids, acetazolamide, or mannitol has not been shown to be effective in the setting of cryptococcal meningitis [ 1 ], but dexamethasone is recommended for bacterial meningitis [ 1 ]. Prompt treatment is crucial, as bacterial meningitis has high mortality if not treated quickly [ 1 ].

From the FDA Drug Label

Ampicillin for Injection, USP diffuses readily into most body tissues and fluids. However, penetration into the cerebrospinal fluid and brain occurs only when the meninges are inflamed.

The patient's symptoms and CSF results suggest meningitis, characterized by high opening pressure, hypoglycorrhachia (low glucose), and hyperproteinorrachia (high protein).

• The presence of inflammation in the meninges may allow ampicillin to penetrate the cerebrospinal fluid and brain.
• Ampicillin has been shown to be effective against several bacteria that can cause meningitis, including Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis. Given the patient's symptoms and CSF results, intravenous ampicillin may be considered as part of the treatment regimen, taking into account the patient's overall clinical picture and potential causes of meningitis 2.

From the Research

Treatment Approach

To treat a patient with meningial symptoms, cerebrospinal fluid (CSF) showing hypoglycorrhachia, hyperproteinorrachia, and high opening pressure, the following steps can be considered:

• Administering empirical antibiotic therapy as early as possible, taking into account the patient's allergy history and the suspected causative bacteria 3
• Using a combination of antibiotics, such as ceftriaxone or cefotaxim, and vancomycin, to cover a broad range of potential pathogens, including Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae 4, 3
• Considering the use of ampicillin or penicillin, in combination with an aminoglycoside, for the treatment of Listeria monocytogenes meningitis, as it remains fully susceptible to aminopenicillin 3
• Adjunctive dexamethasone therapy may be beneficial in certain cases, such as in children with Haemophilus influenzae meningitis, or in adults with raised intracranial pressure 5

Diagnostic Considerations

• Performing a lumbar puncture (LP) to obtain CSF for analysis, including glucose, protein, and microbiological studies 6, 7
• Considering brain imaging studies, such as CT or MRI, to evaluate for potential complications, such as hydrocephalus or cerebral edema 6, 7
• Repeating CSF analysis, such as through follow-up spinal taps, to monitor the patient's response to treatment and to detect potential pathogens, such as Listeria monocytogenes 6

Timing of Treatment

• Administering antibiotics as soon as possible after suspicion of meningitis, ideally within the first 30 minutes after arrival, to reduce mortality and morbidity 7
• Prioritizing antibiotic therapy over other diagnostic procedures, such as LP or brain imaging, in patients with suspected bacterial meningitis 7