()

1. ,

2. ,
:

.
.
1
2
3
4
5
6


. :
1.
- Plasmodium falciparum
- Trypanosoma
- Toxaplasme

2.

- Cryptococcus neoformans
- Candida albicans

3.
4.


3. ,
:

- N. meningitis
- S. pneumoniae
- H. influenzae
- Listeria monocytogenes
- : staphylococcus, Gram(-) ,

1.

2.

, ,
, , ,
,
: ,
:
:

,

:
- Enterovirus (Coxsackie, Echo)
-
- : Herpes, , CMV, LCM

2.

:
(19% ),
,
,

: ,
, , ,
, ,



mantoux:

: Los 250-500


:
(INH + RIF +PZA +SM
+EMB)

: 3-5 / 100.000 /

1,2 . 135.000 - /

, .
(

<5 >60

(
).

(>94%) Hib
<5
(1990-2003 ,

55%

, ..)

25 1995
1978

15

>60

20% 2001 - 8,6% 1986

Gotschlich EC. Bacterial meningitis: the beginning of the end. Am J



(1998
2003)

.
()

1998
1999
2000
2001
2002
2003

60
97
185
179
135
163

41
50
1
20
58
30

70
259
406
984
276
192

220
206
263
227
235
130

()
&


262

(1998)
N. meningitidis 189 (72,1%)

: 43,7 C: 49,3 : 4,2

W: 1,4 : 1,4 %

S. pneumoniae 19 (7,25%)

H. influenzae type 5 (1,9%)

: 6

:
43
. ()

 (%)
(
, 1995)

H. influenzae

6,66

L. monocytogenes

6,66

Group B streptococci

10

N. meningitidis

20
36,66

S. pneumoniae
0

10

15

20

25

30

35

Schuchat A, et al. Bacterial meningitis in the United States in

40

 BM

,
C5-C9

,
,

(,
)

. ()

, , ,

(
)

, ,
,

,

, ,
.

(IL-1

,
DNA,

,
TNF,
IL-6,
PAF),

,
,

M - Poly

(MMP), . (H2O2,
O-, NO)
(, ,
)

Scheld M, et al. Pathophysiology of Bacterial Meningitis:

Mechanism(s)
of Neuronal Injury The Journal of Infectious

, .

Streptococcus pneumonia
Neisseria meningitidis (A, B, C, Y, W-135)
90%
Gram . (E. coli, P. mirabilis, E.
aerogenes)

Listeria monocytogenes

Haemophilus influenzae b

(1998): C: 49.3% 43.7%,

()
4.2%

(>90%),
(>90%),
(>85%)

(80%)
Bruzinski Kerning (50%)
(35%)
(30%)
(10-


Kerning:

Bruzinski :

: 24

,
, .

3-5

, , .
(100%),

, (>1
.)-,

Jolt

Bruzinski
Kerning
(50%)

, ,
(40%)

(30%)

shunt
.

(15%)
. : III, IV, VI, VII,
VIII (10%)
-

(
)
,

Shock D.I.Coagulation
,

()

CRP (95%)

>18 cm H2 >14 mm Hg

1.000-5.000 / mm3

(.

80%)

100-500 mg% ( >1000

mg%)

<40 mg% ( < 40%

)

(>35mg% >2,8

Mycoplasma, Listeria, Leptospira,

Brucella spp
Borrelia burgdorferi [. Lyme]
Treponema pallidum

(, HSV, arbo)
, .

: . & ,

200-300mmH2O

90-200mmH2O

A.
/ mm3

(%)
(mg%)

1000-5.000
>80
100-500(>1000)

100-1000
<50
100-200

(mg%)

<40

. . ()

Gram

(75-80%)

(85%)

Limulus lysate

gram(-) {
}

>35mg%

. .

