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Episode 108: INSIGHTS - Meningitis Encephalitis

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Episode 108: INSIGHTS - Meningitis Encephalitis

Contributors

  • Salia Farrokh, Pharm.D., BCPS, BCCCP

    Salia Farrokh, PharmD, BCPS, BCCCP is a neuro ICU clinical pharmacist specialist at Johns Hopkins Hospital. Dr. Farrokh received her PharmD degree from Saint John Fisher College, Wegmans School of Pharmacy in Rochester, NY. Her postgraduate training includes residencies in Critical Care and Pharmacy Practice at Yale-New Haven Hospital. Dr. Farrokh’s research interests include effective antiplatelet therapy in neuro intervention patients, optimal pain management in neuro ICU patients, and use of neurostimulants in this setting. Dr. Farrokh is passionate about training and precepting students and residents and is a certified ENLS trainer.

  • Casey Albin, MD

    Casey Albin, MD is an Assistant Professor at Emory University School of Medicine where she is a member of the department of Neurocritical Care. She completed both her neurology residency and a fellowship in Medical Simulation at Harvard Medical School/BWH/MGH. She completed Neurocritical Care fellowship at Emory. Dr. Albin’s research interests focus on educational innovations in acute neurologic emergencies and neurocritical care. In addition to running simulation courses, she is the editor of a best-selling textbook The Acute Neurology Survival Guide and is passionate about open access neurologic education through Twitter, blogs, and podcasts. She serves on the Education Committee of the Neurocritical Care Foundation.

  1. 00:00:19
    Hi, everyone and welcome back. This is
  2. 00:00:21
    the insights podcast As a reminder
  3. 00:00:24
    insights is a podcast that is based on
  4. 00:00:28
    the wonderful content that's available
  5. 00:00:30
    on on call, an on -call is a
  6. 00:00:33
    continually edited an online textbook
  7. 00:00:37
    that's produced by leaders of Neuro
  8. 00:00:39
    critical care, and is available at
  9. 00:00:41
    Neuro Critical care Dot Org. We really
  10. 00:00:43
    invite you to check it out. These are
  11. 00:00:45
    bit to be short conversation that
  12. 00:00:47
    highlight some of the important and and
  13. 00:00:50
    denote the most critical things you need
  14. 00:00:54
    to know to manage these patients at the
  15. 00:00:56
    bedside, but the chapters are really in
  16. 00:00:58
    depth and they have wonderful tables and
  17. 00:01:00
    charts and we invite you to check them
  18. 00:01:02
    out, and as a reminder this podcast is
  19. 00:01:05
    sponsored by Biogen and Sarah Bell and
  20. 00:01:07
    we are so grateful for this week's
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    sponsor,
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    Faded image and seventy, Biogen is a
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    leading global biotechnology company.
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    That has pioneered multiple breakthrough
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    portfolio of medicines to treat multiple
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    sclerosis, the first approved treatment
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    for spinal muscular atrophy, and to co
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    develop treatments to address a defining
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    pathology of Alzheimer's disease,
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    Biogen is advancing a pipeline of
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    potential novel therapies across
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    neurology, neurosurgery poetry,
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    specialised immunology and rare diseases,
  35. 00:01:43
    and remains acutely focused on its
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    purpose of serving humanity through
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    science while advancing a healthier more
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    sustainable and equitable world.
  39. 00:01:57
    Alright, hazy, see how are you guys.
  40. 00:02:00
    It's good to be back. Awesome. Yes,
  41. 00:02:02
    answer to today, written when talking
  42. 00:02:04
    about Meningitis and the principal ideas,
  43. 00:02:06
    and as we couldn't talk about this,
  44. 00:02:09
    even in chapter, these disease states
  45. 00:02:11
    are not really that common. Although I
  46. 00:02:13
    feel like in Oregon, every label
  47. 00:02:14
    everyone was strange figures then
  48. 00:02:16
    retried to see if this is something we
  49. 00:02:18
    can rule out bites, and I wanted to ask
  50. 00:02:22
    you how you typically assessed these
  51. 00:02:24
    patients. How do you define these
  52. 00:02:25
    disease states? And when do you usually
  53. 00:02:28
    suspect that these patients may have
  54. 00:02:30
    meningitis or encephalitis. Yeah, It's
  55. 00:02:33
    a great question. I think in general
  56. 00:02:36
    that mean these are to really be
  57. 00:02:38
    diagnosed with meningitis or in separate
  58. 00:02:40
    us. It's actually a rare condition,
  59. 00:02:42
    but it is extremely devastating if it is
  60. 00:02:45
    missed, and I think our patient
  61. 00:02:47
    population with a neuro critical care
  62. 00:02:49
    has really enriched in these patients
  63. 00:02:50
    because we take care of patients who've
  64. 00:02:52
    got you know open access to the Csf
  65. 00:02:55
    whether they. trauma, or they've had
  66. 00:02:57
    recent post-operative cases. And so
  67. 00:02:59
    that really enriches our patient
  68. 00:03:01
    population. But I think it's also
  69. 00:03:04
    really important to kind of step back
  70. 00:03:07
    and recognize that a lot of times we're
  71. 00:03:09
    thinking about meningitis and
  72. 00:03:12
    encephalitis. We're really talking
  73. 00:03:14
    about infectious meningitis and
  74. 00:03:16
    encephalitis. But meningitis,
  75. 00:03:18
    technically, is just inflammation of
  76. 00:03:20
    the meninges. And that can happen from
  77. 00:03:22
    a lot of different ideologies And so I
  78. 00:03:24
    think the conversation we're going to
  79. 00:03:26
    have here today is about infectious
  80. 00:03:28
    etiologies and a lot of that acute
  81. 00:03:30
    management. But I really want to
  82. 00:03:32
    emphasize that a patient with a headache
  83. 00:03:37
    and evidence of CNS inflammation, they
  84. 00:03:40
    may have an autoimmune, they may have a
  85. 00:03:42
    systemic cause, they may have
  86. 00:03:44
    left-to-meningial carcinoma ptosis. So
  87. 00:03:45
    just evidence of inflammation of the
  88. 00:03:48
    meninges does not mean that it is
  89. 00:03:49
    infectious. And so I think we really
  90. 00:03:52
    have to keep a bright differential.
