PROTOCOL

diagnosis and treatment of serous meningitis

Code MKH-10

G 02.0 Meningitis in viral diseases

Meningitis (caused by a virus):

Enteroviral (A 87.0 +)

Mumps (B 26.1+)

Herpes simplex (B00.3+)

Chickenpox (V01.0+)

Herpes zoster (V 02.1+)

Adenovirus (A 87.1+)

Corey (V 05.1+)

Rubella (In 06.0+)

Infectious mononucleosis (B 27.-+)

G 03.0 Nonpyogenic meningitis (nonbacterial)

DIAGNOSTIC CRITERIA

Clinical:

General infectious syndrome:

its clinical manifestations mainly depend on the nature and properties of pathogens

increase in body temperature up to 38-39.5 ° C

severe headache, dizziness

• adynamia

Meningeal Syndrome:

in 10-15% of patients it may be absent in the presence of inflammatory changes in the cerebrospinal fluid

dissociation of the meningeal symptom complex is often detected, some symptoms may be absent

meningeal symptoms - stiff neck and upper symptom of Brudzinski. Often there is visual and tactile hyperesthesia

hydrocephalic-hypertensive syndrome - headache, repeated, sometimes repeated vomiting, which is not associated with food intake

Additional clinical criteria:

With enteroviral meningitis: catarrhal phenomena in the oropharynx, herpangina, pain in skeletal muscles (pleurodynia); polymorphic exanthema; diarrhea syndrome; spring and summer seasonality.

With adenovirus meningitis: catarrhal phenomena in the form of nasal congestion, runny nose, cough, changes in the oropharynx, eye damage (conjunctivitis, scleritis); lymphadenopathy, mesadenitis, diarrhea.

With mumps meningitis: an increase in the parotid salivary glands (submandibular, chin) at the present time or a few days ago; hyperemic, edematous duct of the salivary gland on the buccal mucosa (Murson's symptom); abdominal pain, pancreatitis; lack of vaccinations against mumps.

Paraclinical research

Complete blood count - moderate leukopenia, sometimes a slight lymphocytosis, a shift of the formula to the left, ESR is normal.

CSF analysis - pleocytosis within a few tens to hundreds of lymphocytes, the protein content is normal or slightly increased (0.4-1 g / l), the glucose level is normal, with the exception of tuberculous meningitis, in which a decrease in glucose content is a pathognomonic sign.

PCR of cerebrospinal fluid and blood - the presence of the nucleic acid of the pathogen.

Virological studies of blood, cerebrospinal fluid - isolation of the pathogen from the blood, cerebrospinal fluid by the method of infection of laboratory animals or tissue culture.

Bacteriological cultures of cerebrospinal fluid, blood, mucus from the nasopharynx, by inoculation on nutrient selective media - to isolate the pathogen.

Serological methods of RNGA, RSK, RN in order to detect specific antibodies and increase their titer by 4 or more times; RIF, ELISA to determine the viral antigen.

Etiotropic therapy. In meningitis caused by the herpes simplex virus, chicken pox, herpes zoster, the appointment of acyclovir or its derivatives in a single dose of 10-15 mg / kg 3 times a day, for 5-7 days intravenously is indicated.

Mode. Strict pastel regime to improve the general condition, lower body temperature, improve liquor, an average of 7-10 days. After that - semi-bed rest for 5-7 days, followed by a free regimen.

Nutrition. For children of the first year after stabilization of hemodynamics - expressed milk or adapted milk mixtures with a decrease in the amount of food on the first day to 1/2-1/3 of the age norm, followed by an increase to the norm for 2-3 days. In case of violation of swallowing - food through a tube.

For older children - a diet with the use of steam food 5-6 times a day, fractionally, in small portions - table number 5 according to Pevzner.

The drinking regimen meets the daily need for liquid, taking into account solutions administered intravenously - juices, fruit drinks, mineral water.

pathogenic therapy.

Dehydration (in the presence of hypertensive-hydrocephalic syndrome): a solution of magnesium sulfate 25% intramuscularly; furosemide 1% intravenously or intramuscularly 1-3 mg/kg, acetazolamide by mouth.

Detoxification. With moderate severity, enteral fluid intake in the amount of physiological daily requirement can be dispensed with.

In severe cases, the volume of intravenous infusion on the first day should not exceed 1/2 of the physiological need. The total daily volume of fluid is 2/3 of the FP, subject to normal diuresis and the absence of dehydration. From the second day, maintain a zero water balance, provide diuresis in an amount not less than 2/3 of the total volume of the liquid received.

General approaches to diagnostics.
Diagnosis of meningococcal infection is made by collecting anamnesis, detailed clarification of complaints, clinical examination, additional (laboratory and instrumental) examination methods and is aimed at determining the clinical form, severity of the condition, identifying complications and indications for treatment, as well as identifying factors in the anamnesis that prevent immediate initiation of treatment or requiring correction of treatment. These factors can be:
the presence of intolerance to drugs and materials used at this stage of treatment;
inadequate psycho-emotional state of the patient before treatment;
a life-threatening acute condition/disease or an exacerbation of a chronic disease requiring the involvement of a specialist in the profile of the condition/disease for prescribing treatment;
refusal of treatment.
2.1 Complaints and anamnesis.
MI can occur in various forms with a combination of certain syndromes.
(Appendix D2). The threat is represented by generalized forms, due to the high risk of life-threatening complications (Appendix D3-D6, D9).
For the timely identification of children at risk for the development of GMI, it is recommended, when collecting an anamnesis, to clarify the fact of possible contact with patients with meningococcal infection (carriers of meningococcus).

Comment. Possible contacts in the family, in the close environment of the sick person, facts of stay or close contact with people who visited regions in regions with a high incidence of MI (countries of the "meningitis belt" of Subequatorial Africa; Saudi Arabia) are specified. .
It is recommended to focus on complaints indicating a high risk of developing GMI, which include:
persistent febrile fever;
headache,.
photophobia,.
hyperesthesia.
vomiting (profuse regurgitation in children under 1 year old).
dizziness,.
rapid breathing.
heart palpitations,.
drowsiness,.
unmotivated excitement.
refusal to eat.
reduced fluid intake (more than 50% of normal intake within 24 hours - for children under 1 year old),.
monotonous / shrill cry (for children under one year old),.
change in color and temperature of the skin.
leg pain.
rash,.
decreased diuresis.
Level of persuasiveness of recommendations B (level of evidence - 2+).
Comment. GMI is characterized by a sharp rise in temperature to high numbers (38.5-40 ° C and above); a 2-hump character of the temperature curve is often noted - on the first rise in temperature, a short-term effect on the antipyretics used is noted, with a second rise (after 2-6 hours) - the introduction of antipyretics has no effect. A similar nature of the temperature curve is observed not only with HMI, but also with other severe infections occurring with sepsis syndrome, with viral and bacterial neuroinfections (encephalitis, meningitis).
The presence of hyperesthesia in young children m. B. Suspected with the so-called "mother's hands" symptom: when the mother complains that the child begins to worry sharply when trying to take him in her arms.
In the structure of the general infectious syndrome, complaints of diffuse and local muscle and joint pains are often noted, however, it is complaints of intense pain in the legs and abdomen (in the absence of manifestations of intestinal infection and the presence of surgical pathology) that refer to the symptoms of the so-called "red flags" in case of clinical diagnosis of sepsis, m. B. Signs of developing septic shock. .
In the presence of a rash, it is recommended to specify the time of appearance of the first elements, their nature, localization, dynamics of changes. The presence of a hemorrhagic rash is pathognomonic for HMI, however, in most cases, the appearance of hemorrhagic elements is preceded by a roseolous or roseolous-papular rash (so-called Rash-rash), the elements of which can be located on different parts of the body and are often regarded as allergic manifestations. The appearance of a widespread hemorrhagic rash without a previous rash within a few hours of the onset of the disease, as a rule, indicates the extreme severity of the disease. .
It is necessary to clarify the features of diuresis: the time of the last urination (in infants - the last change of diapers). Decrease / absence of diuresis (more than 6 hours in children of the 1st year of life, more than 8 hours in patients older than a year) may be signs of the development of septic shock. .

