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Zorluk: KolayInfectious Diseases

A 19-year-old college student is admitted to the hospital with a two-day history of fever, severe headache, photophobia, and neck stiffness. On physical examination, the patient is alert but uncomfortable. Temperature is 38.6°C (101.5°F), blood pressure is 118/76 mm Hg, and pulse is 98/min. Nuchal rigidity is present. A lumbar puncture is performed, and empiric intravenous ceftriaxone and vancomycin are initiated. Cerebrospinal fluid (CSF) analysis reveals a leukocyte count of 140/mm³ with 92% lymphocytes, a glucose level of 65 mg/dL (serum glucose 90 mg/dL), and a protein level of 40 mg/dL. Gram stain reveals no organisms. A multiplex polymerase chain reaction (PCR) assay of the CSF is positive for enterovirus and negative for all common bacterial pathogens. Which of the following is the most appropriate next step in this patient's pharmacologic management?

  1. Discontinue all antibacterial therapyCevap
  2. B
    Continue the current antibacterial regimen until 48-hour cultures are negative
  3. C
    Discontinue vancomycin but complete a 7-day course of ceftriaxone
  4. D
    Switch to oral amoxicillin and discharge the patient home
  5. E
    Add intravenous acyclovir to the current antibacterial regimen

Cevap

Discontinue all antibacterial therapy
The patient's clinical presentation and cerebrospinal fluid (CSF) findings (lymphocytic pleocytosis, normal glucose, normal protein) are classic for aseptic meningitis. The definitive diagnosis is established by the multiplex PCR assay, which is highly sensitive and specific, returning positive for enterovirus and negative for bacterial targets. Enteroviruses are the most common cause of viral meningitis. Because the etiology is confirmed to be viral, there is no role for antibacterial therapy. The most appropriate next step is to discontinue the empiric ceftriaxone and vancomycin to adhere to principles of antibiotic stewardship, minimizing the risk of adverse drug reactions, Clostridioides difficile infection, and the development of antimicrobial resistance. Management of enteroviral meningitis is strictly supportive.

Adım Adım Çözüm

1
Analyze the cerebrospinal fluid (CSF) cell count and differential.
The CSF shows a mild pleocytosis (140/mm³) with a strong lymphocyte predominance (92%), alongside normal glucose and normal protein levels.
This pattern is highly characteristic of aseptic (viral) meningitis, distinguishing it from the profound neutrophilic pleocytosis and hypoglycorrhachia typically seen in bacterial meningitis.
2
Interpret the CSF multiplex PCR assay results.
The assay is positive for enterovirus and negative for all common bacterial pathogens.
Multiplex PCR is highly sensitive and specific. A positive result for enterovirus definitively identifies the causative pathogen for the patient's aseptic meningitis.
3
Determine the appropriate pharmacologic intervention based on the definitive diagnosis.
Discontinue the empiric antibacterial agents (ceftriaxone and vancomycin).
Because the infection is definitively viral, antibiotics provide no therapeutic benefit. Their continuation violates antibiotic stewardship principles, increasing the risk of adverse drug events and antimicrobial resistance.

Anahtar Kavram

In patients with suspected meningitis who are empirically started on antibiotics, a definitive diagnosis of viral meningitis via CSF PCR (e.g., enterovirus) should prompt the immediate discontinuation of antibacterial therapy.
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