  91. 00:03:55
    So again, terminology is important and
  92. 00:03:58
    we should. Also you know, make sure
  93. 00:03:59
    that we're really screaming the drug
  94. 00:04:01
    lists, because chemical meningitis,
  95. 00:04:03
    such as one might see with a severe
  96. 00:04:05
    economic hemorrhage, and that blood
  97. 00:04:07
    causing irritation, or even within a
  98. 00:04:09
    medication like ivy, I, G, All of
  99. 00:04:11
    those are reasons that a patient may
  100. 00:04:13
    have it a really severe headache and
  101. 00:04:15
    evidence of inflammation in the Csf that
  102. 00:04:18
    has nothing to do with an infectious
  103. 00:04:20
    etiology, so, let's drill down,
  104. 00:04:23
    though in terms of thinking about
  105. 00:04:25
    infectious etiologies of meningitis and
  106. 00:04:28
    and we'll start with meningitis and the
  107. 00:04:30
    wave, and I really like to kind of
  108. 00:04:32
    categorize This is by thinking about the
  109. 00:04:34
    host risk factors. I'm nino. When we
  110. 00:04:38
    think about who's going to get
  111. 00:04:40
    meningitis. It's really important to
  112. 00:04:42
    consider. Is this patient
  113. 00:04:44
    immunocompromised? Do they have
  114. 00:04:46
    advanced Hiv? Do they have, and you
  115. 00:04:50
    know at cancer, for which they are on
  116. 00:04:52
    really immunosuppressive chemotherapy or
  117. 00:04:54
    the? Chemotherapy for some other
  118. 00:04:56
    autoimmune condition cause that's really
  119. 00:04:59
    kind of change. What can what
  120. 00:05:01
    etiologies you're thinking up, and I
  121. 00:05:03
    certainly think, especially with our
  122. 00:05:05
    advanced Hiv patient population really
  123. 00:05:07
    making sure that we we exonerate
  124. 00:05:09
    cryptococcal meningitis cause, that is
  125. 00:05:13
    of you know, etiologies of meningitis
  126. 00:05:15
    is one of the more common in one mean
  127. 00:05:17
    munoz oppressed population. I also try
  128. 00:05:20
    to think about weirdest the patient live.
  129. 00:05:23
    Because that really determines their
  130. 00:05:24
    exposures. I'm you know when we think
  131. 00:05:27
    about an types of meningitis. There
  132. 00:05:30
    certainly are regional variability and
  133. 00:05:33
    what infectious theologies are prevalent
  134. 00:05:35
    in what part of the country, and then
  135. 00:05:37
    the time of the year or so summertime is
  136. 00:05:39
    where we see an uptick in both admin,
  137. 00:05:41
    Titus and encephalitis based on just
  138. 00:05:44
    Arba virus transmission, so a lot of
  139. 00:05:46
    these etiologies are caused by arbor
  140. 00:05:48
    viruses, and so it's really important
  141. 00:05:51
    or thinking about you know what. Is
  142. 00:05:54
    this patient likely to have infectious
  143. 00:05:56
    meningitis that it is the summertime and
  144. 00:05:58
    you live in an area where there are a
  145. 00:06:00
    lot of mosquitoes or ticks, then we
  146. 00:06:02
    have to think about you know, take born
  147. 00:06:04
    or mosquito borne etiologies, and then
  148. 00:06:09
    really, this definitely depends on
  149. 00:06:12
    analysis of the Csf and so meningitis,
  150. 00:06:15
    I really think you have to prove that
  151. 00:06:17
    there is inflammation in the si enough
  152. 00:06:20
    space, so you know when we think about
  153. 00:06:23
    certain kind of autoimmune encephalitis,
  154. 00:06:25
    you might actually see sort of a normal
  155. 00:06:28
    Csf, but within our Meningitis patient
  156. 00:06:31
    population, you really normally should
  157. 00:06:32
    see inflammation, and and so this this
  158. 00:06:36
    condition. When you are evaluating a
  159. 00:06:39
    patient at the bedside, you know the
  160. 00:06:41
    classic. You know symptoms are going to
  161. 00:06:44
    be that really severe headache and fever
  162. 00:06:46
    for the infectious etiologies, and then
  163. 00:06:48
    nuchal rigidity, and we think about
  164. 00:06:51
    certain signs, but I don't. It signed
  165. 00:06:53
    because I don't think they're very
  166. 00:06:54
    sensitive, and I really what I clue
  167. 00:06:57
    into is that really extreme headache
  168. 00:07:00
    because the managers are interviewed
  169. 00:07:01
    into their very sensitive. I am, so
  170. 00:07:06
    you know once we have that suspicion.
  171. 00:07:09
    Then I think it is really imperative
  172. 00:07:12
    that we get Csf sampling not only to
  173. 00:07:15
    know what the etiology is, but I'm sure
  174. 00:07:18
    hopefully at some point be able to kind
  175. 00:07:19
    of direct our antibiotic course, and
  176. 00:07:24
    one of the things that often comes up is
  177. 00:07:26
    going to be who needs a C T before they
  178. 00:07:30
    get us an An Lp. And yet the data
  179. 00:07:33
    around this is actually quite poor, and
  180. 00:07:35
    so I wish we could say we have really
  181. 00:07:36
    robust studies that show us. Ah, who
  182. 00:07:39
    need this in it. It's really well valid
  183. 00:07:40
    Id. And that is unfortunately not the
  184. 00:07:42
    case and the tips that people who we
  185. 00:07:46
    know, certainly the immunocompromised
  186. 00:07:47
    patient, Any patient with altered
  187. 00:07:50
    mental status. I mean, at that point,
  188. 00:07:51
    you really must start. Think about
  189. 00:07:53
    increased Aicp and you're thinking about
  190. 00:07:55
    increase. Sep. You need to rule out.
  191. 00:07:56
    This is not a hydrocephalus. Especially
  192. 00:07:59
    in obstructive hydrocephalus picture
  193. 00:08:01
    anyone, and who has popular demand
  194. 00:08:06
    again, It's not so much that papel
  195. 00:08:08
    edema is itself a contra indication for
  196. 00:08:11
    an L P, and begin people with H get Lps
  197. 00:08:13
    all the time, But it's like hey. There
  198. 00:08:16
    is something undiagnosed. It's causing
  199. 00:08:17
    mass effect and it may have been there
  200. 00:08:19
    for awhile, and you really need to make
  201. 00:08:20
    sure that that is not an obstructive
  202. 00:08:22
    mask, and and so immunocompromised age
  203. 00:08:26
    greater than sixty. I have to show up
  204. 00:08:31
    in any sort of you know. Depressed
  205. 00:08:33
    level of consciousness again really
  206. 00:08:35
    important to get imaging. That's gonna
  207. 00:08:37
    end up being a lot of patience, and so
  208. 00:08:39
    I think in most cases these patients are
  209. 00:08:41
    ending up with a head siti before they
  210. 00:08:43
    get into lumbar puncture and the the
  211. 00:08:47
    thing that I always tell people when you
  212. 00:08:49
    are about to do this lumbar puncture,
  213. 00:08:51
    it is. Critical in this situation that
  214. 00:08:54
    you do not forget to measure the opening
  215. 00:08:55
    pressure. Right, We've all been there.