2.2 Physical examination.

An objective physical examination is recommended to actively identify signs of HMI and related complications. The presence of GMI should be assumed when identifying:
hemorrhagic rash that does not disappear with pressure.
hyper/hypothermia.
increasing the capillary filling time by 2 seconds,.
changes in the color of the skin (marbling, acrocyanosis, diffuse cyanosis).
hypothermia of the distal extremities.
changes in the level of consciousness.
meningeal symptoms.
hyperesthesia.
tachypnea/dyspnea.
tachycardia.
decrease in blood pressure.
decrease in diuresis.
an increase in the Algover shock index (normal: heart rate / blood pressure systolic = 0.54).
Strength of recommendation C (level of evidence -3).
Comment. In the debut of GMI, excitation can be observed, followed by depression from somnolence to deep coma. The degree of impairment of consciousness is assessed on the Glasgow coma scale, where 15 points corresponds to clear consciousness, a level of 3 points or less corresponds to transcendental coma (Appendix D10).
A certain help in assessing the severity of the patient's condition is the presence / absence of clinical signs of a systemic inflammatory response (SIVR) with the determination of the level of blood pressure, frequency and quality of the pulse, respiration. Identification of 2 or more signs of SIRS is associated with a high risk of severe bacterial (not only meningococcal) infection. Threshold diagnostic values ​​of SSVR depending on age are presented in Appendix D4. .
The presence of pathological types of respiration is detected in the extreme severity of the course of HMI in cases of the development of a dislocation syndrome against the background of BT or in the terminal stage of the disease complicated by refractory septic shock.
The most typical hemorrhagic rash in the form of irregularly shaped elements, dense to the touch, protruding above the level of the skin. The number of elements of the rash is very different - from single to covering the entire surface of the body. Most often, the rash is localized on the buttocks, back of the thighs and legs; less often - on the face and sclera, and usually in severe forms of the disease. Roseolous and roseolous-papular elements of the previous rach-rash (observed in 50-80% of cases of GMI) quickly disappear, leaving no traces within 1-2 days from the moment of appearance. Signs of impaired microcirculation are pallor, cyanosis, marble pattern of the skin, hypothermia of the distal extremities. .
In the first hours from the onset of the disease, meningeal symptoms can be negative even with mixed forms and isolated MM, the maximum severity of meningeal symptoms is observed on days 2-3. Infants are characterized by dissociation of meningeal symptoms; for the first year of life, the most informative symptoms are persistent bulging and increased pulsation of the large fontanel and stiff neck. .

2.3 Laboratory diagnostics.

All patients with suspected MI are recommended to have a clinical blood test with a leukocyte count.
Recommendation strength level C (level of evidence - 3).
Comments. The detection of leukopenia or leukocytosis in the leukocyte formula, which are beyond the age reference values ​​according to the table (Appendix D4), may indicate the presence of a systemic inflammatory reaction characteristic of HMI.
All patients with suspected HMI are recommended to study a general urine test; blood biochemical parameters: urea, creatinine, alanine aminotransferase (ALaT), aspartate aminotransferase (ASaT), blood electrolytes (potassium, sodium), bilirubin, total protein, acid-base balance, lactate levels.

Comments. Changes in the biochemical parameters of blood and urine make it possible to diagnose a specific organ dysfunction, assess the degree of damage and the effectiveness of the therapy. .
It is recommended to determine the CRP and the level of procalcitonin in the blood of all patients with suspected HMI.
Level of persuasiveness of recommendations B (level of evidence - 2++).
Comments. Detection in the blood of an increase in C-reactive protein2 standard deviations from the norm and procalcitonin 2 ng/ml indicates the presence of a systemic inflammatory reaction characteristic of HMI. Evaluation of indicators in dynamics allows you to evaluate the effectiveness of ongoing antibiotic therapy. .
It is recommended to study the parameters of hemostasis in all patients with suspected HMI with the determination of the duration of bleeding, blood clotting time, coagulograms.
Level of persuasiveness of recommendations C (level of evidence - 3).
Comments. For the diagnosis of DIC. The parameters of hemostasis change according to the stages of DIC, the study of the hemostasis system is necessary to assess the effectiveness of the therapy and its correction. .
etiological diagnosis.
Regardless of the form of the disease, bacteriological examination of nasopharyngeal mucus for meningococcus is recommended for all patients with suspected MI.

Comment. Inoculation of meningococcus from the mucous membranes of the nasopharynx allows verifying the etiological diagnosis of nasopharyngitis and establishing the carriage of N. Meningitidis For generalized forms of GMI, in the absence of detection of N. Meningitidis in sterile fluids (blood / cerebrospinal fluid / synovial fluid) cannot be the basis for establishing an etiological diagnosis, however, it is important a factor for the choice of ABT, which should contribute both to the treatment of a systemic disease and the eradication of meningococcus from the mucous membranes of the nasopharynx.
All patients with suspected GMI are recommended bacteriological examination (culture) of blood.

Comments. Isolation and identification of a culture of meningococcus from sterile media of the body (blood, cerebrospinal fluid) is the "gold standard" for the etiological verification of the disease. Blood sampling should be carried out as quickly as possible from the moment the patient enters the hospital until the start of ABT. A blood test is especially important in situations where there are contraindications for CSP. The absence of growth of the pathogen does not exclude meningococcal etiology of the disease, especially when antibiotic therapy is started at the prehospital stage. .
A clinical examination of cerebrospinal fluid is recommended for all patients with suspected mixed HMI or MM.
Level of persuasiveness of recommendations C (level of evidence - 3).
Comments. Cerebrospinal puncture is possible only if there are no contraindications (Appendix D11). Considering the absence of specific meningeal manifestations in young children, CSP is indicated for all patients of the first year of life with HMI. Qualitative characteristics of CSF are assessed (color, transparency), pleocytosis is examined with the determination of the cellular composition, biochemical indicators of protein, glucose, sodium, chloride levels). MM is characterized by the presence of neutrophilic pleocytosis, an increase in protein levels, and a decrease in glucose levels. In the first hours of the disease and during SMP in the later stages, pleocytosis m. B. Mixed, a decrease in glucose levels with an increase in lactate testifies in favor of the bacterial nature of menenitis during differential diagnosis and viral neuroinfections. .
All patients with suspected mixed form of GMI or MM are recommended bacteriological examination (culture) of cerebrospinal fluid.
Strength of recommendation A (level of evidence -1+).
Comments. The study of CSF is possible only in the absence of contraindications (Appendix G11) Isolation of other pathogens from the blood and CSF by the cultural method helps to make a differential diagnosis, verify the etiology of the disease and adjust antimicrobial therapy.
Blood smear microscopy (thick spot) with Gram stain is recommended for patients with suspected GMI.
Level of persuasiveness of recommendations C (level of evidence - 3).
Comments. The detection of characteristic Gram-negative diplococci in a smear serves as a tentative assessment and may be the basis for initiating specific therapy, but the diagnosis of MI is not based on microscopy alone.
For express diagnostics of GMI, it is recommended to carry out the latex agglutination test (RAL) in blood serum and CSF to determine the antigens of the main causative agents of bacterial neuroinfections.
Recommendation strength level C (level of evidence - 3).
Comments. The test systems used in practice for RAL in the diagnosis of bacterial neuroinfections make it possible to detect antigens of meningococci A, B, C, Y / W135, pneumococci, Haemophilus influenzae. The detection of AH of bacterial pathogens in sterile fluids in the presence of a clinical picture of GMI or BGM makes it possible to verify the etiology of the disease with a high degree of probability. False-positive and false-negative results are possible, therefore, in addition to RAL, it is necessary to take into account the results of cultural and molecular methods. In cases of discrepancy between the RAL data and the results of PCR or cultures, preference is given to the latter to verify the etiological diagnosis. .
It is recommended to conduct molecular research methods to identify the causative agent of GMI.
Level of persuasiveness of recommendations B (level of evidence -2+).
Comments. Amplification of nucleic acids of causative agents of bacterial neuroinfection is carried out by using the polymerase chain reaction method. Detection of DNA fragments of meningococcus by PCR in sterile fluids (blood, cerebrospinal fluid, synovial fluid) is sufficient to establish the etiology of the disease. Used in practice, commercial test systems allow you to simultaneously conduct a study for the presence of pneumococcal, hemophilic and meningococcal infections, which allows for differential diagnosis with diseases that have a similar clinical picture, and to choose the optimal antibiotic therapy. .
Criteria for laboratory confirmation of the diagnosis.
It is recommended that a reliable diagnosis of MI be considered cases of typical clinical manifestations of a localized or generalized form of MI in combination with the isolation of a meningococcal culture during bacteriological culture from sterile fluids (blood, cerebrospinal fluid, synovial fluid), or when DNA (PCR) or antigen (RAL) of meningococcus is detected in the blood or CSF.
Level of persuasiveness of recommendations B (level of evidence -2+).
Comment. Inoculation of meningococcus from nasopharyngeal mucus is taken into account for the diagnosis of localized forms of MI (carriage, nasopharyngitis), but is not the basis for the etiological confirmation of the diagnosis of GMI in case of negative results of cultures, RAL, PCR CSF and blood. .
It is recommended to consider cases of the disease with clinical and laboratory manifestations characteristic of GMI with negative results of bacteriological examination as a probable diagnosis of GMI.
Level of persuasiveness of recommendations C (level of evidence - 3).