>6mEq

<6mEq

 <34 mg%

ENY: <0,23
+
>220 mg%
+

>2.000
/mm3

(Poly

>99%
>1180/mm3)

Spanos A, et al. Differential diagnosis of acute meningitis. An

analysis of the predictive value of initial observation. JAMA

(40-60%)
PCR
, ?
. (. 97%,
. 93% )
. (70%),

(90%)
Gram (60-80%) Ziehl-Nielsen
(<50%)
(50-95%)
PCR (87%),
, TBC

( Latex, )

H. Influenzae
S. pneumoniae
N. meningitidis A, C, Y, W135 N.
meningitidis B
. coli 1
S. agalactiae

: 50%-95% :
Gray LD, Fedorko DP. Laboratory
diagnosis of bacterial meningitis. Clin
95%-100%.
Microbiol Rev 1992;5:130-45

(90%)
Gram (60-80%) Ziehl-Nielsen
(<50%)
(50-95%)
PCR (87%), TBC,

(40-60%)
PCR ,
?
. (.

 K. pneumoniae



(SIADH;)

(DIC;)

, ,
, , ,

C (,
, PCR)

/ , ,
,
CT ( ) / MRI

(
)

..
. . ,


. (, . ,
)

OXI
,

CT

.
.

Gram

Tunkel
AR, Scheld WM. Acute bacterial
Lancet
meningitis.


()
+

+ ;

+; +
>55 .
.

+ + TMPSMX
+ (
;)

British Infection Society, Journal of Infection, 2003, Vol. 46 (2)

The Sanford Guide to Antimicrobial Therapy, 1997
Cohen J. Management of bacterial meningitis in adults. BMJ 2003; 326: 996-997

(
) +

+
Infectious Diseases Society of America, American

Thoracic Society
The Sanford Guide to Antimicrobial Therapy, 2005



Shunt

+ +

+


Gram
.

H. influenzae

. menigitidis

S. pneumoniae
S. agalactiae
E. coli
L.

G
( o
)
+
o
A G
(;+) ;

o
A G

. (CRT>4 sec),
, <90mmHg
<8 >30 - <40
>130
(pH <7,30 BE>-%)
<4.000
(GCS<12
GCS>2
,

,

(10 mgx4 4 )

1.

1.

1.

15-20 min 1

PRSP (

de
Gans J, van de Beek)D. for the European Dexamethasone in Adulthood
Bacterial Meningitis Study Investigators Dexamethasone in adults with
bacterial meningitis. N Engl J Med 2002;347:1549-1556

Morris AM. Review: adjuvant corticosteroid therapy

reduces death, hearing loss, and neurological sequelae
in bacterial meningitis. Evid Based Med 2004; 9: 48-48
Mclntyre P. Should dexamethasone be part of routine therapy of
bacterial meningitis in industrialised countries? Adv Exp Med Biol.
2005;568:189-97.

de Gans, J. et al. N Engl J Med 2002;347:1549-1556

: 7% vs 15% :

()

(5-10 mg ) +

()

30
(0,25-1g / Kg /

h),

(PCO2 27-30
mmHg)



( ):

10-14 : S. pneumoniae
7 (-10) : N. meningitidis H.
influenzae
14-21 : S. agalactiae (
)
> 21 : S. ureus, L.
monocytogenes,
gram .
.

24-48
Quagliarello VJ, Scheld WM. Treatment of bacterial meningitis. N Engl J Med 1997; 336:708 DRSP (MIC>2
16.



2

4

.
Kanegaye JT, et al. Lumbar puncture in pediatric
bacterial meningitis: defining the time interval for
recovery of cerebrospinal fluid pathogens after
parenteral antibiotic pretreatment. Pediatrics


H. influenzae
N. meningitidis
S. pneumonia
Cram

L. monocytogens
S. agalactiae

6(40)
10-13
19-26(50-90)
20-30
22-39
12-30
14-77
10-25%

(>20% >60)

: 30-41% (85%
)

( )
( )

,
, .

(600 mg x2, 2 )
80%-

(500 mg)
(400 mg)
( , p.o.)

(500 mg, , p.o.)

(125-250 mgx1 im) 97%-

(1 24, <14 .)


Hib

<6 ( )
<4

(>2
2 )

( + C - + C+Y+W-135 C)
( 85-95%)

(4-)

C5-C9
(. )
, ()

;
:
>3 <3 >10 .

 HIb

(PRT Hib + - PRP-T, PRP-D, HbOC, PRPOMP -)

2 - 5 (, 1998)

> 5

, . ,

2-11 : 2 3 (2, 4, 6
)
12-48 :1

: 100%



(23- -. 56-81%-, 7-
-.>90%-)

> 65
(2-64 , 23)

, , ,

HIV ,

,

(, ).