  216. 00:08:57
    You didn't know P. And like you were
  217. 00:08:59
    trying to get fluid and blah, blah,
  218. 00:09:01
    blah, and then all of a sudden you walk
  219. 00:09:03
    out of the room and you did not get the
  220. 00:09:04
    opening pressure. That is not this
  221. 00:09:07
    patient like this patient. You really
  222. 00:09:09
    really a want to get lots of Csf. You
  223. 00:09:12
    know, once you've proven that there is
  224. 00:09:13
    no midline shift that there is no
  225. 00:09:15
    obstructive hydrocephalus. There's no
  226. 00:09:17
    forefront regular mass. If you're
  227. 00:09:19
    feeling like it's safe to do a lumbar
  228. 00:09:22
    puncture. Make sure you get enough of
  229. 00:09:24
    the Csf so that you can send it for all
  230. 00:09:26
    the studies that you are probably going
  231. 00:09:27
    to want to send four, and then please
  232. 00:09:30
    measure the opening pressure. I think
  233. 00:09:31
    one of the things that is the most
  234. 00:09:35
    devastating is that patients with
  235. 00:09:37
    meningitis can develop increase Aicp,
  236. 00:09:40
    and that increase Aicp can be a result
  237. 00:09:44
    of sort of this communicating
  238. 00:09:45
    hydrocephalus where they get you know
  239. 00:09:47
    there I recommend green Galatians almost
  240. 00:09:49
    gunk up with the purulent. up in the
  241. 00:09:52
    inflammation, and therefore, you know,
  242. 00:09:55
    they have this high IC key and herniate.
  243. 00:09:58
    And so I think in a lot of cases, we're
  244. 00:10:01
    doing a disservice by not putting in a
  245. 00:10:03
    CSF diversion. And I think that
  246. 00:10:06
    conversation has really helped when you
  247. 00:10:08
    can say to your neurosurgical colleagues,
  248. 00:10:10
    like, hey, we didn't open pressure and
  249. 00:10:12
    like the CSF just shot over the top of
  250. 00:10:15
    the manometer. I'm really worried this
  251. 00:10:17
    patient is sleepy and they need
  252. 00:10:18
    definitive CSF diversion while we are,
  253. 00:10:21
    you know, giving them antibiotics,
  254. 00:10:23
    giving them steroids.
  255. 00:10:26
    Once you've done that LP, really you're
  256. 00:10:28
    looking at culture data, you're looking
  257. 00:10:29
    at cell counts, and then if you have
  258. 00:10:31
    access to one of the rapid PCR
  259. 00:10:33
    detections, you know, a brand name
  260. 00:10:35
    like BioFire, those can be really
  261. 00:10:38
    extremely helpful because, again,
  262. 00:10:39
    that's not going to be affected at all
  263. 00:10:42
    if you need to get antibiotics on board
  264. 00:10:45
    before you do a lumbar puncture Imaging
  265. 00:10:48
    in this case, you know with the CT.
  266. 00:10:50
    Probably most patients are gonna have
  267. 00:10:52
    that. Imaging with MRI, I tend to
  268. 00:10:55
    defer that until after we have the
  269. 00:10:57
    lumbar puncture. I try to make sure
  270. 00:10:59
    that we are getting the data that's
  271. 00:11:01
    going to direct our antibiotic therapy
  272. 00:11:03
    before we're kind of putting the patient
  273. 00:11:04
    through an MRI. It's gonna show you
  274. 00:11:06
    helpful stuff, but I'm not sure it
  275. 00:11:08
    changes management in the way that the
  276. 00:11:10
    CSF does. So a big
  277. 00:11:14
    worry of all of ours is when we are
  278. 00:11:17
    working these patients up, this is not
  279. 00:11:20
    something we wanted to drag our feet
  280. 00:11:22
    with treating. So Celia, walk us
  281. 00:11:23
    through sort of how do we approach the
  282. 00:11:26
    antibiotic choices, and especially in
  283. 00:11:29
    the difficult situations where patients
  284. 00:11:30
    have allergies to the most commonly used
  285. 00:11:32
    antibiotics?
  286. 00:11:35
    Sure, yes. I kind of wanted to
  287. 00:11:37
    highlight what you said, can you see
  288. 00:11:38
    about the patient? I think knowing
  289. 00:11:41
    about the patient's history can really
  290. 00:11:43
    help you a lot with what are the risk
  291. 00:11:45
    factors, what are you trying to cover,
  292. 00:11:48
    what antimicrobial should you use to
  293. 00:11:50
    actually cover the bugs that you're
  294. 00:11:51
    trying to cover? Before we get to the
  295. 00:11:54
    antimicrobial, a few things also about
  296. 00:11:56
    the LP and all, but I know that
  297. 00:11:58
    everyone wants to get that best LP that
  298. 00:12:01
    you talked about in Champagne and LP and
  299. 00:12:03
    all that. The rule of thumb is though,
  300. 00:12:05
    if you are highly suspicious that
  301. 00:12:07
    someone has meningitis, I know it's
  302. 00:12:09
    best to get the LP and then start an
  303. 00:12:11
    antibiotics that really you don't want
  304. 00:12:13
    to delay antibiotics if the suspicion is
  305. 00:12:16
    really high, because if you're just
  306. 00:12:18
    trying to like do your best and get the
  307. 00:12:20
    best LP in maybe hours and hours. So
  308. 00:12:20
    again, kind of risk versus benefit, if
  309. 00:12:20
    this is high in our differential list,
  310. 00:12:20
    I think
  311. 00:12:27
    everyone would agree that you just have
  312. 00:12:29
    to start treatment and then really not
  313. 00:12:32
    worry about that because this, just
  314. 00:12:34
    like success, every hour of delay could
  315. 00:12:36
    be devastating as we talked about. This
  316. 00:12:39
    is a very devastating disease state.
  317. 00:12:41
    Now, as far as how to treat these
  318. 00:12:43
    patients,
  319. 00:12:45
    Going back to the patient's risk factor,
  320. 00:12:47
    as I think. Typically, what I do and
  321. 00:12:50
    how I categorize these patients as
  322. 00:12:53
    community acquired man died as Vs
  323. 00:12:56
    hospital apartment, enjoy this, and
  324. 00:12:57
    then when you think about community
  325. 00:12:59
    acquired manga is also you have to think
  326. 00:13:01
    about the risk backers with a patient.