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2015

Meningococcal infection (A39)

Short description

Recommended by the Expert Council
RSE on REM "Republican Center for Health Development"
Ministry of Health and Social Development of the Republic of Kazakhstan
dated September 15, 2015
Protocol #9

Meningococcal infection- an acute infectious anthroponotic disease caused by the bacteria Neisseria meningitidis, transmitted by airborne droplets and characterized by a wide range of clinical manifestations from nasopharyngitis and meningococcal carriage to generalized forms in the form of purulent meningitis, meningoencephalitis and meningococcemia with damage to various organs and systems.

I. INTRODUCTION

Protocol name: Meningococcal infection in adults.

Protocol code:

ICD-10 code(s):

A39 - Meningococcal infection
A39.0 Meningococcal meningitis
A39.1 - Waterhouse-Friderichsen syndrome (meningococcal adrenal syndrome)
A39.2 - Acute meningococcemia
A39.3 Chronic meningococcemia
A39.4 Meningococcemia, unspecified
A39.5 ​​- Meningococcal heart disease
A39.8 - Other meningococcal infections
A39.9 Meningococcal infection, unspecified

Abbreviations used in the protocol:

ABP - antibacterial drugs

BP - blood pressure

APTT - activated partial thromboplastin time

GP - general practitioner

VR - recalcification time

GHB - gamma-hydroxybutyric acid

DIC - disseminated intravascular coagulation

IVL - artificial lung ventilation

ITSH - infectious-toxic shock

KHF - Crimean hemorrhagic fever

CT - computed tomography

KShchR - acid-base balance

INR - international normalized ratio

MRI - magnetic resonance imaging

ENT - laryngootorhinologist

OARIT - department of anesthesiology and resuscitation and intensive care

In / in - intravenously

V / m - intramuscularly

AKI - acute kidney injury

BCC - volume of circulating blood

PHC - primary health care

PCR - polymerase chain reaction

FFP - fresh frozen plasma

CSF - cerebrospinal fluid

ESR - erythrocyte sedimentation rate

MODS - multiple organ failure syndrome

CVP - central venous pressure

TBI - traumatic brain injury

ECG - electrocardiography

EEG - electroencephalography

Protocol development date: 2015

Protocol Users: general practitioners, general practitioners, infectious disease specialists, neurologists, emergency physicians / paramedics, obstetrician-gynecologists, anesthesiologists-resuscitators.

Note: The following classes of recommendations and levels of evidence are used in this protocol:

Recommendation classes:
Class I - the benefit and effectiveness of the diagnostic method or therapeutic intervention is proven and / or generally recognized
Class II - conflicting evidence and/or differences of opinion about the benefit/effectiveness of treatment
Class IIa - available evidence of benefit/effectiveness of treatment
Class IIb - benefit/effectiveness less convincing
Class III - available evidence or general opinion that treatment is not helpful/effective and in some cases may be harmful

BUT	High-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias whose results can be generalized to an appropriate population.
AT	High-quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias, the results of which can be generalized to the appropriate population .
With	Cohort or case-control or controlled trial without randomization with low risk of bias (+). The results of which can be generalized to the relevant population or RCTs with a very low or low risk of bias (++ or +), the results of which cannot be directly generalized to the appropriate population.
D	Description of a case series or uncontrolled study or expert opinion.
GPP	Best Pharmaceutical Practice.

Classification

Clinical classification

I. According to clinical manifestations(V.I. Pokrovsky, 1965):
Localized Forms:

meningococcal carriage;

Acute nasopharyngitis.

Generalized forms:

Meningococcemia (typical, fulminant or "fulminant" - 90% of deaths, chronic);

Meningitis;

Meningoencephalitis;

Mixed form (meningitis and meningococcemia).

Rare forms of meningococcal infection:

Endocarditis, pneumonia, iridocyclitis, septic arthritis, urethritis.

II. According to the severity of clinical manifestations:

Clinically expressed (typical);

Subclinical form; abortive form (atypical).

III. By severity:

Light;

Medium;

heavy;

Extremely heavy.

IV. According to the course of the disease:

Lightning;

Acute;

lingering;

Chronic.

V. By the presence and absence of complications :

Uncomplicated

Complicated:

Infectious-toxic shock;

DIC;

Acute edema and swelling of the brain;

Acute renal failure.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Basic (mandatory) diagnostic examinations performed at the outpatient level in patients with meningococcal nasopharyngitis, meningococcal carriage and contact persons:

General blood analysis;

Bacteriological examination of a smear from the nasopharynx for meningococcus.

Additional diagnostic examinations performed at the outpatient level: not performed.

The minimum list of examinations that must be carried out when referring to planned hospitalization: not carried out.

Basic (mandatory) diagnostic examinations carried out at the hospital level:

General blood analysis;

General urine analysis;

Biochemical blood test (according to indications: blood electrolytes - potassium, sodium, determination of the level of PO2, PCO2, glucose, creatinine, urea, residual nitrogen);

Coagulogram (according to indications: blood clotting time, activated partial thromboplastin time, prothrombin index or ratio, fibrinogen A, B, ethanol test, thrombin time, plasma heparin tolerance, antithrombin III);

Spinal puncture with CSF analysis (in the presence of general cerebral symptoms and meningeal symptoms);

Bacterioscopic examination of cerebrospinal fluid, blood, smear from the nasopharynx with Gram stain (depending on the clinical form);

Serological blood test (RPHA) to determine the dynamics of the increase in the titer of specific antibodies;

Bacteriological examination of a smear from the nasopharynx, blood, cerebrospinal fluid for meningococcus with the determination of sensitivity to antibiotics (depending on the clinical form);

Measurement of daily diuresis (according to indications).

Additional diagnostic examinations carried out at the hospital level:

Blood culture for sterility (according to indications);

Determination of blood type (according to indications);

Determination of Rh-affiliation (according to indications);

CSF analysis for the presence of arachnoid cells (according to indications);

X-ray of the chest (if pneumonia is suspected);

X-ray of the paranasal sinuses (with suspicion of ENT pathology);

ECG (with pathology of the cardiovascular system);

MRI of the brain (according to indications: for differential diagnosis with a volumetric process in the brain);

CT scan of the brain (according to indications: for differential diagnosis with vascular diseases of the brain);

EEG (according to indications).

Diagnostic measures taken at the stage of emergency medical care:

Collection of complaints and anamnesis of the disease, including epidemiological;

Physical examination (required - determination of meningeal syndrome, measurement of temperature, blood pressure, pulse, examination of the skin for the presence of a rash with an emphasis on typical locations of the rash - buttocks, distal lower extremities, time of last urination, degree of consciousness disorder).

