� Discharge

A minority of sepsis patients may be discharged. Typically,

these are young, healthy patients without tissue hypoperfusion or end-organ failure who have normalized their vital

signs and have self-limited infections or infections that are

rapidly responsive to antimicrobial therapy. Viral pharyngitis,

strep throat, and pyelonephritis are examples of infections

that often may enable the patient to be discharged to home.

SUGGESTED READING

Booker E. Sepsis, severe sepsis, and septic shock: Current evi ­

dence for Emergency Department management. Emerg Med

Pract. 20 1 1;13:1-24.

Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis

Campaign: International guidelines for management of severe

sepsis and septic shock. Grit Care Med. 2008;36:296-327

[published correction appears in Grit Care Med. 2008;36:1 394-

1396).

]ones AE, Shapiro NI, Trzeciak S, et al. Lactate c learance vs cen ­

tral venous oxygen saturation as goals of early sepsis therapy:

A randomized clinical trial. lAMA. 201 0;303:739-746.

]ui ]. Septic shock. In: Tintinalli JE, Kelen GD, Stapczynski JS,

eds. Tintinalli's Emergency Medicine: A Comprehensive Study

Guide. 7th ed. New York, NY: McGraw-Hill, 20 1 1,

pp. 1 003-1014.

Kumar A, Roberts D, Woods KE, et al. Duration of hypotension

prior to initiation of effective antimicrobial therapy is the

critical determinant of survival in human septic shock. Grit

Care Med. 2006;34:1 589-1 596.

Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy

for the treatment of severe sepsis and septic shock. N Eng! J

Med. 200 1 ;345:1 368-1377.

Society of Critical Care Medicine. Surviving Sepsis Campaign.

www.survivingsepsis.org

Meningitis and

Encephalitis

El izabeth W. Kelly, MD

Michael T. Fitch, MD

Key Points

• The classic triad of meningitis includes fever, neck stiffness, and altered mental status. However, all 3 of these

are present less than half of patients with bacterial

meningitis.

• Patients who are very young, very old, or immunocompromised may present with atypical signs and

symptoms.

• Empiric antibiotics should not be delayed while waiting

for a computed tomography (CT) scan before a lumbar

INTRODUCTION

Bacterial meningitis and viral encephalitis are lifethreatening causes of infection and inflammation within

the central nervous system (CNS). In the early stages of

illness the diagnosis can be very challenging, and evaluation is focused on identifying patients who require urgent

diagnostic testing and treatment.

Until antibiotics became available at the beginning of

the 20th century, bacterial meningitis was nearly 100% fatal.

Morbidity and mortality still remain high even with appropriate treatment. Meningitis affects patients of all ages, but

those at the extremes of age or immunosuppressed are at

increased risk. Accurate diagnosis, timely administration of

antibiotics, and other adjunctive therapies (eg, dexametha ­

sone) are important for patients with suspected bacterial

disease.

Meningitis is an inflammatory process of the membranes that surround the brain and spinal cord. The most

common causative agents of bacterial meningitis are

encapsulated organisms, namely Streptococcus pneumoniae

and Neisseria meningitidis. Listeria monocytogenes more

commonly infects older patients (>50 years old), infants

pu ncture (LP) if meningitis is a likely diagnosis. When a

CT scan is necessary, draw blood cultures and administer

steroids and appropriate antibiotics before the LP.

• Consider the diagnosis of herpes simplex virus encephalitis in patients with focal neurologic findings or altered

mental status and add intravenous acyclovir to the

empiric antimicrobial regimen.

( <3 months old), and immunocompromised or pregnant

individuals. These pathogens often invade the host through

the upper airway by infecting the mucosa and bloodstream

and ultimately cross the blood-brain barrier, entering the

CNS. CNS inoculation can also occur after trauma, surgery,