  327. 00:13:03
    Right Is this like a twenty year old
  328. 00:13:06
    previously healthy football player who
  329. 00:13:08
    came from like summer camp, and now
  330. 00:13:11
    they have meningitis. His treatment
  331. 00:13:13
    obviously is very different from you
  332. 00:13:15
    know a seventy five year old who came
  333. 00:13:17
    from home, also community, but they
  334. 00:13:19
    have very different kind of risk
  335. 00:13:21
    stratification, so if someone has no
  336. 00:13:24
    risk factors right that, most simply in
  337. 00:13:26
    case of meningitis, he can get as
  338. 00:13:28
    football player to comms, and the rule
  339. 00:13:31
    of thumb is really to cover for an
  340. 00:13:34
    community acquired bugs, and doubts,
  341. 00:13:36
    usually strep pneumonia, and
  342. 00:13:38
    haemophilus Missouri. I'm in
  343. 00:13:40
    indebtedness that as the name suggests,
  344. 00:13:43
    I am for that. Weekly, we do subtracts
  345. 00:13:46
    one in Bingham Isin and I kind of wanted
  346. 00:13:49
    to clarify here that we're not getting
  347. 00:13:51
    Vancomycin for Amara. They were given
  348. 00:13:54
    Vancomycin resistant shirt pneumonia. I
  349. 00:13:57
    have to highlight this because I can't
  350. 00:13:59
    tell you how many times people
  351. 00:14:00
    companions they audit Mars as slot is
  352. 00:14:02
    negative. Can I just not do bank. I
  353. 00:14:04
    dunno know that this is a different
  354. 00:14:07
    indication. Let's keep it until we know
  355. 00:14:09
    we're not dealing with a resistant strep
  356. 00:14:12
    pneumonia, and that's a big thing. I'm
  357. 00:14:13
    very stewart. If I say that we have to
  358. 00:14:15
    depend. We really ought to keep it,
  359. 00:14:19
    and you know the target for high trust,
  360. 00:14:21
    fifteen to twenty eyes, a trough, or
  361. 00:14:23
    vancomycin, our shooting for and all
  362. 00:14:25
    that, and if now you have that seventy
  363. 00:14:28
    five year old, who comes from a
  364. 00:14:30
    community, guess what anyone over fifty
  365. 00:14:33
    or less than two years of age, we have
  366. 00:14:35
    to think about, in addition to
  367. 00:14:36
    everything that we talked about, we
  368. 00:14:38
    have to think about this theory a
  369. 00:14:39
    meningitis, and then be an ampicillin
  370. 00:14:42
    to that combo or combination. It gets a
  371. 00:14:45
    little bit, obviously, tricky if
  372. 00:14:47
    penicillin allergy is a problem or
  373. 00:14:49
    siftraaxin allergy is a problem. My
  374. 00:14:52
    biggest
  375. 00:14:54
    piece of advice is that please
  376. 00:14:56
    investigate to make sure that is really
  377. 00:14:58
    a true reaction. If they receive onset,
  378. 00:15:01
    you know, two days ago, that's not a
  379. 00:15:03
    real reaction. But if you know for sure
  380. 00:15:05
    that they have enough laxes or something
  381. 00:15:08
    is described in the know that makes you
  382. 00:15:10
    really uncomfortable and you really
  383. 00:15:12
    wanna treat them So the way you got
  384. 00:15:14
    lines really talk about is that
  385. 00:15:16
    four-step tracks on which is
  386. 00:15:18
    really intended to treat the stress and,
  387. 00:15:20
    you know, community bugs,
  388. 00:15:24
    usually moxifloxacin is the agent of
  389. 00:15:25
    choice that is led into IDSA guidelines.
  390. 00:15:27
    And that should be pretty, you know,
  391. 00:15:29
    hopefully most patients can tolerate
  392. 00:15:31
    that. But if ambicellin is a problem,
  393. 00:15:34
    meaning that, oh, you wanna cover for
  394. 00:15:36
    listeria and that's the problem, back
  395. 00:15:38
    trim is an alternative in that setting
  396. 00:15:41
    that the patient has a penicillin
  397. 00:15:43
    allergy.
  398. 00:15:45
    The next question that I usually have
  399. 00:15:47
    the kind of deal with it as one route,
  400. 00:15:49
    Dexamethasone Wang, Do the actually
  401. 00:15:51
    think about giving Jackson Memphis on
  402. 00:15:54
    and the literature behind us to be very
  403. 00:15:57
    honest, Isn't that convincing and bite
  404. 00:16:01
    There are studying is looking at
  405. 00:16:03
    efficacy of Dexamethasone in Strep
  406. 00:16:05
    Pneumo infections in adult patients.
  407. 00:16:07
    This is really the focus of his
  408. 00:16:09
    originally an adult, so I'm going to
  409. 00:16:11
    focus on the adult dosing, and all that,
  410. 00:16:14
    so really the only convincing evidence
  411. 00:16:16
    as for Strep Pneumo and that meets
  412. 00:16:19
    typically used eczema, there is one am,
  413. 00:16:22
    and you know, as you can imagine, just
  414. 00:16:25
    is really only for community acquired
  415. 00:16:27
    meningitis, and reducing his point,
  416. 00:16:29
    one five Mc, for Keurig, and every six
  417. 00:16:32
    hours for two to four days, and real
  418. 00:16:35
    guidelines don't want you to continue
  419. 00:16:37
    that exam episode, unless you have
  420. 00:16:39
    strep, Pneumo, bacteremia, or your
  421. 00:16:41
    Csf is growing gram -positive diplock,
  422. 00:16:43
    hawks, I, or anything, really. It is
  423. 00:16:45
    giving you a huge kind of add flag about
  424. 00:16:50
    Strep Pneumo. So really. That's when
  425. 00:16:52
    we add extra matters. One. I have to
  426. 00:16:54
    be honest in our hospital. It's rare
  427. 00:16:56
    for us to give excellent. Has one.
  428. 00:16:57
    It's rare to know what the patient
  429. 00:16:59
    really has. It's rare to state. It's
  430. 00:17:01
    definitely too many appliance.