Diagnostic Criteria for Making a Diagnosis

Complaints:

Meningococcal nasopharyngitis:

Nasal congestion;

Dryness and sore throat;

An increase in body temperature up to 38.5 ° C;

Headache;

Brokenness;

Dizziness.

meningococcal meningitis

Headache (excruciating, pressing or bursting nature, not relieved by conventional analgesics);

Increase in body temperature up to 38-40°C, with chills;

Repeated vomiting, not associated with eating, not bringing relief;

Hyperesthesia (photophobia, hyperacusis, hyperosmia, tactile hyperalgesia);

lethargy;

Sleep disturbance.

Meningococcemia(the onset is acute, sudden or against the background of nasopharyngitis):

Sudden increase in body temperature up to 40 ° C with chills;

Headache;

Pain in bones, joints;

Muscle pain;

Feeling of brokenness;

Dizziness;

Hemorrhagic rash on the lower extremities, gluteal regions, trunk (on the first day of illness).

Anamnesis:

Acute onset of the disease against the background of complete health (with generalized forms with an indication of the exact time).

Epidemiological history:

Contact with a patient with fever, rash and catarrh in the last 10 days;

Contact with a meningococcal carrier or a patient with a confirmed diagnosis of Meningococcal infection within the last 10 days;

Frequent visits and prolonged stay in public places (transport, shopping centers, cinemas, etc.);

High-risk groups (schoolchildren, students, military personnel; persons living in dormitories, boarding schools, closed-type institutions; persons from large families; employees of a children's preschool educational organization, orphanage, orphanage, school, boarding school, family members of the sick person, all persons interacting with the patient

Physical examination:

Meningococcal nasopharyngitis:

Nasopharyngitis - nasal congestion, the predominance of inflammatory changes on the back of the pharynx (the mucosa is edematous, brightly hyperemic, with sharply enlarged multiple lymphoid follicles, abundant mucopurulent overlays);

Other parts of the pharynx (tonsils, uvula, palatine arches) may be slightly hyperemic or unchanged;

Subfebrile body temperature

meningococcal meningitis:

Triad of symptoms: fever, headache, vomiting;

Positive meningeal symptoms (after 12-14 hours from the onset of the disease, neck stiffness and / or symptoms of Kernig, Brudzinsky (upper, middle, lower) appear;

Impaired consciousness (with the development of cerebral edema);

Reduction of abdominal, periosteal and tendon reflexes, their unevenness (anisoreflexia) is possible.

Meningococcal meningoencephalitis:

Fever with chills;

Impaired consciousness (deep stupor, psychomotor agitation, often visual or auditory hallucinations);

convulsions;

Positive meningeal symptoms (stiff neck muscles, symptoms of Kernig, Brudzinsky;

Damage to the cranial nerves, cortical disorders - mental disorders, partial or complete amnesia, visual and auditory hallucinations, euphoria or depression;

Persistent focal cerebral symptoms (paresis of facial muscles in the central type, severe anisoreflexia of tendon and periosteal reflexes, severe pathological symptoms, spastic hemi- and paraparesis, less often - paralysis with hyper- or hypoesthesia, coordinating disorders).

Meningococcemia(acute meninococcal sepsis):

Fever up to 40 ° C and above (without pronounced local foci of infection) OR normal / subnormal body temperature (with the development of infectious-toxic shock);

Severe intoxication (arthralgia, myalgia, weakness, headache,

Dizziness);

Hemorrhagic rash (usually on the 1st day of the disease, of various sizes, irregular shape ("star"), protruding above the level of the skin, dense to the touch, may be with elements of necrosis) on the lower extremities, gluteal regions, torso, less often on the upper limbs, face); may be accompanied by severe pain syndrome (simulation of "acute abdomen", etc.), diarrhea;

Paleness of the skin, acrocyanosis;

Hemorrhages in the sclera, conjunctiva, mucous membranes of the nasopharynx;

Other hemorrhagic manifestations: nasal, gastric, uterine bleeding, micro- and macrohematuria, subarachnoid hemorrhages (rarely);

Drowsiness, impaired consciousness;

Decreased blood pressure over 50%, tachycardia

Criteria for the severity of meningococcemia:

Progressive hemodynamic disorders (hypotension, tachycardia);

Decrease in body temperature against the background of an increase in symptoms of intoxication;

Increasing thrombo-hemorrhagic syndrome;

Spread of hemorrhagic rash on the face, neck, upper half of the body;

Bleeding of mucous membranes;

Dyspnea;

Anuria;

Multiple organ failure;

decompensated acidosis;

Leukopenia<4,0 х 109/л на фоне прогрессирования заболевания.

Standard case definition for meningococcal disease(WHO, 2015)

Supposed case:
All diseases characterized by a sudden rise in temperature (more than 38.5 ° C - rectal and more than 38 ° C - axillary) AND one or more of the following signs:

Neck stiffness;

Altered consciousness;

Other meningeal symptoms;

Petechial purple rash.

Probable case: suspected case AND

Turbidity of the cerebrospinal fluid with the number of leukocytes in the cerebrospinal fluid> 1000 cells in 1 µl or in the presence of Gram-negative diplococci in it)

Unfavorable epidemiological situation and / or epidemiological relationship with a confirmed case of the disease

Confirmed case: suspected or probable case AND culture isolation of N. meningitides (or detection of N. meningitides DNA by PCR).

Laboratory research :
General blood analysis: leukocytosis of a neutrophilic nature with a stab shift, an increase in ESR; possible anemia, thrombocytopenia.

General urine analysis: proteinuria, cylindruria, microhematuria (in severe generalized forms as a result of toxic damage to the kidneys).

Blood chemistry: increased levels of creatinine and urea in the blood, hyponatremia, hypokalemia (with the development of AKI).

CSF study:
. color - on the 1st day of illness, the cerebrospinal fluid may be transparent or slightly opalescent, but by the end of the day it becomes cloudy, milky white or yellowish green;
. pressure - the liquid flows out in a jet or frequent drops, the pressure reaches 300-500 mm of water. Art.;
. neutrophilic cytosis up to several thousand in 1 µl or more;
. increase in protein to 1-4.5 g / l (the highest - with the development of meningoencephalitis);
. moderate decrease in sugar and chlorides.

Coagulogram: decrease in prothrombin index, prolongation of prothrombin time, prolongation of APTT, increase in INR.

Gram coloring of cerebrospinal fluid: Identification of Gram-negative diplococci.

Serological blood test(RPHA): an increase in the titer of specific antibodies in dynamics by 4 times or more (diagnostic titer 1:40);

Bacteriological examination of a smear from the nasopharynx: detection of Neisseria meningitidis and sensitivity of the microbe to antibiotics;

Bacteriological blood test: blood culture of Neisseria meningitidis and sensitivity of the microbe to antibiotics;

Bacteriological examination of cerebrospinal fluid: culture of Neisseria meningitidis and sensitivity of the microbe to antibiotics;

PCR smear from the nasopharynx, blood, cerebrospinal fluid: Neisseria meningitides DNA detection.

Table 1- Criteria for assessing the severity of the disease based on the results of laboratory diagnostics:

sign	mild severity	Moderate severity	Severe severity	Very severe (fulminant)
Level of leukocytosis	increased to 12.0-18.0 x109/l	increased to 18.0-25 x109/l	increased more than 18-40.0 x109/l	5.0-15.0 x109/l
platelets	150-180 thousand	80-150 thousand	25-80 thousand	Less than 25 thousand
fibrinogen	6-10 g/l	8-12 g/l	3-12 g/l	Less than 2 g/l
Creatinine	No deviation from the norm	No deviation from the norm	Up to 300 µmol/l	Over 300 µmol/l
PaO2	80-100 mmHg Art.	Less than 80 - 100 mmHg Art.	Less than 60-80 mmHg Art.	Less than 60 mmHg Art.
blood pH	7,35-7,45	7,35-7,45	7,1-7,3	Less than 7.1

Instrumental Research:
. X-ray of the chest organs: signs of pneumonia, pulmonary edema (with the development of non-specific complications);

X-ray of the paranasal sinuses: signs of sinusitis;

CT / MRI of the brain: cerebral edema, signs of meningoencephalitis, dyscirculatory encephalopathy;

ECG: signs of myocarditis, endocarditis;

EEG: assessment of the functional activity of brain cells (when confirming the diagnosis of brain death).

