Meningitis monitoring

Monitor culture and sensitivity data from the microbiology laboratory to determine whether any refinements are needed in the patient s treatment regimen. Design a therapeutic plan to finish out the patient s course of therapy for acute meningitis. 

Mercaptopurine [6-MP] (Purinethol) [Antineoplastic/ Antimeta lite] Uses Acute leukemias, 2nd-line Rx of CML NHL, maint ALL in children, immunosuppressant w/ autoimmune Dzs (Crohn Dz) Action Antimetabolite, mimics hypoxanthine Dose Adults. 80-100 mg/mVd or 2.5-5 mg/kg/d maint 1.5-2.5 mg/kg/d Peds. Per protocol X w/ renal/hepatic insuff on empty stomach Caution [D, ] Contra Severe hepatic Dz, BM suppression, PRG Disp Tabs SE Mild hematotox, mucositis, stomatitis, D rash, fever, eosinophilia, jaundice. Hep Interactions T Effects W/ allopurinol T risk of BM suppression W/ trimethoprim-sulfamethoxazole X effects OF warfarin EMS May falsely T glucose OD May cause NA and liver necrosis symptomatic and supportive Meropenem (Merrem) [Antibiotic/Carbapenem] Uses lntra-abd Infxns, bacterial meningitis Action Carbapenem X cell wall synth, a [3-lactam Dose Adults. 1 to 2 g IV q8h Peds. >3 mo, <50 kg 10-40 mg/kg IV q 8h in renal insuff Caution [B, ] Contra [3-Lactam sensitivity Disp Inj 500 mg, 1 g SE Less Sz potential than imipenem D, thrombocytopenia Interactions T Effects W/ probenecid EMS Monitor for signs of electrolyte disturbances and... 

Flucytosine (5-fluorocytosine) is metabolised in the fungal cell to 5-fluorouracil which inhibits nucleic acid synthesis. It is weU absorbed from the gut, penetrates effectively into tissues and almost all is excreted unchanged in the urine (t) 4 h). The dose should be reduced for patients with impaired renal function, and the plasma concentration should be monitored. The drug is well tolerated when renal function is normal. Candida albicans rapidly becomes resistant to flucytosine which ought not to be used alone it may be combined with amphotericin (see Table 14.2) but this increases the risk of adverse effects (leucopenia, thrombocytopenia, enterocolitis) and it is reserved for serious infections where the risk-benefit balance is favourable (e.g. Cryptococcus neoformans meningitis). 

Imipenem is a more common cause of seizures than other beta-lactam antibiotics, particularly when high doses are given (13-15). In one study, seven of 21 children developed seizure activity while receiving imipenem + cilastatin for bacterial meningitis, a recognized risk factor (13). However, computer-assisted monitoring of imipenem + cilastatin dosages in relation to renal function resulted in a reduced incidence of seizures (16). 

Ceftriaxone and vancomycin are the agents of choice to treat presumed pneumococcal meningitis empirically until the susceptibility is known. Penicillin may be used for drug-susceptible isolates with MICs of 0.06 mg/L or less, but for intermediate isolates, ceftriaxone is used, and for highly drug resistant isolates, a combination of ceftriaxone and vancomycin should be used. Vancomycin should not be used as monotherapy. In especially severe cases, therapeutic drug monitoring of the CSF and possibly even direct antibiotic instillation may be necessary. 

CSF cultures may remain positive for several days or more with a regimen that eventually will be curative. Therapeutic efficacy can be monitored through bacterial colony counts every 2 or 3 days, which should decrease progressively over the period of therapy. Therapy for gram-negative meningitis should be continued for a minimum of 21 days from the start of treatment. ... 

THERAPEUTIC USES Vancomycin (vancocin, others) is marketed for intravenous use as a sterile powder. It should be diluted and infused over at least 60 minutes to avoid infusion-related adverse reactions. The usual dose of vancomycin for adults is 30 mg/kg/day in 2-3 divided doses. A trough serum concentration of 5-15 (Xg/mL (10-20 (Xg/mL for serious infections such as endocarditis or meningitis) is recommended. Doses above 30 mg/kg/day may be required to achieve these trough concentrations, and up to 60 mg/kg/day has been suggested for meningitis. The peak concentration is not monitored routinely but should generally remain below 60 (Xg/mL to avoid ototoxicity. 

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