  431. 00:17:03
    Definitely strep, pneumo. But the idea
  432. 00:17:06
    is that if you want to do it, you have
  433. 00:17:08
    to give it ten or twenty methods before
  434. 00:17:10
    you start your antibiotics, and the
  435. 00:17:12
    idea is that you're really trying to,
  436. 00:17:14
    and and Hebert are minimized as profound
  437. 00:17:16
    inflammatory ones that you're gonna get
  438. 00:17:19
    when you give the antibiotics, because
  439. 00:17:21
    it's going to kill the bacteria in order
  440. 00:17:22
    to give it before the antibiotics, and
  441. 00:17:24
    really give it before and or for when
  442. 00:17:28
    you think that you are dealing with
  443. 00:17:30
    Strep, Pneumo, Kennedy required arm
  444. 00:17:33
    meningitis, so I would say those are
  445. 00:17:35
    really the highlights. Are the clinical
  446. 00:17:37
    pearls for community acquired meningitis.
  447. 00:17:40
    Obviously, your story is a little bit
  448. 00:17:41
    different when we talk about. Start
  449. 00:17:43
    patients are people who just got a new
  450. 00:17:44
    Bd or they were operated on rates. I,
  451. 00:17:47
    I think of those patients, and I think
  452. 00:17:49
    of that being such a different risk
  453. 00:17:51
    factor group, and unfortunately, in
  454. 00:17:53
    our in our setting mean, I think that
  455. 00:17:55
    we probably see more of those patients
  456. 00:17:57
    than we do of the patients who come in
  457. 00:17:59
    off the streets, but the new diagnosis
  458. 00:18:01
    of bacterial meningitis and so walk us
  459. 00:18:04
    through kind of what are the other bugs
  460. 00:18:06
    that we need to consider and cover for
  461. 00:18:08
    if the patients had recent school -based
  462. 00:18:11
    intervention like a T. S A, or they
  463. 00:18:13
    have as skull fracture, Where the note
  464. 00:18:16
    there is you know something that is
  465. 00:18:18
    disrupting the skull base that would
  466. 00:18:19
    make them at higher risk of having movie
  467. 00:18:22
    a typical pathogens.
  468. 00:18:25
    Yeah, absolutely everything goes
  469. 00:18:27
    nowhere like the extreme cases, and
  470. 00:18:30
    barely know what a. What are the cases
  471. 00:18:31
    that are maybe not as extreme everything,
  472. 00:18:34
    and when your house on long drives and
  473. 00:18:36
    are armed with an E V D, or right while
  474. 00:18:39
    gone. Flipping or am very deep kind of
  475. 00:18:42
    manipulations, and then a few days
  476. 00:18:44
    later there are fat row are very altered.
  477. 00:18:48
    Their initial kind of neurological
  478. 00:18:49
    injury is not really explaining what's
  479. 00:18:51
    happening to them. Now. I mean that as
  480. 00:18:54
    a perfect population to think about okay,
  481. 00:18:56
    this could be nosocomial, and then for
  482. 00:18:58
    that really thinking about really big
  483. 00:19:01
    and difficult bugs, and those were you
  484. 00:19:03
    know Pseudomonas comes to mind. Ah am
  485. 00:19:07
    ar re status. You know that comes to
  486. 00:19:08
    mind. As seen it about her. You know
  487. 00:19:11
    other kind of gram negatives enter a
  488. 00:19:13
    backer. Things like that. These are
  489. 00:19:15
    indications that should be pro actively
  490. 00:19:19
    and treated with vancomycin. An sap
  491. 00:19:22
    appeal is typically the agent of choice,
  492. 00:19:24
    Now you, If you have a patient, West
  493. 00:19:26
    made it prior step, If him exposure,
  494. 00:19:28
    or you know, a damn had some assistance,
  495. 00:19:30
    obviously dots the time to think about
  496. 00:19:31
    meat, even, and brought her to
  497. 00:19:33
    antibiotics, such as Meropenem,
  498. 00:19:35
    remember that if you have someone in
  499. 00:19:37
    Bell, pray you have to get developed it
  500. 00:19:39
    off because of the dirt. there are
  501. 00:19:40
    interactions that we talked about. Such
  502. 00:19:42
    a pearl. Such a pearl. Such a pearl.
  503. 00:19:45
    So a couple of things, and honestly,
  504. 00:19:48
    even in that case, I think your CSF
  505. 00:19:50
    analysis should give you a lot of good
  506. 00:19:51
    information of, you know, what is
  507. 00:19:53
    happening. And then, you know,
  508. 00:19:57
    thinking about other, kind of, musical
  509. 00:20:00
    reinfections. If someone comes in, you
  510. 00:20:01
    know, with, let's say, just skull
  511. 00:20:03
    base and a nasal neurosurgical procedure,
  512. 00:20:07
    and we're just suspicious
  513. 00:20:18
    that maybe this is not deep, this is
  514. 00:20:18
    not penetrating, whereas a fracture, I
  515. 00:20:19
    think in those cases, you're probably
  516. 00:20:19
    still thinking about, you know, your
  517. 00:20:21
    strep infections, your hemophilus strap
  518. 00:20:22
    that we talked about, and I think
  519. 00:20:23
    ceteraaxone should be probably enough.
  520. 00:20:25
    Obviously, if you were concerned that
  521. 00:20:28
    because of your patient's risk factors,
  522. 00:20:29
    you have to be broader. That's always a
  523. 00:20:32
    very good idea to actually have them
  524. 00:20:33
    broad, and then narrow them. If, you
  525. 00:20:36
    know, you have ruled out all the other
  526. 00:20:38
    causes, Quarterly data to support your
  527. 00:20:41
    clinical suspicion. I another clinical
  528. 00:20:44
    pearl here cause I see that a lot cetera
  529. 00:20:46
    it's inducing per minute, enjoyed. As
  530. 00:20:48
    is not one gram daily. It is two rams.
  531. 00:20:50
    Cute was just making sure cause that
  532. 00:20:52
    this happens all the time you may get
  533. 00:20:54
    pieces from the D. Near. That's the
  534. 00:20:56
    beauty. I do, saying it's it's just
  535. 00:20:58
    fascinating. How little pearls are
  536. 00:21:00
    little details like that could be really
  537. 00:21:03
    life -saving and suggest making sure
  538. 00:21:05
    that everything that you're using all
  539. 00:21:08
    the medications are really dose for Cns
  540. 00:21:10
    penetration, and usually garner a
  541. 00:21:11
    higher doses now, Obviously, if you
  542. 00:21:14
    have someone with a troop has an allergy.