Indications for consultation of narrow specialists:

Consultation of a neurologist: to clarify the nature of the topical CNS lesion, if intracranial complications are suspected, to clarify the diagnosis in doubtful cases, to determine indications for CT / MRI;

Consultation of a neurosurgeon: for differential diagnosis with volumetric brain processes (abscess, epiduritis, tumor, etc.);

Ophthalmologist's consultation: determination of papilledema, craniocerebral insufficiency (examination of the fundus) (according to indications);

Consultation of an otolaryngologist: for differential diagnosis with secondary purulent meningitis in the presence of pathology from the ENT organs, in case of damage to the auditory analyzer (neuritis of the VIII pair of cranial nerves, labyrinthitis);

Consultation with a cardiologist: in the presence of clinical and electrocardiographic signs of severe heart damage (endocarditis, myocarditis, pericarditis);

Consultation of a phthisiatrician: for differential diagnosis with tuberculous meningitis (according to indications);

Consultation of the resuscitator: determination of indications for transfer to the intensive care unit.

Differential Diagnosis

Differential Diagnosis

table 2- Differential diagnosis of meningococcal nasopharyngitis

signs	Meningococcal nasopharyngitis	bird flu	Flu	parainfluenza
Pathogen	Neisseria meningitides	Influenza A virus (H5 N1)	Influenza viruses: 3 serotypes (A, B, C)	Parainfluenza viruses: 5 serotypes (1-5)
Incubation period	2-10 days	1-7 days, on average 3 days	From several hours to 1.5 days	2-7 days, usually 34 days
Start	Acute	Acute	Acute	gradual
Flow	Acute	Acute	Acute	Subacute
Leading clinical syndrome	Intoxication	Intoxication	Intoxication	catarrhal
The severity of intoxication	strong	strong	strong	Weak or moderate
Duration of intoxication	1-3 days	7-12 days	2-5 days	1-3 days
Body temperature	38 °С	38 °С and above	More often than 39 ° C and above, but there may be subfebrile	37-38 ° C, can be stored for a long time
Catarrhal manifestations	Moderately pronounced	Missing	Moderately expressed, join later	Expressed from the first day of the course of the disease. Hoarseness of voice
Rhinitis	Difficulty in nasal breathing, nasal congestion. Serous, purulent discharge in 50% of cases	Is absent	Difficulty in nasal breathing, nasal congestion. Serous, mucous or sanious discharge in 50% of cases	Nasal obstruction, nasal congestion
Cough	Is absent	Expressed	Dry, painful, hoarse, with pain behind the sternum, wet for 3 days, up to 7-10 days. course of the disease	Dry, barking, can persist for a long time (sometimes up to 12-21 days)
Mucosal changes	hyperemia of the mucous membrane, dryness, swelling of the posterior pharyngeal wall with hyperplasia of lymphoid follicles	Missing	The mucous membrane of the pharynx and tonsils is cyanotic, moderately hyperemic; vascular injection	Weak or moderate hyperemia of the pharynx, soft palate, posterior pharyngeal wall
Physical signs of lung damage	Missing	From 2-3 days of the course of the disease	Absent, in the presence of bronchitis - dry scattered rales	Missing
Leading respiratory syndrome	Nasopharyngitis	lower respiratory syndrome	Tracheitis	Laryngitis, false croup is extremely rare
Enlarged lymph nodes	Missing	Missing	Missing	Posterior cervical, less often - axillary lymph nodes are enlarged and moderately painful
Enlargement of the liver and spleen	Missing	Maybe	Missing	Missing
UAC	Leukocytosis, neutrophilic shift to the left, accelerated ESR		Leukopenia or normocytosis, relative lymphomonocytosis, slow ESR	Leukopenia or normocytosis, relative lymphomonocytosis, slow ESR

Table 3- Differential diagnosis of meningococcal meningitis

Symptoms	meningococcal meningitis	Pneumococcal meningitis	Hib meningitis	Tuberculous meningitis
Age	any	any	1-18 years old	any
Epidemiological history	from the center or without features	without features		social factors or contact with a patient, history of pulmonary or extrapulmonary tuberculosis, HIV infection
Premorbid background	nasopharyngitis or no features	pneumonia	pneumonia, ENT pathology, TBI
The onset of the disease	sharp, stormy	acute	acute or gradual	gradual, progressive
Complaints	severe headache, repeated vomiting, fever up to 39-40 C, chills	headache, repeated vomiting, fever up to 39-40 C, chills		headache, fever, chills
Presence of exanthema	in combination with meningoccemia - hemorrhagic rash	with septicemia - a hemorrhagic rash (petechiae) is possible	not typical	not typical
meningeal symptoms	pronounced with an increase in the first hours of the disease	become pronounced from 2-3 days	become pronounced from 2-4 days	moderately pronounced, in dynamics with an increase
Organ lesions	pneumonia, endocarditis, arthritis, iridocyclitis. In case of complication	pneumonia, endocarditis	pneumonia, otitis media, sinusitis, arthritis, conjunctivitis, epiglottitis	specific damage to various organs, tuberculosis of the lymph nodes with hematogenous dissemination

Table 4- Differential diagnosis of meningitis by CSF

CSF indicators	Norm	Purulent meningitis	Viral serous meningitis	Tuberculous meningitis
Pressure, mm of water. Art.	120-180 (or 40-60 drops/min)	Upgraded	Upgraded	Moderately increased
Transparency	Transparent	Turbid	Transparent	Opalescent
Colour	Colorless	whitish, yellowish, greenish	Colorless	Colorless, sometimes xanthochromic
Cytosis, x106/l	2-10	Usually > 1000	Usually< 1000	< 800
Neutrophils, %	3-5	80-100	0-40	10-40
Lymphocytes, %	95-97	0-20	60-100	60-90
Erythrocytes, x106/l	0-30	0-30	0-30	Can be upgraded
Protein, g/l	0,20-0,33	Often > 1.0	Usually< 1,0	0,5-3,3
Glucose, mmol/l	2,50-3,85	Decreased, but usually from the 1st week of illness	Norm or increased	Decreased sharply at 2-3 weeks
fibrin film	Not	Often rough, sac of fibrin	Not	When standing for 24 hours - a delicate "cobweb" film

Table 5- Differential diagnosis of meningococcemia

Characteristics of the rash	Meningococcal infection (meningococcemia)	CHF (hemorrhagic form)	Leptospirosis	Hemorrhagic vasculitis
Frequency of occurrence	100%	Often	30-50%	100%
Appearance date	4-48 hours	3-6 days	2-5 days	In most cases, the first clinical manifestation of the disease
Morphology	Petechiae, ecchymosis, necrosis	Petechiae, purpura, ecchymosis, hematoma	Spotted, maculopapular, petechial	Hemorrhagic, more often petechiae, purpura
abundance	not plentiful, plentiful	not plentiful, plentiful	not plentiful, plentiful	Abundant
Primary localization	Distal limbs, thighs, in severe cases - chest, abdomen, face, neck	Abdomen, lateral surface of the chest, limbs. Hemorrhagic enanthems on mucous membranes.	Trunk, limbs	Symmetrically on the extensor surfaces of the lower extremities (on the legs under the knees, in the area of ​​the feet), buttocks. It is not typical on the face, palms, torso, arms.
Rash metamorphosis	Hemorrhagic, necrosis, ulceration, pigmentation, scarring	Hemorrhagic, from petechiae to purpura and ecchymosis, without necrosis	Hemorrhagic, various sizes, without necrosis, pigmentation	From petechiae to purpura and ecchymosis, pigmentation, with frequent relapses - peeling
Rash monomorphism	Polymorphic	Polymorphic	Polymorphic	Polymorphic

Picture 1- Algorithm for diagnosing meningitis

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Treatment

Treatment Goals:

Prevention of development and relief of complications;

clinical recovery;

CSF sanitation (for meningitis/meningoencephalitis);

Eradication (elimination) of the pathogen.

