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Infectious meningitis and encephalitis are often life-threatening illnesses, though prompt workup and targeted treatment can greatly reduce morbidity and mortality. Although presentation of central nervous system infection can sometimes be subtle, this issue focuses on evidence-based strategies for identifying combinations of signs and symptoms to narrow the diagnosis. Identifying meningitis versus encephalitis; bacterial versus viral, fungal, or iatrogenic causes; and providing prompt empiric antimicrobials and appropriate diagnostic testing are key to management. Cerebrospinal fluid testing findings are outlined to help determine a potential cause for symptoms, along with blood and serum testing options. International society guidelines and evidence regarding the need for computed tomography prior to lumbar puncture are presented, which can help reduce unnecessary imaging. Disposition criteria are expanded to help determine whether a patient can go home, or the level of hospital care that will be required for those admitted.
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Following are the most informative references cited in this paper, as determined by the authors.
1. * van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016;22:S37-S62. (Practice guideline) DOI: 10.1016/j.cmi.2016.01.007
12. * Wright WF, Pinto CN, Palisoc K, et al. Viral (aseptic) meningitis: a review. J Neurol Sci. 2019;398:176-183. (Review) DOI: 10.1016/j.jns.2019.01.050
17. * Venkatesan A, Tunkel AR, Bloch KC, et al. Case definitions, diagnostic algorithms, and priorities in encephalitis: consensus statement of the International Encephalitis Consortium. Clin Infect Dis. 2013;57(8):1114-1128. (Practice guideline) DOI: 10.1093/cid/cit458
22. * Attia J, Hatala R, Cook DJ, et al. The rational clinical examination. Does this adult patient have acute meningitis? JAMA. 1999;282(2):175-181. (Systematic review; 10 studies) DOI: 10.1001/jama.282.2.175
25. * Julián-Jiménez A, Morales-Casado MI. Usefulness of blood and cerebrospinal fluid laboratory testing to predict bacterial meningitis in the emergency department. Neurologica (Engl Ed). 2019;34(2):105-113. (Review) DOI: 10.1016/j.nrl.2016.05.009
27. * McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016;72(4):405-438. (Practice guideline) DOI: 10.1016/j.jinf.2016.01.007
39. * Costerus JM, Brouwer MC, Bijlsma MW, et al. Community-acquired bacterial meningitis. Curr Opin Infect Dis. 2017;30(1):135-141. (Review) DOI: 10.1097/QCO.0000000000000335
74. * Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015(9):CD004405. (Cochrane review, meta-analysis; 25 studies, 4121 patients) DOI: 10.1002/14651858.CD004405.pub5
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Keywords: meningitis, encephalitis, bacterial, viral, aseptic, fungal, CNS, neck, herpes, HSV, varicella, Kernig, Brudzinski, CSF, fluid, lactate, CT, lumbar puncture, corticosteroids
Dr. Ashoo is a practicing emergency physician, board-certified in emergency medicine and clinical informatics. Join him as he takes you through the April 2022 issue of Emergency Medicine Practice: Emergency Department Management of Adults With Infectious Meningitis and Encephalitis (Infectious Disease CME)
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+4 Credits!
Andrew N. Hogan, MD; C. Reece Brockman II, MD, FACEP; Amanda Santa Maria, MD
Corlin Jewell, MD; Benjamin Schnapp, MD, MEd
April 1, 2022
April 30, 2025
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME credits
CME Objectives
CME Information
Date of Original Release: April 1, 2022. Date of most recent review: March 10, 2022. Termination date: April 1, 2025.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME credits, subject to your state and institutional requirements.
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Needs Assessment: The need for this educational activity was determined by a practice gap analysis; a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation responses from prior educational activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) identify areas in practice that require modification to be consistent with current evidence in order to improve competence and performance; (2) develop strategies to accurately diagnose and treat both common and critical ED presentations; and (3) demonstrate informed medical decision-making based on the strongest clinical evidence.
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