How to prevent secondary complications in Streptococcus pneumoniae meningitis?

Prevention of Secondary Complications in Streptococcus pneumoniae Meningitis

Vaccinate all patients after recovery from pneumococcal meningitis with pneumococcal vaccines to prevent recurrence, as the risk of recurrent pneumococcal meningitis is 1-5%. 1

Vaccination Strategy for the Index Patient

Post-recovery vaccination is essential and should include sequential administration of pneumococcal vaccines:

• Administer both the 23-valent polysaccharide vaccine and the 10- or 13-valent pneumococcal conjugate vaccines sequentially 1
• This recommendation is based on substantial benefits given the 1-5% recurrence risk in survivors 1
• If CSF leakage is present or identified, add H. influenzae type b and N. meningitidis vaccines in addition to pneumococcal vaccines 1
• CSF leakage requires surgical reconstruction of the dural barrier along with vaccination 1

Management of Acute Complications During Hospitalization

Neurological Complications (occur in ~50% of cases)

Monitor closely for neurological deterioration and obtain cranial imaging (MRI preferred, CT acceptable) when patients develop:

• Decreased mental status 1
• New focal neurological deficits 1
• Signs of increased intracranial pressure 1

Key complications requiring specific interventions:

• Seizures (occur in 15% of cases): Start anticonvulsant treatment immediately when seizures are suspected or proven, as they are associated with worse outcomes 1
• Status epilepticus: Requires EEG monitoring in addition to anticonvulsant therapy 1
• Obstructive hydrocephalus: Place external ventricular drain to prevent cerebral herniation 1
• Communicating hydrocephalus: Consider repetitive lumbar punctures or external lumbar drain in awake, monitorable patients, though may not always be necessary 1
• Space-occupying lesions (subdural empyema, brain abscess, intracerebral hemorrhage): Neurosurgical consultation for possible intervention 1

Intracranial Pressure Management

Control raised intracranial pressure through the following measures:

• Maintain normal to elevated mean arterial pressure 1
• Elevate head of bed 1
• Avoid hyperthermia and hyponatremia 1
• Maintain normocarbia and normoglycemia 1
• Control venous pressure 1

Important caveat: ICP monitoring can be life-saving in selected patients but is not recommended as routine management due to lack of solid evidence and potential for harm 1

Systemic Complications

Manage hemodynamic instability and coagulopathy:

• Septic shock: Fluid resuscitation targeting lactate normalization and urine output ≥0.5 mL/kg/h 1
• Consider albumin in patients with worsening shock requiring significant fluid resuscitation 1
• Refractory septic shock: Consider low-dose steroid supplementation if documented adrenal hypo-responsiveness is present 1
• DIC with bleeding: Treat according to established guidelines with blood product support 1

Avoid Harmful Interventions

Do not use the following adjunctive therapies as they are contraindicated or ineffective:

• Therapeutic hypothermia (associated with higher mortality) 1
• Glycerol (no benefit in adults) 1
• Routine mannitol, acetaminophen, antiepileptic drugs, or hypertonic saline 1
• Immunoglobulins, heparin, or activated protein C 1

Long-Term Sequelae Prevention and Monitoring

Arrange early audiological evaluation during clinical course:

• Hearing loss occurs in 30-54% of survivors when systematically assessed 1
• Early identification may lead to cochlear implant placement in appropriate cases 1

Neuropsychological evaluation when indicated:

• Perform if cognitive deficits (cognitive slowness, difficulty concentrating) are suspected that interfere with return to normal activities 1
• These deficits occur in 32% of survivors 1
• Refer for neurorehabilitation if deficits are present 1

Contact Prophylaxis (Not Applicable for Pneumococcal Meningitis)

Important distinction: Unlike meningococcal meningitis, antibiotic prophylaxis for household contacts is not indicated for pneumococcal meningitis cases 1, 2. The prophylaxis recommendations in the guidelines specifically apply only to meningococcal disease, where the risk to close contacts is increased 400-800 fold 1.

Critical Timing Considerations

Early antibiotic treatment is the only modifiable factor associated with mortality:

• Delay in antibiotic initiation is independently associated with 30-day mortality (OR 18.69) 3
• This emphasizes prevention of complications begins with prompt initial treatment, not just management of established complications 3