  543. 00:21:16
    If you have investigated that they have
  544. 00:21:18
    yes and a fox's. Are you have had
  545. 00:21:22
    significant hives and you're really
  546. 00:21:24
    concerned about that, but you have to
  547. 00:21:26
    obviously think about an alternative for
  548. 00:21:28
    yourself if you knew him, and that's a
  549. 00:21:30
    really difficult conversation. At least
  550. 00:21:31
    I can tell you and marionette. The
  551. 00:21:34
    options are, or any I should say in
  552. 00:21:36
    adoptions are after, and almonds the
  553. 00:21:37
    prophylaxis, then, but. Problem in
  554. 00:21:39
    our institutions, Ivy have a very high
  555. 00:21:41
    rate of resistance for Cipro, because a
  556. 00:21:44
    lot of people come in with Kunal one
  557. 00:21:47
    exposure and a community, so these are
  558. 00:21:49
    just some of the conversation to have it,
  559. 00:21:50
    the Id specialists to kind of figure out.
  560. 00:21:53
    Can you be sentenced Desensitize these
  561. 00:21:55
    patients if you have to, just because
  562. 00:21:57
    Cipro, or astronaut, or may not really
  563. 00:21:59
    be the best option for them If they're
  564. 00:22:01
    very sick, and you need a very good
  565. 00:22:03
    anti Tsukamoto antibiotic Yet Sale?
  566. 00:22:06
    What what about Zeus? Can I use Olsen?
  567. 00:22:09
    And unfortunately, you can not Because
  568. 00:22:12
    I lack of good penetration into the Cns
  569. 00:22:15
    rented a brain, and the real idea is
  570. 00:22:18
    that you know pepper to have for
  571. 00:22:19
    personal, and his aback naturally to
  572. 00:22:20
    tease a vacuum component which makes
  573. 00:22:22
    those great doesn't get into the brain
  574. 00:22:24
    that that much so unfortunately you
  575. 00:22:27
    cannot bite in earthly. Have someone
  576. 00:22:29
    who has a different impression. You'll
  577. 00:22:31
    probably a. You can cover you know gram
  578. 00:22:34
    negatives with that engineers accept.
  579. 00:22:37
    In name wishes our topic today, but
  580. 00:22:39
    unfortunately this this antibiotic is
  581. 00:22:42
    out, and that's why we're not talking
  582. 00:22:43
    about it. Right. I think that is a
  583. 00:22:45
    really important pearl. Because they
  584. 00:22:46
    think oftentimes at critical care. You
  585. 00:22:49
    know uses this in quite a lot and it's
  586. 00:22:52
    just really important for any provider
  587. 00:22:55
    out there to recognize that that's a
  588. 00:22:56
    great drug, but it is not going to get
  589. 00:22:58
    you good Cns penetration, And so if if
  590. 00:23:01
    you're really worried about meningitis,
  591. 00:23:03
    this is not this is not the drug for
  592. 00:23:04
    that cool, Alright, Let's move along a
  593. 00:23:07
    little bit and started to think about
  594. 00:23:09
    encephalitis and just sort of the
  595. 00:23:10
    definition again, Encephalitis can have
  596. 00:23:13
    multiple different etiologies. We're
  597. 00:23:15
    going to focus on infections, and but
  598. 00:23:18
    again just like from an entitled, you
  599. 00:23:19
    could have auto immune. You can have
  600. 00:23:22
    para infectious. You could have
  601. 00:23:24
    malignant. You know, there's a very
  602. 00:23:26
    broad differential, but we think about
  603. 00:23:28
    and encephalitis is caused by infectious
  604. 00:23:32
    etiologies were really looking a lot at
  605. 00:23:35
    sort of them. Hsv Vz be West Nile virus
  606. 00:23:40
    as being some of the most common
  607. 00:23:42
    etiologies for patients to have sort of
  608. 00:23:44
    viral encephalitis and of that, I think
  609. 00:23:47
    Hsv is properly one of the most common
  610. 00:23:49
    of this sort of rarer and conditions,
  611. 00:23:52
    and I think it's important for us to
  612. 00:23:55
    recognize that, because it is a
  613. 00:23:56
    treatable cause for a lot of these other
  614. 00:24:00
    etiologies, you know the treatment may
  615. 00:24:01
    not be as if ethic, efficacious,
  616. 00:24:04
    Whereas Hsv we have really good data
  617. 00:24:07
    that a cycle of year can treat, and we
  618. 00:24:10
    also have to think about you know others
  619. 00:24:12
    who have infectious bacterial infections,
  620. 00:24:15
    and then toxoplasmosis so I think
  621. 00:24:18
    toxoplasmosis again really important for
  622. 00:24:20
    us to clue in especially for our
  623. 00:24:22
    immunocompromised patient population.
  624. 00:24:24
    When we think about sort of bacterial
  625. 00:24:26
    causes of encephalitis. Really What
  626. 00:24:28
    we're actually kind of moving more
  627. 00:24:31
    towards Is what are often brain
  628. 00:24:33
    abscesses, ain't so when the when?
  629. 00:24:36
    Period tend to take over brain
  630. 00:24:37
    parenchyma. It's not so much that it's
  631. 00:24:38
    causing global inflammation. It tends
  632. 00:24:41
    to cause an actual native of infection
  633. 00:24:44
    that then becomes walled off, and I
  634. 00:24:47
    just want to clue in an hour Just
  635. 00:24:49
    mentioned. Is this term Sarah brightest,
  636. 00:24:51
    which gets thrown around. I don't love
  637. 00:24:53
    that term. Because it's not really well
  638. 00:24:55
    defined as an etiology. It is. I am.
  639. 00:24:59
    At best I can say that it's sort of this
  640. 00:25:01
    like stage before an abscess where
  641. 00:25:03
    there's some purulent discharge, but it
  642. 00:25:05
    is not encapsulated. It can be in
  643. 00:25:08
    multiple brain spaces, so it can be
  644. 00:25:10
    both sort of within the print them off,
  645. 00:25:12
    and then also sort of within this a
  646. 00:25:14
    regulated space, and then maybe in them
  647. 00:25:16
    and in Jesus. So it's sort of, it's
  648. 00:25:18
    not really localized infection, and
  649. 00:25:21
    it's not walled off, and so it's sort
  650. 00:25:22
    of this like collection of bacteria that
  651. 00:25:26
    before it becomes an abscess, but I, I,
  652. 00:25:29
    I shy away from that term because I
  653. 00:25:31
    don't think that it's universally agreed
  654. 00:25:33
    on what that actually is.
  655. 00:25:36
    So when we're thinking about Hsv and
  656. 00:25:39
    then I er, let's say when we're
  657. 00:25:41
    thinking about encephalitis, there are
  658. 00:25:43
    some that can be diagnosed from the Lp,
  659. 00:25:46
    which like Hsv as a prime example, you
  660. 00:25:49
    can get a Pcr test if it's negative,
  661. 00:25:52
    and you have a very high suspicion.
