Bacterial Meningitis

Dive into the intricate world of Biology and unravel the mystery behind Bacterial Meningitis. This comprehensive guide provides in-depth analysis while shedding light on the causes, symptoms, treatment options and preventive measures for bacterial meningitis. For comparison, the guide also contrasts bacterial meningitis with its viral counterpart, for a more rounded understanding. Let's voyage into this fascinating subject and enrich your knowledge about this critical health issue.

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Table of contents

    Understanding Bacterial Meningitis

    Bacterial Meningitis is a severe infection that predominantly affects the membranes surrounding your brain and spinal cord. This condition is potentially life-threatening and requires immediate medical attention.

    What is Bacterial Meningitis?

    Bacterial Meningitis, a condition with rapid onset, can be caused by several strains of bacteria. Once inside the bloodstream, they can travel to the brain and spinal cord, provoking severe inflammation in the meninges - the protective membranes. Due to this, early diagnosis is crucial as the condition escalates fast, often leading to serious repercussions such as hearing loss, learning disabilities, and brain damage if not provided with immediate treatment. Symptoms of bacterial meningitis encompass rash, stiffness in the neck, fever, severe headaches, and light sensitivity, amongst others.

    • Causes: Bacteria such as Streptococcus pneumoniae (Pneumococcus) and Neisseria meningitidis (Meningococcus) are often at play.
    • Transmission: The transmittance of bacteria is usually through close contact, coughing, sneezing, or even kissing.
    • Risk Factors: It primarily affects children, teens, and those with weakened immune systems.
    • Complications: Permanent neurological damage, kidney or adrenal gland failure, shock, and even death are potential complications.

    Did you know some types of bacterial meningitis are preventable through immunisation? Vaccines are available against some of the most common strains, such as Pneumococcal, Meningococcal, and Haemophilus influenza type B meningitis. Nevertheless, they do not completely eradicate the risk, emphasizing the importance of early diagnosis and treatment.

    Detailed Explanation of Bacterial Meningitis

    In bacterial meningitis, bacteria invade the bloodstream, reaching the central nervous system and triggering inflammation. As a result, the protective membranes enveloping the brain and spinal cord - known as the meninges - swell.

    Inflammation: It's a defensive response of your body to harmful stimuli, causing discomfort and swelling. It aims to eliminate the harm and push the healing process.

    The body generates this reaction as a consequence of released endotoxins and other inflammatory substances from bacteria, alongside your immune system's response towards infection. This contributes to an increase in intra-cranial pressure and interrupts the normal function of the brain, potentially leading to life_threatening issues.

    Bacterium Route of Entry At Risk Individuals
    Meningococcus (Nisseria meningitidis) Respiratory secretions/ close contact Children and teens
    Pneumococcus (Streptococcus pneumoniae) Respiratory secretions/ close contact Elderly, children, immune-compromised
    Haemophilus influenzae Respiratory secretions/ close contact Children, especially < 5 years

    For example, if a teenager sharing a dormitory contract Meningococcal meningitis, those living in proximity may have a greater risk of exposure. Quick isolation, treatment, and preventive measures for those exposed are critical.

    It's essential for everyone, especially those at risk, to be aware of bacterial meningitis. Recognizing the symptoms, understanding the possible bacteria involved, their transmission methods, and measures for prevention can play an essential role in protecting yourself and those around you.

    Bacterial Meningitis Causes

    Understanding the causes of Bacterial Meningitis can help individuals identify their risks, and take necessary action. Bacterial Meningitis is caused by different bacteria, with the most common ones being Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Furthermore, these bacteria are transmitted from person to person through droplets of respiratory or throat secretions.

    Identifying the Causes of Bacterial Meningitis

    As previously stated, bacterial meningitis is largely caused by infection with certain bacteria. Every individual is unique, so when these bacteria enter your body, your immune response may differ from another person. Particularly, the severity of an infection may be influenced by underlying genetic factors, age, and overall state of your health.

    Close contact is a crucial factor in the transmission of these bacteria. Exchange of respiratory and throat secretions via activities like kissing or coughing nearby can transfer bacteria between individuals. It's important to be vigilant in settings where close contact may occur, such as schools, dormitories, or child care centres.