Treatment tactics

Non-drug treatment:

Bed rest (generalized forms);

Diet - complete, easily digestible food, tube feeding (in the absence of consciousness).

Medical treatment

Medical treatment provided on an outpatient basis:

Treatment of meningococcal nasopharyngitis and meningococcal carriage:
Antibacterial therapy (treatment course 5 days):
Monotherapy with one of the following drugs is recommended:

Chloramphenicol 0.5 g x 4 times a day, by mouth;

Amoxicillin - 0.5 g x 3 times a day, inside;

Ciprofloxacin 500 mg x 2 times a day orally (in the absence of the effect of chloramphenicol and amoxicillin);

Paracetamol- tablets of 0.2 and 0.5 g, rectal suppositories 0.25; 0.3 and 0.5 g (with hyperthermia above 38 ° C);

Rinsing the oropharynx with antiseptic solutions.

Treatment (prophylactic) of contacts (persons who have been in contact with patients with meningococcal infection(without isolation from the collective)): Antibacterial therapy, monotherapy with one of the following drugs is recommended

Rifampicin* 600 mg/day 12 hourly for 2 days;

Ciprofloxacin** 500 mg IM once;

Ceftriaxone 250 mg IM once.

List of essential medicines:
Antibacterial therapy, monotherapy with one of the following drugs is recommended:

Amoxicillin - tablets, 250 mg;

Ciprofloxacin - tablets of 250 mg, 500 mg;

Rifampicin - capsules 300 mg.

List of additional medicines:

Paracetamol - tablets of 0.2 and 0.5 g, rectal suppositories 0.25; 0.3 and 0.5 g.

Chloramphenicol 0.5 g x 4 times a day, by mouth

Amoxicillin - 0.5 g x 3 times a day, by mouth

Ciprofloxacin 500 mg x 2 times a day orally (in the absence of the effect of chloramphenicol and amoxicillin).

Benzylpenicillin sodium salt 300-500 thousand U / kg per day, administered every 4 hours, intramuscularly, intravenously;

Ceftriaxone 2.0-3.0 gr. 2 times a day, administered every 12 hours, intramuscularly, intravenously; (UD - A)

Cefotaxime 2.0 gr., every 6 hours. The highest daily dose of the drug for adults is 12 g. In people with elevated BMI, the daily dose is 18 grams. (UD - A)

With intolerance to β-lactam antibiotics:

Ciprofloxacin 0.2% - 200 mg/100 ml twice daily IV (LE: A)

Reserve drugs in the absence of effect:

Meropenem (for meningitis / meningoencephalitis, 40 mg / kg every 8 hours is prescribed. The maximum daily dose is 6 g every 8 hours). (UD - V)

Chloramphenicol - 100 mg/kg per day IV (no more than 4 g/day) for 1-2 days

With the subsequent appointment of benzylpenicillin sodium salt - 300-500 thousand U / kg per day, every 4 or 6 hours, intramuscularly, intravenously or alternative drugs (see above).

Criteria for stopping antibiotics:

Clinical recovery (normalization of temperature, absence of intoxication and cerebral symptoms);

Normalization of indicators of the general blood test;

CSF sanitation (lymphocytic cytosis in 1 µl less than 100 cells or total cytosis less than 40 cells).

Detoxification therapy in dehydration mode:
Infusion of physiological saline, 10% dextrose solution IV in a volume of 30-40 ml/kg per day under the control of blood glucose and sodium (when determining the volume of infusion, take into account physiological needs, pathological losses, CVP, diuresis; maintain a negative balance in the first 2 days therapy);
Mannitol (15% solution) with furosemide and / or L-lysine aescinate (5-10 ml). (UD - V)

hormone therapy(in order to prevent severe neurological complications, reduce the risk of hearing loss):

Dexamethasone 0.2-0.5 mg / kg (depending on the severity) 2-4 times a day for no more than 3 days (due to a decrease in brain inflammation and a decrease in the permeability of the BBB).

With the subsequent appointment of benzylpenicillin sodium salt - 300 - 500 thousand U / kg per day, every 3-4 hours, intramuscularly, intravenously or alternative drugs (see above).

Criteria for antibiotic withdrawal:
. clinical recovery (normalization of temperature, absence of intoxication and cerebral symptoms, regression of hemorrhagic rash)
. normalization of indicators of the general blood test

TSS treatment:

Restoration of airway patency, if necessary - tracheal intubation and transfer to mechanical ventilation;

Continuous oxygenation by supplying humidified oxygen through a mask or nasal catheter;

Ensuring venous access (catheterization of central/peripheral veins).

The introduction of a catheter into the bladder for a period until the patient is taken out of shock to determine the hourly diuresis in order to correct the therapy;

Monitoring the patient's condition - hemodynamics, respiration, level of consciousness, nature and growth of the rash.

Sequence of administration of drugs for TSS
. The volume of injected solutions (ml) = 30-40 ml * patient's body weight (kg);

Intensive infusion therapy: crystalloid (physiological saline, acesol, lactosol, di- and trisol, etc.) and colloidal (hydroxyethyl starch solutions) solutions are used in a ratio of 2:1.

(!) Fresh frozen plasma is not administered as a starting solution.

Administer hormones at a dose:
with TSS 1 degree - Prednisolone 2-5 mg / kg / day or Hydrocortisone - 12.5 mg / kg / day per day;
with ITSH of the 2nd degree - Prednisolone 10-15 mg / kg / day or Hydrocortisone - 25 mg / kg / day per day;
with TSS 3 degrees - Prednisolone 20 mg / kg / day or Hydrocortisone - 25-50 mg / kg / day per day;

Administer an antibiotic- Chloramphenicol at a dose of 100 mg / kg per day (no more than 2 g / day), every 6-8 hours;

Heparin therapy(every 6 hours):
ITSH 1 degree - 50-100 IU / kg / day;
ITSH 2 degrees - 25-50 IU / kg / day;
ITSH 3 degrees -10-15 units / kg / day.

In the absence of the effect of hormonal therapy, start the introduction of first-order catecholamine - Dopamine with 5-10 mcg / kg / min under the control of blood pressure;
. Correction of metabolic acidosis;
. In the absence of a hemodynamic response to Dopamine (at a dose of 20 mcg / kg / min), start the introduction of Epinephrine / norepinephrine at a dose of 0.05-2 mcg / kg / min;
. Re-introduction of hormones at the same dose - after 30 minutes - with compensated TSS; after 10 minutes - with decompensated ITSH;
. Protease inhibitors - Aprotinin - from 500-1000 ATE (antitrypsin units) / kg (single dose); (Gordox, Kontrykal, Trasilol);
. With stabilization of blood pressure - furosemide 1% - 40-60 mg;
. In the presence of concomitant cerebral edema - mannitol 15% - 400 ml, intravenously; L-lysine aescinat (5-10 ml in 15-50 ml of sodium chloride solution IV drip; maximum dose for adults 25 ml / day); dexamethasone according to the scheme: initial dose 0.2 mg/kg, after 2 hours - 0.1 mg/kg, then every 6 hours during the day - 0.2 mg/kg; further 0.1 mg/kg/day while maintaining signs of cerebral edema;
. Transfusion of FFP, erythrocyte mass. Transfusion of FFP 10-20 ml/kg, erythrocyte mass, if indicated, in accordance with the order of the Ministry of Health of the Republic of Kazakhstan No. 501 dated July 26, 2012 “On approval of the Nomenclature, Rules for the procurement, processing, storage, sale of blood and its components, as well as the Rules for storage, transfusion blood, its components and preparations

Albumin - 10% solution, 20% solution for infusions if indicated according to the order of the Ministry of Health of the Republic of Kazakhstan No. 501 dated July 26, 2012 "On approval of the Nomenclature, Rules for the preparation, processing, storage, sale of blood and its components, as well as Rules for storage, transfusion of blood, its components and preparations.

