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were not affected Based on a number of smaller studies, authorities in the eld of bacterial meningitis have endorsed the administration of dexamethasone in the doses mentioned above only if they can be started before antibiotics, as in the main trial, and only in those with pneumococcal infection (see Tunkel and Scheld) They also advise against the use of the drug if there is septic shock We favor the use of corticosteroids in cases with overwhelming infection at any age (very high CSF pressure or signs of herniation, high CSF bacterial count with minimal pleocytosis, and signs of acute adrenal insuf ciency, ie, the Waterhouse-Friderichsen syndrome) Other Forms of Therapy There is no evidence that repeated drainage of CSF is therapeutically effective In fact, increased CSF pressure in the acute phase of bacterial meningitis is largely a consequence of cerebral edema, in which case the lumbar puncture may predispose to cerebellar herniation A second lumbar puncture to gauge the effectiveness of treatment is generally not necessary, but it may be of value if the patient is worsening without explanation Mannitol and urea have been employed with apparent success in some cases of severe brain swelling with unusually high initial CSF pressures (400 mmH2O) Acting as osmotic diuretics, these agents enter cerebral tissue slowly, and their net effect is to decrease brain water However, neither mannitol nor urea has been studied in controlled fashion in the management of meningitis An adequate but not excessive amount of intravenous normal saline (avoiding uids with free water) should be given, and anticonvulsants should be prescribed when seizures are present In children, particular care should be taken to avoid hyponatremia and water intoxication potential causes of brain swelling Anticonvulsants need not be administered routinely but should

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be given if a seizure has occurred or there is evidence of cortical vein occlusion Prophylaxis All household contacts of patients with meningococcal meningitis should be protected with antibiotic treatment The risk of secondary cases is small for adolescents and adults but ranges from 2 to 4 percent for those less than 5 years of age and is probably higher in the elderly A single dose of cipro oxacin is effective An alternative is a daily oral dose of rifampin 600 mg every 12 h in adults and 10 mg/kg every 12 h in children for 2 days suf ces If 2 weeks or more have elapsed since the index case was found, no prophylaxis is needed As mentioned, immunization against H in uenzae is steadily reducing the incidence of meningitis from this organism Also, fortunately many institutions housing young adults, such as colleges and the military, have instituted programs of immunization against N meningitidis

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Untreated, bacterial meningitis is usually fatal The overall mortality rate of uncomplicated but treated H in uenzae and meningococcal meningitis has remained at about 5 percent for many years; in pneumococcal meningitis, the rate is considerably higher (approximately 15 percent) Fulminant meningococcemia, with or without meningitis, also has a high mortality rate because of the associated vasomotor collapse and infective shock associated with adrenocortical hemorrhages (Waterhouse-Friderichsen syndrome) A disproportionate number of deaths from meningitis occur in infants and in the aged The mortality rate is highest in neonates, from 40 to 75 percent in several reported series, and at least half of those who recover show serious neurologic sequelae In adults, the presence of bacteremia, coma, seizures, and a variety of concomitant diseases including alcoholism, diabetes mellitus, multiple myeloma, and head trauma all worsen the prognosis The triad of pneumococcal meningitis, pneumonia, and endocarditis has a particularly high fatality rate It is often impossible to explain the death of a patient with meningitis or at least to trace it to a single speci c mechanism The effects of overwhelming infection, with bacteremia and hypotension or brain swelling and cerebellar herniation, are clearly implicated in some patients during the initial 48 h These events may occur in bacterial meningitis of any etiology; however, they are more frequent in meningococcal and pneumococcal infection Some of the deaths occurring later in the course of the illness are attributable to respiratory failure, often consequent to aspiration pneumonia It has been stated that relatively few adult patients who recover from meningococcal meningitis show residual neurologic defects, whereas such defects are encountered in at least 25 percent of children with H in uenzae meningitis and up to 30 percent of child and adults patients with pneumococcal meningitis Kastenbauer and P ster, reporting on 87 adults with pneumococcal meningitis, have emphasized that the mortality remains quite high (24 percent in their series) and that cerebral venous or arterial thrombosis occurred in almost a third of cases as discussed further on They also had two patients with an associated myelitis We have seen two instances of upper cervical cord infarction in bacterial meningitis; quadriparesis and respiratory failure were the result of compression from descent of the cerebellar tonsils (Ropper and Kanis) As already discussed, the role of lumbar puncture in promoting this complication has not been clari ed.

Once we have identified the structure of the information, application of it to the chart would be similar to the following illustration

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