At the emergency unit in a local hospital in north London, the inpatient department was consulted to offer services to a 21-year-old female college student who was presenting to the ED department for the third time in one week. For the purpose of patient confidentiality as stipulated by HIPAA, this client will be referred to as patient W. HIPAA’S privacy rule defines that investigators can only acquire a limited amount of data regarding a patient that does not include crucial confidential information such as identification name or medical data entry without prior authorization by the patient for confidentiality and specific security measures (Cohen et al., 2018). During those outpatient visits, she had received a prescription of paracetamol 1g TDS to relieve her headache and a short course of antibiotics.
During this particular visit, when patient W was questioned about her symptoms, she reported having continuous frontal headaches, which had increased in intensity over the past four days and that she had associated fevers and chills. On further inquiry, it was noted that she had experienced one episode of vomiting the day before, and she also had mild neck pain and photophobia. Her travel history was significant in that she had travelled to the western coast of Africa the week before to what she termed as a business visit. She reported not feeling unwell while abroad, other than having a short-lived episode of diarrhoea. No other member of the crew she had travelled with had manifested such symptoms since their return. Her pre-travel vaccinations were up to date except for the fact that she forgot to take the malaria prophylaxis. Patient W had no noteworthy medical illness, was not on any regular medications, and she was not a habitual smoker or drinker.
On general examination, patient W appeared anxious, unwell though oriented in time, place and person. Her vital signs were: temperature of 38.4°C, blood pressure of 110/72 mm Hg, pulse 104 bpm and oxygen saturation of 93% on air. On examination of her neurological system, there were prominent, remarkable findings. She had striking photophobia, neck stiffness, and a negative Kernig’s sign. The neurological symptoms exhibited were consistent with a febrile illness as the examination of other body systems was nearly normal.
For an initial evaluation, a lumbar puncture was carried out to analyze the cerebrospinal fluid results to rule out the possibility of meningitis. CSF results were as follows: CSF appeared clear and colourless, no organisms were present on microscopy, the CSF glucose and protein levels were within the reference ranges, and on CSF culture no bacterial growth was apparent. Due to a high index of suspicion for malaria based on the clinical presentation of miss W, coupled with her recent travel to a malaria-endemic zone, the author performed malaria diagnostic tests. However, the rapid diagnostic test was negative, and no malarial parasites were detectable on both thin and thick blood films. Given her normal CSF findings, the initial management entailed the administration of intravenous fluids, analgesia, and antiemetic therapy of which she remained hemodynamically stable, and her symptoms improved within seven days of admission.
Miss W’s case represents a diagnostic dilemma because of the discordance between clinical presentation and the results obtained from the laboratory work-up. Based on Miss W’s clinical presentation, physical examination, and the results from the laboratory work-up, a presumptive diagnosis of meningitis was arrived at with a majority of other possible differentials being eliminated. One would be torn between starting on empirical antibiotic therapy or instead perform further investigations such as radiographic imaging to come up with an appropriate diagnosis. All the same, owing to the high clinical suspicion of meningitis, empirical antimicrobial therapy was imminent because this was the third time she was presenting to the facility with her previously stated complaints. However, in consultation with the emergency and the inpatient team, a decision was reached to further evaluate patient W with the aid of radiographic neuroimaging studies.
Further, the team decided to withhold antibiotic treatment. The CT, MRI, and venogram radiographic studies conducted during the second day of admission showed no evidence of focal neurological disease. The objective of this paper is to critically analyze the therapeutic interventions as they pertain to the patient in reference.
Evidence Base And Critical Justification
Critical justification and support from evidence-based practice will be of great utility in devising the best approach in handling the case of patient W. The standard treatment for miss W at this time would be to start her on empirical antibiotic therapy for meningitis and preferably change the antibiotic regimen once the results of additional laboratory or imaging work-up are out with other institution of adjuvant treatment. Evidence suggests that when there is suspicion of acute bacterial meningitis, a clinician should institute antimicrobial therapy as a first line of management since the disease is an acute emergency and failure of prompt treatment can highly reduce patient survival rate. However, this approach poses a few clinical dilemmas. How effective is the empirical antibiotic treatment in the management of suspected meningitis when there is no apparent predisposing factor that can narrow down the aetiology of the disease? What are the risks associated with empirical antibiotic treatment? What is the role of neuroimaging studies in the confirmation of a diagnosis of meningitis, and how do they determine treatment outcomes?
The Utility Of Neuroimaging Studies
There has been ample discussion on the role of neuroimaging studies in the diagnosis and management of meningitis. Most studies suggest that although a head CT scan or MRI are commonly performed, in the majority of patients, they are deemed unnecessary. This is evident from a retrospective analytic study that was carried out to determine the utility of neuroimaging studies. In this study, among 614 adults diagnosed with meningitis, 66.3% of them had no indication for a head CT scan whereas33.7% did. The group of patients who needed further evaluation using a brain CT scan were those who were older, were more ill, and had significant comorbidities (Salazar & Hasbun, 2017). The CT scans results were statistically significant in that remarkable intracranial abnormalities were noted in 18.1% of those patients whose neuro-imaging had been indicated as compared to only 0.05% in those who had no indication.
Additionally, amongst the cohort group, only eight patients had significant pathologies that impacted heavily on disease management. The retrospective analytic study concluded that the utility of CT in clients with community-acquired meningitis who have no indication for neuro-imaging is limited and it does not heavily impact the management of the disease.
In a randomized control trial to determine the role of imaging in the diagnosis of meningitis and its complications, it was found that MRI is superior to CT scan. The study made a conclusive finding that neuroimaging should be reserved for patients with adverse clinical features and this should not detur the progress of conventional treatment for meningitis (Hughes et al., 2010).