Systemic hemostatics: Etamzilat 12.5% ​​solution, 2 ml (250 mg) 3-4 times / day. in / in, in / m

Prevention of steroid and stress lesions of the gastrointestinal tract (Famotidine (Kvamatel) 20 mg intravenously x 2 times a day; Controloc 40 mg intravenously x 1 time per day).

Treatment of cerebral edema:
Raised head end.
Adequate lung ventilation and gas exchange (oxygen therapy).
Dehydration therapy:

Infusion therapy in the amount of ½ - ¾ physiological needs. Composition: glucose-salt solutions (with control of blood sugar and plasma sodium);

Osmodiuretics: mannitol (10, 15 and 20%): - 400 ml for 10-20 minutes.

Saluretics: furosemide in doses of 40-60 mg (in severe cases up to 100 mg) 1 time per day; diacarb - tablets 250.0 mg

Angioprotectors and microcirculation correctors: L-lysine aescinate (5-10 ml in 15-50 ml of sodium chloride solution IV drip; maximum dose for adults 25 ml / day);

Corticosteroids:
Dexamethasone according to the scheme: initial dose 0.2 mg/kg, after 2 hours - 0.1 mg/kg, then every 6 hours during the day - 0.2 mg/kg; further 0.1 mg/kg/day while maintaining signs of cerebral edema;

Barbiturates:
10% sodium thiopental solution intramuscularly at 10 mg/kg every 3 hours. Daily dose up to 80 mg/kg.
You should pay attention! Do not use barbiturates for arterial hypotension and unreplenished BCC.

Antihypoxants - sodium oxybutyrate 20% solution at a dose of 50-120 mg / kg (single dose); (UD - D)
Dopamine at a dose of 5-10 mcg / kg / min.

List of Essential Medicines:

Benzylpenicillin sodium salt - powder for solution for intravenous and intramuscular administration in a vial of 1,000,000 IU;

Ceftriaxone - powder for solution for injection for intramuscular and intravenous administration in a 1 g vial;

Cefotaxime - powder for solution for injection for intramuscular and intravenous administration in a 1 g vial;

Chloramphenicol - powder for solution for intravenous and intramuscular administration - 0.5 g, 1.0 g;

Chloramphenicol - tablets 250 mg, 500 mg;

Ciprofloxacin - solution for infusion 0.2%, 200 mg / 100 ml; 1% solution in 10 ml ampoules (concentrate to be diluted); coated tablets 250 mg, 500 mg, 750 mg;

:
Prehospital stage:
Patients with meningococcemia with TSS clinic undergo infusion antishock therapy in the following order (all measures are taken during the patient's transportation to the hospital):

Immediate intravenous administration of 0.9% 800.0 ml of NaCl solution and 400.0 ml of a colloidal solution.

Prednisolone - 90-120 mg intravenously, 15 minutes before the administration of the antibiotic.

Chloramphenicol - 1.0-2.0 g intramuscularly.

Provide humidified oxygen supply.

Other treatments
Other outpatient treatments: None.
Other types of treatment provided at the inpatient level: not available.
Other types of treatment provided at the stage of emergency medical care: not carried out.

Surgical intervention
Surgical intervention provided on an outpatient basis: not performed.

Surgical intervention provided in a hospital setting:

In the presence of deep necrosis with meningococcemia, necrectomy is performed;

In the presence of abscesses and empyema of the brain, a craniotomy is performed to remove the abscess (in the conditions of the neurosurgery department).

Preventive actions:

Isolation of patients;

Frequent ventilation of the room where the patient is located; . wet cleaning indoors;

All persons who communicated with the patient should be subject to medical supervision with daily clinical examination and thermometry, a single bacteriological examination (nasopharyngeal swab);

Persons who have been in contact with patients are given preventive treatment (see above);

During the period of a seasonal rise in the incidence, it is prohibited to hold events with a large crowd of people, the breaks between screenings in cinemas are lengthened;

Vaccination with meningococcal vaccine according to epidemiological indications is carried out when the incidence rises and its level is exceeded (more than 20.0 per 100 thousand population). The order and scheme of immunization are provided for by the instructions for the vaccine.

Further management:

Meninococcosis carriers are admitted to groups with a negative single bacteriological examination result, the material for the study is taken from the nasopharynx 3 days after the end of antibiotic therapy;

Clinical examination of patients who have had a generalized form of meningococcal infection (meningitis, meningoencephalitis) is carried out for 2 years with an examination by a neurologist during the first year of observation 1 time per quarter, then 1 time in 6 months.

Treatment effectiveness indicators:

Clinical indicators:
. persistent normal body temperature;
. relief of meningeal syndrome;
. relief of symptoms of ITS;
. regression of the rash

Laboratory indicators:
. sanitation of liquor: cytosis of less than 100 cells in 1 μl, lymphocytic nature (at least 80% of lymphocytes);
. with a localized form: a single negative result in bacteriological examination of mucus from the nasopharynx, performed 3 days after the end of antibacterial treatment;
. in the generalized form - a double negative result in bacteriological examination of mucus from the nasopharynx 3 days after the end of antibacterial treatment, with an interval of 2 days.

Drugs (active substances) used in the treatment

L-lysine aescinat (L-lysine aescinat)

Human albumin (Albumin human)

Amoxicillin (Amoxicillin)

Aprotinin (Aprotinin)

Acetazolamide (Acetazolamide)

Benzylpenicillin (Benzylpenicillin)

Hydrocortisone (Hydrocortisone)

Hydroxyethyl starch (Hydroxyethyl starch)

Dexamethasone (Dexamethasone)

Dextran (Dextran)

Dextrose (Dextrose)

Diclofenac (Diclofenac)

Dopamine (Dopamine)

Potassium chloride (Potassium chloride)

Calcium chloride (Calcium chloride)

Ketoprofen (Ketoprofen)

Magnesium chloride (Magnesium chloride)

Mannitol (Mannitol)

Meropenem (Meropenem)

Sodium acetate

Sodium bicarbonate (Sodium bicarbonate)

Sodium lactate (Sodium lactate)

Sodium hydroxybutyrate (Sodium hydroxybutyrate)

Sodium chloride (Sodium chloride)

Norepinephrine (Norepinephrine)

Paracetamol (Paracetamol)

Plasma, fresh frozen

Prednisolone (Prednisolone)

Rifampicin (Rifampicin)

Thiopental-sodium (Thiopental sodium)

Famotidine (Famotidine)

Furosemide (Furosemide)

Chloramphenicol (Chloramphenicol)

Cefotaxime (Cefotaxime)

Ceftriaxone (Ceftriaxone)

Ciprofloxacin (Ciprofloxacin)

Epinephrine (Epinephrine)

erythrocyte mass

Etamzilat (Etamsylate)

Groups of drugs according to ATC used in the treatment

Hospitalization

Indications for hospitalization

Indications for planned hospitalization: not carried out.

Indications for emergency hospitalization :

According to clinical indications: generalized forms.

According to epidemiological indications: localized forms.

Acute nasopharyngitis - persons living in dormitories, communal apartments, barracks, other closed institutions; persons from large families; employees of a children's preschool educational organization, an orphanage, an orphanage, a school, a boarding school, family members of the sick person, all persons who communicated with the sick person;
- meningococcal carriers - during the period of epidemiological trouble. Minutes of the meetings of the Expert Council of the RCHD MHSD RK, 2015

1. 1. Yushchuk N.D.; ed. Vengerov Yu.Ya. Infectious diseases: Nat. hand-in / ed. M.: GEOTAR-Media, 2009.-1056 p. 2. Guide to infectious diseases / Ed. - corresponding member RAMS prof. Yu.V. Lobzin - St. Petersburg: Folio, 2000. - 936 p. 3. Infectious Diseases / Edited by S.L. Gorbach, J.G. Barlett, N.R. blacklow. - Lippincott Williams Wilkins. A Wolters Kluwer Company. - Philadelphia, Baltimore, N.Y., London, Buenos Aires, Hong Kong, Sydney, Tokyo. - 2004. - 1000 p. 4. Centers for Disease Control and Prevention. Serogroup Y meningococcal disease - Illinois, Connecticut, and selected areas, Unired States, 1989-1996. //MMWR. – 1996. Vol.45. – P.1010-1013. 5. Order of the First Deputy Chairman of the Agency of the Republic of Kazakhstan for Health Affairs dated 12.06.2001. No. 566 "On measures to improve epidemiological surveillance, prevention and diagnosis of meningococcal infection". 6. Amireev S.A., Bekshin Zh.M., Muminov T.A. Standard definitions of cases and algorithms of measures for infectious diseases. Practical guide, 2nd edition revised. - Almaty, 2014 - 638 p. 7. Karpov I.A., Matveev V.A. Modern technologies for the treatment of meningococcal infection at various stages of medical care. Minsk, 2006. - 12 p. 8 Meningococcal disease. /Washington State Department of Health, 2015, January. – 14 p.m. 9. Managing meningitis epidemics in Africa. A quick reference guide for health authorities and health-care workers. WHO, Revised 2015. - 34 p. 10. Shopaeva G.A., Duisenova A.K., Utaganov B.K. Algorithm for the diagnosis of meningitis of various etiologies. International professional journal "Medicine" No. 12/150 2014 73-76 p.
is absent.