  662. 00:25:54
    This is one of those where you may have
  663. 00:25:56
    to wait an L. P. The patient again and
  664. 00:25:59
    then get the positive result. That's
  665. 00:26:00
    actually pretty rare that that happens,
  666. 00:26:02
    but it is reported, and so I always
  667. 00:26:04
    kind of keep that in mind for patients
  668. 00:26:06
    who are really presenting with you know
  669. 00:26:08
    a limbic encephalitis and probable
  670. 00:26:11
    seizures and evidence of inflammation in
  671. 00:26:13
    the temporal lobes, If that Hsv pcr as
  672. 00:26:16
    negative in his early in the case, I'm
  673. 00:26:18
    going to keep treating them and then
  674. 00:26:20
    doing another Lp and a couple of days
  675. 00:26:23
    to, We have some cases where the Lp can
  676. 00:26:26
    diagnose encephalitis, but I think it's
  677. 00:26:28
    really important to to focus or to
  678. 00:26:31
    acknowledge that once an infection like
  679. 00:26:34
    bacterial abscess. It becomes walled
  680. 00:26:36
    off that Lp is not going to be very
  681. 00:26:39
    sensitive for diagnosing and a bacterial
  682. 00:26:42
    abscess, and so unfortunately the only
  683. 00:26:45
    time where that might be positive, as
  684. 00:26:47
    if the abscess is a ruptured into the
  685. 00:26:49
    ventricular system and that's really
  686. 00:26:51
    usually a very serious. I consequence
  687. 00:26:54
    that patients going to be extremely ill.
  688. 00:26:57
    Unfortunately, that doesn't happen all
  689. 00:26:59
    that often, so you know when we think
  690. 00:27:01
    about our bacterial infections that have
  691. 00:27:03
    walled off or often left it needing sort
  692. 00:27:06
    of surgical biopsy or removal of the
  693. 00:27:08
    abscess to get a true pathogen
  694. 00:27:11
    confirmation, and says all yet when we
  695. 00:27:14
    think about encephalitis, we've talked
  696. 00:27:16
    a lot about you know Hsv And how how do
  697. 00:27:20
    you do the medical management of this
  698. 00:27:25
    young, and as security think this is
  699. 00:27:28
    where it gets a little bored, an
  700. 00:27:30
    uncomfortable and complicated, because
  701. 00:27:32
    sometimes you really don't know what you
  702. 00:27:34
    are treating. You may not have all the
  703. 00:27:36
    information right away. I think the Hsv
  704. 00:27:38
    is probably the one that is the easiest,
  705. 00:27:41
    and just like you said, I think you
  706. 00:27:43
    either have the Pcr that is positive or
  707. 00:27:46
    the pizza is negative, and with the
  708. 00:27:48
    other information from your Csf analysis,
  709. 00:27:50
    you're like you know white. This does
  710. 00:27:51
    not been viral. I had the cycle of beer,
  711. 00:27:54
    and again, reducing is Henrik for
  712. 00:27:55
    keurig, A B. Q. Eight. It's not a
  713. 00:27:57
    rule. It's not five Mc prepared again,
  714. 00:28:00
    like you do have to do suggest in renal
  715. 00:28:02
    failure, but in a normal renal function,
  716. 00:28:04
    re really want to give the Cns. Do sing
  717. 00:28:06
    of ten mg per kg. I V. Every eight
  718. 00:28:09
    hours. Arms. Remember also that you
  719. 00:28:10
    have to use the. Adjust their body
  720. 00:28:12
    weight. You have to hydrate patients.
  721. 00:28:14
    The risk of nephrotoxicity is pretty
  722. 00:28:16
    high, so it's a pretty tricky drive,
  723. 00:28:18
    but if you do it correctly, and if you
  724. 00:28:19
    do all the precautions, hopefully you
  725. 00:28:21
    know it's done safely and it's it's
  726. 00:28:24
    efficacious. Now. If just like you
  727. 00:28:27
    said, If the suspicions high in the Pcr
  728. 00:28:28
    is negative, it as happened for us.
  729. 00:28:30
    Also that the repeat it, you know that.
  730. 00:28:33
    Pcr and it came back positive and we're
  731. 00:28:35
    happy that we kept everything on and we
  732. 00:28:37
    didn't give up, especially if the
  733. 00:28:39
    clinical or Mri you know finding was
  734. 00:28:41
    very suspicious now and on the flip side,
  735. 00:28:45
    I think it's important to note that Hsv
  736. 00:28:48
    in an immunocompetent patient without
  737. 00:28:50
    encephalitis does not need treatments if
  738. 00:28:53
    you just have someone that has like not
  739. 00:28:55
    altered, and they don't have
  740. 00:28:56
    encephalitis and they just have Hsv Pcr
  741. 00:28:59
    positive, That doesn't necessarily mean
  742. 00:29:00
    that you have to treat them Vz bees
  743. 00:29:03
    Another, I think viral encephalitis
  744. 00:29:07
    infectious cause that we see from time
  745. 00:29:09
    to time and you could use a sucker for
  746. 00:29:11
    that, and I think that's one of the
  747. 00:29:13
    encephalitis kind of indications that
  748. 00:29:15
    especially used the vasculitis. You
  749. 00:29:17
    could consider critical, and that's you
  750. 00:29:18
    know when we talk of neurology folks and
  751. 00:29:20
    are very hopeful with that management
  752. 00:29:23
    and talks takedown as very kind of. I
  753. 00:29:25
    think interesting. We see that
  754. 00:29:27
    definitely ain't him or compromised
  755. 00:29:29
    patient, Especially you know Hiv
  756. 00:29:31
    patients with really, allow city or
  757. 00:29:32
    county. I highly recommend that ID is
  758. 00:29:35
    involved in those cases just because
  759. 00:29:37
    they need longer duration, but just a
  760. 00:29:40
    broad clinical pro is that they do need
  761. 00:29:43
    the agent of choices per methamphetamine,
  762. 00:29:45
    plus localizing, plus local warren.
  763. 00:29:48
    And really these patients, I mean, you
  764. 00:29:50
    definitely need ID and your clinical
  765. 00:29:52
    pharmacist to be involved. They need up
  766. 00:29:53
    to six weeks of treatment even longer,
  767. 00:29:55
    depending on what's happening with them.