    Respiratory secretions: Fluid produced by the respiratory tract, often carrying various pathogens that can cause diseases.

    Furthermore, having certain medical conditions can increase your susceptibility to bacterial meningitis. Individuals with a compromised immune system, due to reasons like chemotherapy or organ transplantation, are more susceptible. Similarly, chronic diseases, such as diabetes, also increase vulnerability.

    Even environmental factors play a role. For instance, bacterial meningitis is statistically more common in the cold months of late winter and early spring. This aligns with the heavier prevalence of upper respiratory tract infections during these periods, which can more easily lead to meningitis.

    Neisseria meningitidis is uniquely adapted to humans. It does not exist in the environment but thrives in the nasopharynx (the upper part of the throat behind the nose). Many individuals may carry it without ever falling sick, but, under certain conditions, it can suddenly invade the bloodstream and cause disease.

    Common Causes of Bacterial Meningitis

    Let's delve a bit more into the specific bacteria commonly implicated in bacterial meningitis:

    • Neisseria meningitidis: This bacterium, also known as Meningococcus, mainly affects teenagers and young adults. It is the cause of meningococcal meningitis and can also result in widespread blood infection (meningococcal sepsis).
    • Streptococcus pneumoniae: Commonly referred to as Pneumococcus, it affects individuals at the extreme ends of the age spectrum – the very young and the elderly. Besides meningitis, it leads to other illnesses like pneumonia and ear infections.
    • Haemophilus influenzae: Particularly type b (Hib), was a leading cause of bacterial meningitis in children below five, prior to the introduction of the Hib vaccine.
    Bacterium Population Group Mainly Affected Other Diseases Caused
    Neisseria meningitidis Teenagers, Young Adults Meningococcal sepsis
    Streptococcus pneumoniae Elderly, Young Children Pneumonia, Ear Infections
    Haemophilus influenzae type b (Hib) Children < 5 years None

    For example, imagine a young child attending a crowded daycare centre during the cold months of the year. The environment makes it easier for bacteria such as Streptococcus pneumoniae to not only infect that child but rapidly spread to other children in the same environment.

    Comprehending the causes of Bacterial Meningitis as well as its risk factors and the bacteria involved is crucial in understanding how to prevent and control its spread. This can aid in the early detection and diagnosis of the disease, which significantly increases the chances of successful treatment and recovery.

    Bacterial Meningitis Symptoms

    Bacterial Meningitis typically manifests with stark symptoms that may develop over several hours or spread over one to two days. Owing to its potential severity and rapid progression, prompt recognition of these signs is vital.

    Recognising the Symptoms of Bacterial Meningitis

    The symptoms of Bacterial Meningitis tend to strike swiftly and with great intensity. Initially, it might seem like the flu, but the symptoms quickly worsen. Both children and adults can exhibit similar signs, but there are also age-specific symptoms. However, bear in mind that not everyone with meningitis will have the same symptoms.

    Generally speaking, the classic triad of meningitis symptoms includes sudden high fever, stiff neck, and severe headache. These symptoms can appear in any order, or some might not appear at all. Furthermore, they are frequently accompanied by other symptoms such as nausea, vomiting, sensitivity to light (photophobia), and confusion or difficulty concentrating.

    Photophobia: an oversensitivity to light, causing discomfort or the need to close the eyes.

    In some cases, the bacteria causing the meningitis rush into the bloodstream and create a wide-spreading, severe infection called septicemia. When this occurs, symptoms such as cold hands and feet, joint or muscle pain, and a rash can appear.

    The rash associated with meningitis septicemia is particularly noteworthy. It appears as tiny red or purple pinpricks that can occur anywhere on the body. Over time, these can become larger and look like fresh bruises. This rash does not fade under pressure – if you press a glass against it, the rash stays visible. This is known as the 'glass test'. A meningitis rash is a medical emergency.

    Meningitis in infants and young children might not cause the classic symptoms mentioned. Instead, they might show signs like irritability or drowsiness, difficulty in feeding, a high-pitched cry, stiffness in the body, or a bulge in the soft spot on top of a baby's head (fontanel).

