Emergency care and indications for resuscitation
If severe meningococcemia and the threat of infectious-toxic shock (ITS) are suspected, treatment must be initiated immediately. Emergency hospitalization is carried out by intensive care teams.
At the initial examination stage, the following measures are performed:
- A single dose of penicillin is administered immediately.
- In extremely severe cases or when there is a risk of ITS, intravenous administration of chloramphenicol sodium succinate is preferred.
- Additionally, prednisolone is prescribed intravenously at a dose of 0.5–1 mg/kg.
- If signs of meningitis develop, lasix is used (20–40 mg for adults, 1 mg/kg for children).
- Adequate detoxification therapy is a mandatory requirement.
Indications for transfer to the ICU include: development of ITS, coma in severe meningoencephalitis, presence of convulsive syndrome, signs of cerebral edema and brainstem dysfunction.
Etiotropic therapy of generalized forms
In a hospital setting, antibacterial drugs form the basis of treatment.
- Drug of choice: parenteral penicillin. For adults, the daily dose for meningitis reaches 18–24 million IU (calculated as 300,000–500,000 IU per 1 kg of body weight). In severe and complicated forms (ventriculitis, encephalitis, late admission), the dose is increased to 1 million IU/kg/day. The interval between injections must not exceed 4 hours.
- Reserve drugs: chloramphenicol (80–100 mg/kg/day), ciprofloxacin (0.8–1.2 g/day), carbapenems (meropenem), and 3rd-generation cephalosporins (e.g., ceftriaxone up to 4 g/day intravenously).
The duration of the course for meningococcemia without meningitis is 4–5 days, for meningitis 5–10 days, and a prolonged course of up to 14 days is required for ventriculitis. Antibiotics are discontinued only after CSF control (pleocytosis less than 100 cells per 1 µL, lymphocyte predominance of 75–80%).
Pathogenetic and symptomatic treatment
Combating shock and severe toxemia requires a comprehensive approach:
- Detoxification: the forced diuresis method is used. Polyionic solutions, blood substitutes, plasma, and serum albumin are administered under strict monitoring of the acid-base and electrolyte balance.
- Glucocorticosteroids: strictly indicated for ITS and cerebral edema. Prednisolone (60–90 mg 2–3 times a day) or dexamethasone (4 mg 6 times a day intravenously) is used.
- Seizure control: phenobarbital, sodium oxybutyrate (100–150 mg/kg/day), and seduxen are prescribed. If ineffective, thiopental or hexenal is used.
- Tactics for acute kidney injury (AKI): the patient is switched to a minimal fluid regimen, potassium intake is restricted, and the doses of renally excreted drugs are adjusted. A glucose-novocain mixture with aminophylline is administered. If conservative measures fail within 2–3 days, extracorporeal hemodialysis is indicated.
Physical methods (ice packs on the head and major vessels, fan cooling, wiping the skin with menthol alcohol) and antipyretics are used to combat hyperthermia.
Clinical follow-up and focus control
Discharge of convalescents is possible no earlier than 2.5–3 weeks, provided there is complete clinical recovery and cerebrospinal fluid sanitation. After suffering from meningitis or meningoencephalitis, patients are monitored by a neurologist for 2 to 3 years (in the first year after discharge, examinations are carried out every 3 months, then every 6 months).
Medical observation of contacts is established in the epidemic focus for 10 days with the participation of an otolaryngologist. To prevent secondary cases, chemoprophylaxis is administered to all contacts within the next 24 hours. One of the following drugs is prescribed: rifampicin (600 mg for adults every 12 hours for 2 days), ampicillin, or a single dose of ciprofloxacin (500 mg for individuals over 18 years of age). Bacteriological screening is organized to identify asymptomatic carriers.
Briefly: answers to topical questions
What is the pathogenesis of Waterhouse-Friderichsen syndrome in meningococcemia?
The pathogenesis of Waterhouse-Friderichsen syndrome in meningococcemia is associated with thrombohemorrhagic syndrome and adrenal damage.
In meningococcemia, the basis of pathogenesis is thrombohemorrhagic syndrome: thrombi are detected in small vessels, and hemorrhages and microthromboses are found in internal organs. In the adrenal glands, total or subtotal hemorrhages with necrosis of the cortical and medullar layers occur in the majority of cases. Acute adrenal insufficiency in meningococcemia is referred to as Waterhouse-Friderichsen syndrome.
What characteristic rashes and clinical symptoms are observed in Waterhouse-Friderichsen syndrome?
Waterhouse-Friderichsen syndrome is classified as a severe complication of fulminant meningococcemia; therefore, the clinical description includes manifestations of fulminant meningococcemia and acute adrenal insufficiency.
Fulminant meningococcemia is characterized by:
- early rash — 6–12 hours from disease onset; elements tend to coalesce, present as ecchymoses, possible localization on the face;
- hemorrhagic rashes in meningococcemia: petechiae or large hemorrhages of irregular 'stellate' shape, often with central necrosis;
- hyperacute onset, chills, hyperthermia up to 40–41 °C, algesia, rapid impairment of consciousness;
- early appearance and rapid escalation of symptoms of infectious-toxic shock;
- pronounced DIC syndrome with hemorrhages, bleeding, and hematuria;
- microcirculation disorders with possible formation of deep necrosis and gangrene.
Sources indicate decreased blood pressure, hypothermia, and total metabolic disturbance for acute adrenal insufficiency.
To memorize emergency drugs for the threat of ITS, use the 'P-L-P' rule: Penicillin (or Chloramphenicol in shock) + Prednisolone.
Class and exam questions
When can antibiotics be discontinued in the treatment of the generalized form?
Discontinuation is possible when CSF normalizes: a decrease in pleocytosis to less than 100 cells per 1 µL and a lymphocyte count of at least 75–80%.
What antibiotics are used for the chemoprophylaxis of contacts?
Within the first 24 hours, contacts are prescribed rifampicin, ampicillin, or ciprofloxacin in prophylactic dosages (e.g., ciprofloxacin 500 mg once for adults).
What to do in case of acute kidney injury (AKI)?
The patient is switched to a minimal fluid regimen, medication doses are reduced, and potassium intake is restricted. If conservative therapy is ineffective for more than 2–3 days, hemodialysis is prescribed.
What else to study on this topic
- Treatment of nasopharyngitis in meningococcal infection
- Differential diagnosis with tick-borne spotted fevers
- Features of the course of hemorrhagic fever with renal syndrome (HFRS)
- Prevention of pneumonia in severe meningoencephalitis
- Indications for parenteral and tube feeding in impaired consciousness
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