Empirical Treatment Of Meningitis With Antibiotics
Literature suggests that when bacterial meningitis is suspected in patients, empiric therapy should not be withheld by the concern of performing a further diagnostic evaluation. Observational studies suggest that delays in therapy by two and a half to five hours can lead to unfavourable outcomes even though no prospective comparative trials have been carried out to investigate this phenomenon (Smith, 2005). Several factors can lead to a delay in the administration of antibiotics such as cases with an atypical clinical presentation where the cardinal features of meningitis such as fever, altered mental status, and neck stiffness are lacking.
A retrospective study on a cohort group of 189 with presumed bacterial meningitis was carried out to identify the extent to which delay of antibiotic therapy correlated to patient outcomes. The mortality rate in adults amounted to 33% and unfavourable results with neurological sequelae were present in 52% (Bodilsen et al. 2016). The study concluded that there is a significant correlation between delays in the administration of antibiotics and the overall morbidity and mortality from acute bacterial meningitis in the adult population. Further, the odds of unfavourable outcomes per hour of treatment delay can increase by up to 30% (Bodilsen et al., 2016).
In a prospective study at the Netherlands Reference Laboratory for Bacterial Meningitis (NRLBM) to determine the choice of antibiotics in patient with meningitis it was found that on the first day of hospitalization, 44 % of the patients were prescribed amoxicillin and penicillin, 18 % cephalosporin, and 14% a combination of both (van de Beek et al, 2002).
On the flip side, irrational usage of antibiotics can lead to the emergence of microorganisms that are drug-resistant, which can pose treatment challenges in the management of infectious diseases such as community-acquired meningitis in this case. Studies have shown that in about 30% to 50% of patients who require antibiotic therapy; the indication of treatment, the choice of antimicrobial agents, and the duration of antibiotic treatment is often incorrect (Luyt et al., 2014).
A research study to determine the reasons for drug-resistance indicated that causative microorganisms were only defined in 7.6% of 17,435 patients who had been admitted due to pneumonia (Bartlett et al., 2013). Such studies pose a complex clinical question on whether to use antibiotics irrationally and subsequently give rise to resistant organisms versus whether to withhold treatment to pave the way for further diagnostic work-up to unravel the aetiology of the infections that patients suffer.
Treatment Options
In light of the evidence discussed, the author deemed it necessary to institute pharmacological interventions. The patient was therefore started on a 3-day course of ceftriaxone at a dose of 2g intravenously every day to be switched to oral ceftazidime to complete a total of 14 days. The rationale for that choice of antibiotics is that most guidelines recommend third-generation cephalosporins such as ceftriaxone and ceftazidime as first-line treatment in the initial therapy of uncomplicated community‐acquired bacterial meningitis in people aged 18 years and above (Mount & Boyle, 2017). Cephalosporins easily penetrate the blood-brain barrier and reach high therapeutic levels within the CSF hence their choice in meningitis (El Bashir et al., 2003). Cephalosporins also have improved antibacterial spectrum, have favourable pharmacokinetics, and are generally have a large volume of distribution.
Further, cephalosporin agents are cost-effective, safe, and convenient to administer (Fitch et al., 2007). To shed light on the financial costs of these therapeutic agents, they are generally more costly than other antimicrobial agents yet easily available.
The potential organisms that cause meningitis in this age group are also known to be highly sensitive to beta-lactam antibiotics hence the choice of a third-generation cephalosporin (McGill et al., 2016).
The patient was also started on acyclovir at a dose of 650mg intravenously every 8 hours for a duration of 5 days. Literature suggests that acyclovir should be administered in cases where viral meningitis or encephalitis is suspected even though in most circumstances, the latter is self-limiting.
On the other hand, treating meningitis with antibiotics without bacteriological confirmation can result in the occurrence of adverse events and increased susceptibility to antibiotic resistance (Brouwer et al., 2010). Hence, newer agents such as carbapenems, fluoroquinolones, vancomycin, and rifampicin should be considered.
Additionally, Patient W was continued on acetaminophen at a dose of 500mg every 6 hours for a duration of 4 days to reduce the fever and also avert meningeal irritation.
Patient W was additionally started on dexamethasone at a dose of 10mg at intervals of 6 hours for a duration of 4 days. As part of treatment for adults with suspected bacterial meningitis in whom the aetiology has not been derived, it is recommended that intravenous glucocorticoids be administered. Literature studies show that intravenous administration of dexamethasone before or at the time of administering antibiotics has been associated with a reduction in the rate of neurological complications such as hearing loss (Brouwer et al., 2015). Also, in the case that Streptococcus pneumoniae is identified as the causative agent, dexamethasone should be continued as it averts the complications caused by later.
In an observational cohort study conducted in the Netherlands, it was proven that adjunctive treatment with dexamethasone decreased the incidence of mortality due to pneumococcal meningitis mortality by 10% (Brouwer et al., 2010).
On the part of non-pharmacological management, patient W was put in a low stimulus environment preferably in a quiet, dimly lit room to reduce agitation, which can be provoked by the photophobia she was experiencing.
Conclusion
The case of patient W presents the dynamics that can occur in a clinical setting where the decisions made tend to have a significant impact on patient outcomes. In light of this, the evidence-based practice has provided an algorithm where scientific analysis guides clinicians on the management approaches that offer the best treatment outcomes. Evidence-based practice has proven to be of utility in understanding the complexity present in the case scenario of patient W and to further justify and critic the treatment approach additionally. Moving forward, this case scenario serves as a manuscript in emphasizing the need for using comprehensive guidelines that are based on pure evidence to demystify clinical dilemmas and complexities. Ultimately, this will go a long way in ensuring compliance to laid down treatment guidelines and further lead to increased positive treatment outcomes.