  768. 00:29:58
    West Nile supported care I know that we
  769. 00:30:01
    actually had a case of HHV6,
  770. 00:30:05
    and that was mostly supportive care,
  771. 00:30:07
    and ID was very involved in that. If
  772. 00:30:10
    you have tick warren infections that
  773. 00:30:14
    you're worried about, obviously Dr.
  774. 00:30:15
    Seikman is something to consider,
  775. 00:30:17
    especially if that's high on your list.
  776. 00:30:20
    Duration therapy really depends on what
  777. 00:30:22
    you're treating as we talk about toxic
  778. 00:30:24
    plasma. Plasma can be very long, but
  779. 00:30:26
    then, you know, depending on the
  780. 00:30:30
    significance of the disease, could be
  781. 00:30:31
    anything from 10 days really to 21 days,
  782. 00:30:34
    depending on how sick the patient is.
  783. 00:30:36
    So that's just something to keep in mind.
  784. 00:30:37
    But I think it's very variable. But you
  785. 00:30:40
    have these kind of not very typical
  786. 00:30:43
    infections that you really need to think
  787. 00:30:47
    about your patients' progress and how
  788. 00:30:49
    they're doing.
  789. 00:30:53
    Yeah, absolutely. I think Doxycycline
  790. 00:30:55
    is just really an unsung, like it is an
  791. 00:30:57
    unsung hero. What can Doxycycline
  792. 00:31:01
    do? The other thing question becomes
  793. 00:31:03
    what these patients is, you know, who,
  794. 00:31:06
    if they have a bacterial or assumed
  795. 00:31:09
    bacterial abscess, when are we going to
  796. 00:31:13
    intervene to remove the abscess versus
  797. 00:31:15
    just supportive care with medical
  798. 00:31:16
    treatment? And unfortunately, when it
  799. 00:31:18
    gets to the point where it's a walled
  800. 00:31:19
    off infection, medical therapy is
  801. 00:31:22
    likely to be ineffective And so I think,
  802. 00:31:25
    you know, The one the times were
  803. 00:31:27
    thinking about maybe getting by with
  804. 00:31:29
    medical therapy is very small abscesses,
  805. 00:31:32
    less lesson two and a half centimeters
  806. 00:31:34
    multiple, Where it seems like it. It's
  807. 00:31:36
    a hammer and hematologists spread until
  808. 00:31:39
    we're treating for you know the
  809. 00:31:40
    endocarditis for a very long time
  810. 00:31:42
    anyways, and, but normally,
  811. 00:31:45
    especially in these larger cases, with
  812. 00:31:47
    this sort of literature cut off, being
  813. 00:31:49
    that two and a half centimeters, we
  814. 00:31:51
    really are thinking about you know
  815. 00:31:53
    surgical debridement and source control,
  816. 00:31:55
    and that also serves as you know the way
  817. 00:31:57
    to identify what actually the pathogen
  818. 00:32:00
    is, and unfortunately a lot of these
  819. 00:32:01
    are probably my wheel, and sometimes
  820. 00:32:04
    you know it is just unfortunate that the
  821. 00:32:06
    reality is that these patients need to
  822. 00:32:07
    be on multiple antibiotics for a very
  823. 00:32:09
    long duration, and you know again, you
  824. 00:32:13
    have to have the ones that risk with you
  825. 00:32:15
    know where is it located, and how much
  826. 00:32:17
    eloquent and brain tissue would be
  827. 00:32:18
    injured with the surgery, and so this
  828. 00:32:20
    really is a multi disciplinary
  829. 00:32:22
    conversation between Id neurosurgery and
  830. 00:32:24
    the neuro critical. team and with
  831. 00:32:26
    pharmacy on board about the duration of
  832. 00:32:28
    antibiotics that might be needed and the
  833. 00:32:30
    risk factors of long-term antibiotics.
  834. 00:32:34
    These can be really interesting cases
  835. 00:32:37
    and often are very complex and I think
  836. 00:32:40
    that's sort of one of the things that
  837. 00:32:41
    makes the treatment of both meningitis
  838. 00:32:44
    and encephalitis really interesting. So,
  839. 00:32:47
    Salia, wrapping up, anything you know,
  840. 00:32:49
    final pearls to leave us with.
  841. 00:32:53
    I think we covered most of, you know,
  842. 00:32:55
    the infections. One thing I wanted to
  843. 00:32:56
    kind of mention, we didn't really spend
  844. 00:32:58
    a lot of time about fungal enamel
  845. 00:33:00
    engeitis. It's obviously very
  846. 00:33:02
    complicated, again, immunocompromised
  847. 00:33:04
    patients. I think it's fair to know
  848. 00:33:06
    that if you're starting something for
  849. 00:33:09
    fungal infections, it's very reasonable
  850. 00:33:11
    to start very broad with something like
  851. 00:33:12
    alpha-tericin against CNS, they're
  852. 00:33:15
    saying usually 5-meg per gig of the
  853. 00:33:17
    liposomal formulation because their risk
  854. 00:33:19
    of nephrotoxicity is really lower. And
  855. 00:33:22
    then the other thing we didn't really
  856. 00:33:23
    talk about as much as this Ambience of
  857. 00:33:25
    supplied as that, you know that also
  858. 00:33:26
    could be a very complex, as far as you
  859. 00:33:29
    know what other risk factors the patient
  860. 00:33:32
    may have and that's when we think about
  861. 00:33:33
    guess I could are some. We would come
  862. 00:33:35
    combining and consecutive face Karnak,
  863. 00:33:38
    If if they have a resistant kind of
  864. 00:33:40
    strain of Cmv which he really have to
  865. 00:33:42
    watch out their kidney function and all
  866. 00:33:44
    the things by, it's obviously
  867. 00:33:46
    impossible to talk about all the
  868. 00:33:47
    infections, but those were the two that
  869. 00:33:48
    I really wanted to kind of highlight
  870. 00:33:50
    quickly before the wrapped up
  871. 00:33:53
    and and just a reminder to the listeners
  872. 00:33:55
    like this is a great chapter and there
  873. 00:33:57
    are so many nice tables within it have
  874. 00:34:00
    sort of common ideologies. Your initial
  875. 00:34:02
    treatment strategy, What you had
  876. 00:34:04
    narrowed to an end, China, think about
  877. 00:34:07
    sort of risk -benefit decisions in terms
  878. 00:34:09
    of things like the surgical management
  879. 00:34:10
    of patients with bacterial abscesses,
  880. 00:34:12
    So really, I want to emphasize go and
  881. 00:34:15
    check out the chapter, but this was a
  882. 00:34:17
    lotta fun and it was great to be back.