Reviewers:
Kulzhanova Sholpan Adlgazievna - Doctor of Medical Sciences, Professor of the Department of Infectious Diseases and Epidemiology of JSC "Astana Medical University".

Indication of the conditions for revising the protocol: revision of the protocol 3 years after its publication and from the date of its entry into force or in the presence of new methods with a level of evidence.




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And antivirals. If the disease is severe, then resuscitation procedures may be required.

Can meningitis be cured or not? Obviously yes. Next, consider how to treat meningitis.

What to do when discovered?

The course of the disease is often rapid. If you notice one of the symptoms of purulent meningitis, then treatment should begin as soon as possible. The problem can become more global if a person loses consciousness. In this case, it will be very difficult to determine what he feels at the moment. The patient must be taken to the vascular center, where they will do a CT scan and MRI.

Which doctor treats meningitis? If violations are not detected, in this case, the victim will be sent to the hospital. When a patient has a fever, he should be sent to an infectious disease specialist. In no case should you leave him alone at home, since assistance in such situations must be provided immediately.

The appearance of a hemorrhagic rash is a very bad symptom. This suggests that the disease is severe, so the lesion can spread to all organs.

Important! Often, for the treatment of such a disease, they turn to an infectious disease doctor, and if a child has received a lesion, then to a pediatric infectious disease specialist.

Now you know who treats this disease.

Basic principles of meningitis treatment

The main principle of meningitis treatment is timeliness. Treatment of the inflammatory process in the brain is carried out only in a hospital - in this case, the disease begins to develop very rapidly, which, if not treated in time, leads to death. The doctor may prescribe antibiotics and broad-spectrum medications. This choice is due to the fact that it is possible to establish the pathogen when taking cerebrospinal fluid.

Antibiotics are administered intravenously. The activity of antibacterial drugs is determined on an individual basis, but if the main signs have disappeared and the patient's temperature is at a normal level, then antibiotics will be administered for several days in order to consolidate the result.

The next direction is the appointment of steroids. Hormone therapy will help the body cope with the infection and bring the pituitary gland back to normal. Diuretics are used in the treatment, as they relieve swelling. However, it is worth taking into account that all diuretics wash out calcium from the human body. Spinal puncture not only relieves the condition, but also reduces pressure on the brain.

How and how to treat meningitis? There are several methods.

Medical method

The best cure for meningitis is antibiotics. Together with them, antibacterial agents are also prescribed:

• Amikacin (270 rubles).
• Levomycetin succinate (58 p.).
• Meronem (510 rubles).
• Tarivid (300 rubles).
• Abaktal (300 rubles).
• Maximim (395 rubles).
• Oframax (175 rubles).

Among the antipyretics, the following are prescribed:

• Aspinat (85 rubles).
• Maxigan (210 rubles).
• Paracetamol (35 p.).

Corticosteroid drugs include:

• Daxin
• Medrol

All tablet prices are approximate. They may vary depending on the region and area.

Taking herbs and fruits

Advice! Before using any of the recipes, it is important to consult a specialist. In the process of taking alternative medicine, a person is provided with complete peace of mind and is protected from loud sounds.

You can use these methods:

Diet

The doctor should tell you that you need to follow a special diet for such a disease. It will be supported by vitamin balance, metabolism, protein and salt-water balance. Prohibited products include the following:

• Horseradish and mustard.
• beans.
• Hot sauces.
• Buckwheat, barley.
• Whole milk.
• Sweet dough.

exercise therapy

General strengthening exercises will help you recover faster and return to your usual rhythm of life. But you need to resort to exercise therapy only with the permission of the doctor - you do not need to make decisions on your own.

Physiotherapy

Physiotherapy includes taking such means:

• Immunostimulating.
• Sedative.
• Tonic.
• Ion-correcting.
• Diuretic.
• Enzyme stimulating.
• Hypocoagulants.
• Vasodilator.

When is an operation needed?

Surgery is needed if meningitis is severe. Indications for surgical intervention are as follows:

• Sudden increase in blood pressure and heart rate.
• Increased dyspnea and pulmonary edema.
• Respiratory paralysis.

Is it possible to get rid of at home?

Can it be treated at home? You can treat meningitis at home only if it is at an early stage.

Also at home, you can restore the health of the patient, providing him with proper care and peace. During this period, a person is given antibiotics, and folk remedies are also used.

It is important to comply with the following conditions:

1. Follow bed rest.
2. Darken the room in which the patient is located.
3. Nutrition should be balanced, and drinking plentiful.

Terms of recovery

How long does it take to treat an illness? It depends on:

• Forms of the disease.
• General condition of the body.
• The time the treatment started.
• individual susceptibility.

REFERENCE! The duration of treatment depends on the form - if it is severe, then more time will be needed to recover.

Possible complications and consequences

They can be represented like this:

• ITSH or DVS. They develop as a result of circulating endotoxin in the blood. All this can lead to bleeding, impaired activity and even death.
• Waterhouse-Frideriksen syndrome. It manifests itself as an insufficiency of the function of the adrenal glands, which produce a number of hormones. All this is accompanied by a decrease in blood pressure.
• Myocardial infarction. This complication occurs in older people.
• Cerebral edema due to intoxication and subsequent wedging of the brain into the spinal canal.
• Deafness as a result of toxic nerve damage.

Read more about the complications and consequences of meningitis in the separate materials of the site.

Timing of follow-up for contact patients?

The observation period for contacts is 10 days. During this time, the patient fully recovers.

Symptoms

All symptoms are conditionally divided into the following:

1. Syndrome of intoxication.
2. Craniocerebral Syndrome.
3. meningeal syndrome.

The first is the syndrome of intoxication. It is caused due to septic lesions and the appearance of infection in the blood. Often sick people are very weak, they get tired quickly. Body temperature rises to 38 degrees. Very often there is a headache, cough, fragility of the joints.

The skin becomes cold and pale, and the appetite is significantly reduced. In the early days, the immune system fights the infection, but after that, you can’t do without the help of a professional doctor. The craniocerebral syndrome is the second.

It develops as a result of intoxication. Infectious agents quickly spread throughout the body and are introduced into the blood. Here they attack cells. Toxins can lead to blood clotting and blood clots. In particular, the medulla is affected.

ATTENTION! Blockage of blood vessels leads to the fact that the metabolism is disturbed, and fluid accumulates in the intercellular space and brain tissues.

Due to edema, different parts of the brain are affected. The center of thermoregulation is affected, and this leads to an increase in body temperature.

Often, the patient is observed vomiting, because the body can not tolerate the smell and taste of food. Progressive cerebral edema increases intracranial pressure. This leads to impaired consciousness and psychomotor agitation. The third syndrome is meningeal.

It is caused by a violation of the circulation of cerebrospinal fluid against the background of intracranial pressure. Fluid and edematous tissue irritates the receptors, the muscles contract, and the patient's movements become abnormal. Meningeal syndrome can manifest itself in this way:

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