    Symptom Adults Infants
    High Fever Yes Yes
    Stiff Neck Yes Sometimes
    Rash If Meningococcal If Meningococcal
    Difficulty Feeding No Yes

    Early Signs of Bacterial Meningitis

    The first signs of Bacterial Meningitis might seem like those of common viral illnesses such as flu. However, the rapid escalation and intensification of symptoms distinguish meningitis.

    Often, people with meningitis but without sepsis will have sudden onset of fever, headache, and stiff neck. It's important to mention that stiffness isn't just about discomfort or muscle tension. Stiff neck in the context of meningitis usually means that the neck is so rigid that bending the head forward causes resistance or is practically impossible.

    Stiff neck: In meningitis, this is a symptom wherein the neck becomes rigid and its mobility is compromised due to the inflammation of the meninges in the spinal cord.

    Other early symptoms can include fatigue, poor appetite or nausea, and being irritable or agitated. Flu-like symptoms that are improving and then suddenly worsen can also be an early sign of meningitis and should be evaluated carefully.

    For instance, imagine an adult who initially has moderate fever, some tiredness, and a headache. This could seem like a simple case of flu. However, if within the next few hours, the fever spikes, the headache becomes intense, a stiff neck develops, and confusion sets in, bacterial meningitis is a very serious possibility. Early recognition of these signs and timely medical consultation are essential.

    Note that early signs of bacterial meningitis can be swiftly followed by severe and life-threatening symptoms, including seizures, difficulty in establishing consciousness or even coma. Therefore, if you suspect meningitis based on these symptoms, do not hesitate to seek immediate medical attention.

    Bacterial Meningitis Treatment

    Bacterial Meningitis is considered a medical emergency demanding immediate hospitalisation. Due to the potential for catastrophic consequences if not treated promptly, treatment ought to be initiated even before the diagnosis is definitively confirmed. Importantly, the specific treatment will depend on the exact type of bacteria involved.

    Available Treatment Options for Bacterial Meningitis

    The treatment of bacterial meningitis largely revolves around supportive care – that is, managing the symptoms – and antibiotic therapy, which fights the bacterial infection. After commencing treatment, monitoring for complications and managing these should they arise is another crucial element.

    Supportive care involves controlling fever and associated discomfort with antipyretics like paracetamol. Measures to control seizures, which are a common complication, are also instigated. Analgesics (pain killers) can help take care of headache and other pains.

    The mainstay, however, is antibiotic therapy. As bacterial meningitis is a potentially life-threatening condition that rapidly progresses, antibiotics are often initiated even before the causative bacteria are definitively identified via laboratory examinations.

    Antibiotics: These are medicines that help stop infections caused by bacteria. They do this by killing the bacteria or preventing them from reproducing and spreading.

    High-dose intravenous antibiotics are typically chosen based on the suspected bacteria, patient age, and local patterns of antibiotic resistance. For instance, a combination of a third-generation cephalosporin like ceftriaxone or cefotaxime, and vancomycin is usually considered first-line, pending the results of laboratory testing.

    Once the causative bacteria are confirmed and their antibiotic susceptibility is established through testing of the cerebrospinal fluid (CSF), the choice of antibiotics can be refined. The antibiotics are usually continued for around 7-21 days, depending on the responsible bacteria.

    • Bacterium: Streptococcus pneumoniae
      • Common Antibiotics : Penicillin, Ceftriaxone, Cefotaxime, Vancomycin
    • Bacterium: Neisseria meningitidis
      • Common Antibiotics : Penicillin, Ceftriaxone, Cefotaxime
    • Bacterium: Haemophilus influenzae
      • Common Antibiotics : Ceftriaxone, Cefotaxime

    Dexamethasone, a potent corticosteroid, is often co-administered with antibiotics, before or with the first dose. It acts to dampen the brain's inflammatory response to the invading bacteria, thereby helping to reduce the risk of potential complications like hearing loss and cognitive impairment.

    Patients require hospitalisation, often in Intensive Care Units (ICU), for close observation and management of complications. Some severe complications may necessitate additional treatments or procedures, such as brain surgery or hearing aids for hearing loss.

