| Author | 9 Posts |
Justice
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An 80-year-old man is hospitalized because of headache, fever, and altered sensorium. He was in his usual state of health until 2 days prior to admission when he developed a frontal headache that kept him awake that night. The next day, he felt feverish and told his wife that his neck was aching. Acetaminophen provided some relief. The following morning, his wife was unable to arouse him from sleep, and he was brought to the emergency department.
On physical examination in the emergency department, temperature is 38.9°C (102.0 °F), pulse rate is 130/ min, respiration rate is 40/mm, and blood pressure is 110/50 mm Hg. He is obtunded and has a stiff neck. Lumbar puncture is performed. The opening pressure is high. Leukocyte count is 1200/μL. (with 95% neutrophils), glucose is 22 mg/dL (simultaneous plasma glucose is 85 mg/dL), and protein is 200 mg/dL. Gram stain of cerebrospinal fluid is negative. Empiric antimicrobial therapy with vancomycin, ampicillin, and ceftriaxone is begun.
Which of the following statements is correct regarding administration of adjunctive dexamethasone to this patient?
A. Dexamethasone should be administered within 1 hour of the first dose of antimicrobial therapy
B. Dexamethasone has no role in the adjunctive treatment of bacterial meningitis in an adult patient
C. Dexamethasone will increase the risk of an unfavorable outcome in an adult patient with bacterial meningitis
D. If this patient has pneumococcal meningitis, dexamethasone will improve his chance of survival
E. If this patient hasListeria meningitis, dexamethasone will improve his chance of survival
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| peter90036
Forum Elite
Topics: 28
Posts: 315
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i'm ok, i wont try this one, i'll wait for the explanation 
...or i could just look it up on uptodate, made me curious...
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| DrVirgo
Forum Hero
Topics: 1055
Posts: 3,374
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D. If this patient has pneumococcal meningitis, dexamethasone will improve his chance of survival
http://content.nejm.org/cgi/content/abstract/347/...
Mortality and morbidity rates are high among adults with acute bacterial meningitis, especially those with pneumococcal meningitis. In studies of bacterial meningitis in animals, adjuvant treatment with corticosteroids has beneficial effects.
OK so I cheated. 
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| CocaCola
Forum Guru
Topics: 35
Posts: 908
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??? A
just my guess
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| Markus2009
Forum Senior
Topics: 9
Posts: 189
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A
Data on the adult need for dexamethasone are limited. Sanford suggests administering dexamethasone to patients with positive CSF Gram stain (indicates many bacteria), those in a coma, or those with increased CSF pressure with or without cranial nerve palsy. Administer first dose of dexamethasone (0.4 mg/kg IV q12h for 2 d or 0.15 mg/kg q6h for 4 d) 15-20 minutes before first dose of antibiotics.(e medicine)
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| Justice
Forum Fanatic
Topics: 100
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I will put correct answers on Friday so more people could test their knowledge/learn from this Qn... Meantime, I want to remind my colleagues to vote on the top of the page...
Thank you
 
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| Jcala
Forum Junior
Topics: 10
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D
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| aspire
Forum Senior
Topics: 24
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D-Use in pneumococcal meningitis.
I cheated though.
Washington says-Dexamethasone is started just before or during initial antibiotics and given for 4 days reduces the risk of a poor neurologic outcome. The benefit is greatest for meningitis caused by strep pneumoniae and h. influenzae, thus it should be discontinued if a different pathogen is isolated.
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| Justice
Forum Fanatic
Topics: 100
Posts: 1,907
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The correct answer is D
The rationale for use of adjunctive dexamethasone in patients with bacterial meningitis is to attenuate the subarachnoid space inflammatory response that results from antimicrobial agent-induced lysis of meningitis pathogens. Previous studies, predominantly in infants and children, have demonstrated that adjunctive dexamethasone is beneficial for patients with meningitis caused byHaemophilus influenzae type b and, if started along with or prior to parenteral antimicrobial therapy, may be beneficial for patients with pneumococcal meningitis. In a recently published trial in adults with bacterial meningitis, adjunctive dexamethasone was beneficial in the subset of patients with pneumococcal meningitis and was associated with a reduction in the number of patients who had an unfavorable outcome or who died.
If used, adjunctive dexamethasone must be administered concomitant with or just prior to the first dose of antimicrobial therapy. Although dexamethasone has been shown to decrease penetration of antimicrobial agents into cerebrospinal fluid, this has not been associated with a worse outcome.
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