脑炎与脑膜炎

1、 北京医院 蒋景文lHerpes simplex virus I (HS encephalitis)lHerpes simplex virus II (新生儿HSE, 复发l 性脑膜炎)lJC virus (进行性多灶白质脑病)lCytomegalovirus(CMV 室管膜炎及伴AIDSl 的多神经根病)l结核菌 (结核性脑膜炎)lBorrellia burgdorferi(莱姆病)lTropheryma whippelii(CNS Whipples 病)l致病原 发病率(%)l新生儿新生儿l B族链球菌 60l Escherichia coli, 其他肠道l 格兰氏阴性菌 30l Cand

2、ida albicans 5l Listeria monocytogenes 2l 其他 3l婴儿婴儿l Hemophilus influenzae, type b 60l Neisseria meningitidis 25l Streptococcus pneumoniae 15l致病原 发病率(%)l成人成人l Streptococcus pneumoniae 40l Neisseria meningitidis 30l Escherichia coli, other gram-l negative enteric organisms 10 l Listeria monocytogenes

3、 5l 其他 15lCharacteristic Viral BacteriallOpening pressureNormal or mildly elevated 250 mmR2OlCell count 200-2000 cells/mm3 100 cells/mm3l Lymphocytic pleocytosis Polymorphonuclearl pleocytosislProtein concentration Normal or mildly elevated 45 mg/dllGlucose concentration 40 mg/dl 40 mg/dllCSF: Serum

4、 glucose ratio 0.31 0.31lGrams stain Negative PositivelLactic acid concentration 35 mg/dl 35 mg/dll1.Elevate the head of the bed 30ol2.Hyperventilation to maintain PaCO2 between 25-30 mmHg*l3.Hyperosmolar therapy-mannitoll Loading dose: 1.0 g/kg bolus injectionl Maintenance dose: 0.25-0.5 g/kg every

5、 3-5 h to achieve l serum osmolarity of 295-320 mOsm/literl4.Pentobarbital comal Loading dose: 5-10 mg/kg IV at a rate of 1 mg/kg/minl Maintenance dose: 1-3 mg/kg/h. Titrate dose to achieve l a therapeutic serum concentration of 25-40 g/d1 or al burst-suppression pattern on EEGl*Hyperventilation may

6、 compromise cerebral perfusion resulting in lcerebral isehemia if PaCO2 is lowered below 25 mmHg.l1.细菌性脑膜炎l 包括化脓性脑膜炎、结核性脑膜炎、螺l 旋体感染引起的脑膜炎l2.真菌性脑膜炎l3.支原体脑膜炎l3.病毒性l4.寄生虫性脑膜炎Children l Ceftriaxone(Rocephin)100 mg/kg/day IV in a once or twice daily dosing interval orl Cefotaxime(Claforan) 225 mg/kg/day

7、IV in divided doses every 8 h plusl Vancomycin 40 mg/kg/day IV in divided doses every 6 hlAdults Community- acquiredl Ceftriaxone 2 g IV every 12 h orl Cefotaxime 8-12 g/day IV (in divided doses every 4 h) plusl Vancomycin 2 g/day IV in divided doses every 6 h plusl Ampicillin 12 g/day IV in divided

8、 doses every 4 h when indicatedlNeurosurgical procedurel Ceftriaxone or cefotaxime or ceftazidime(Fortum) 6 g/day IV (for coverage of P aeruginosa) in divided doses every 8 h plusl Gentamicin or tobramycin 1.5 mg/kg every 8 h IV plusl Oxacillin 12 glday IV (in divided doses every 4 h) orl Vancomycin

9、 2 g/day IV (in divided doses every 6 b)lAlcoholisml Cefotaxime or ceftriaxone plusl Vancomycin plusl AmpicillinlDiabetes mellitusl Cefotaxime or ceftnaxone plus VancomycinlNeutropenial Ceftriaxone or cefotaxime or ceftazidime (for P aeruginosa) plusl Vancomycin lOrgan transplant recipient and/or im

10、munosuppressive therapyl Ampicillin plus ceftazidimelCancerl Cefotaxime or ceftriaxone plus Ampicillin plusl Vancomycinl 病原建议治疗时间(日)H. influenzae 7N. meningitidis 7S. Pneumoniae 10-14L. Monocytogenes 14-21Group B streptococci 14-21Gram (-) bacilli(除流感杆菌外) 21lChildl1.Isoniazid 10-15mg/kg/dayl2.Rifamp

11、in 10-20mg/kg/dayl3.Pyrazinamide 20-40mg/kg/dayl4.Sreptomycin 20-40mg/kg/dayl5. Corticosteroidsl6. VP shuntImmunocompetent adultl1. Isoniazid 5mg/kg/day l2. Rifampin 10mg/kg/dayl3. Pyrazinamide15-30mg/kg/dayl4.Pyridoxine 50mg/dayl5. Ethambutol or streptomycinl6. Corticosteroidsl7. VP shunt lImmunosuppressed individuall1. Isoniazid 10-15mg/kg/dayl2. Rifampin 10-15mg/kg/dayl3. Pyrazina