    Steps to Take in Treating Bacterial Meningitis

    In treating bacterial meningitis, the most critical step is to seek immediate medical attention if meningitis is suspected. It is a medical emergency requiring quick administration of antibiotics. The specific steps involved usually include:

    1. Seeking emergent care: If you or someone around you exhibits symptoms suggestive of meningitis, seek immediate medical consultation.
    2. Hospitalization: Given the severity and rapid development of bacterial meningitis, hospitalisation is mandatory. This allows for careful monitoring and timely treatment adjustments if needed.
    3. Initiating treatment: Physicians will not wait for laboratory test confirmation to start treatment due to the disease's severity and rapid progression. A broad-spectrum antibiotic, at times combined with a corticosteroid, will be initiated promptly, until more specific information becomes available.
    4. Diagnostic tests: While treatment has been started, diagnostic tests, including blood tests and a lumbar puncture to obtain cerebrospinal fluid for examination, are conducted to confirm the diagnosis and identify the responsible bacterium.
    5. Refining treatment: When the test results become available, the treatment can be customised – using the most effective antibiotic that the identified bacterium is most susceptible to.
    6. Ongoing care and monitoring: Continuous monitoring for complications is crucial for optimal recovery. Sometimes rehabilitation may be necessary, especially in severe cases.

    Let's consider a situation where a patient comes in with a high fever, intense headache, and a stiff neck. Rather than wait for definitive confirmation of bacterial meningitis, the healthcare team will promptly commence antibiotic therapy while simultaneously conducting the necessary laboratory tests. Once the causative bacteria are identified from the CSF culture, the antibiotics might be switched to ones that are particularly effective against that specific bacteria, ensuring the most efficient treatment.

    Recognising that bacterial meningitis is a severe, swiftly progressing infection underlines the significance of immediate medical consultation when symptoms are noticed. Timely and appropriate treatment with antibiotics and symptomatic management constitute the crux of bacterial meningitis treatment, managed vigilantly by the healthcare team in a hospital setting.

    Protecting Yourself from Bacterial Meningitis

    Prevention is always better than cure, and this is particularly true in the case of bacterial meningitis. Due to its severe implications and rapid onset, knowing how to protect yourself is crucial. This encompasses vaccinations and precautions in daily activities, especially for those at an elevated risk.

    Bacterial Meningitis Vaccine

    The primary line of defence against bacterial meningitis is vaccination. Vaccines are available against the most common strains of bacteria causing meningitis – Neisseria meningitidis, Haemophilus influenzae type b (Hib), and Streptococcus pneumoniae.

    The administration of these vaccines, and the exact type utilised, depends on age, risk, and prevailing national or regional vaccination policies. For instance, the Meningococcal vaccine is recommended for adolescents, especially those heading to college or living in dormitories, where outbreaks are more common. Pre-teens and teenagers are usually given a single dose at age 11 or 12, with a booster dose at 16.

    Two vaccines – PCV13 and PPSV23 – help protect against Streptococcus pneumoniae. They are routinely given to infants and toddlers, and to older adults and those at risk, respectively.

    The Hib vaccine is typically administered as part of routine childhood immunisations, significantly reducing these cases.

    Vaccine: A substance that stimulates the body's immune system to provide protection against a specific disease, usually by causing the production of antibodies.

    It's important to understand that no vaccine offers 100% protection, and they do not stave off all bacterial meningitis, since some bacteria that can cause meningitis do not have developed vaccines yet. Regular updates and boosters are required, as their effectiveness can decrease over time.

    Protection from vaccines is twofold. Firstly, they directly shield by causing your immune system to produce a response, including the creation of memory cells that will give a fast and effective reaction if exposed to the disease later. Secondly, when significant numbers are vaccinated, herd immunity develops. In effect, the bacteria are unable to find enough hosts to sustain their spread, conferring indirect protection to even unvaccinated individuals.

    Effectiveness and Importance of the Bacterial Meningitis Vaccine

    Vaccines against bacterial meningitis have proven their significance in effectively reducing the prevalence of this potentially life-threatening condition. Their introduction has led to a notable decline in cases of bacterial meningitis from the covered strains.

    Studies confirm that the vaccines have a high effectiveness rate in eliciting a robust immune response. Still, it's important to bear in mind that no vaccine is 100% effective, and the best defence is to combine vaccination with awareness of the symptoms and early diagnosis.

    For instance, in the 10 years following the introduction of the routine meningococcal conjugate vaccination for adolescents in the United States, the incidence of meningococcal disease in this age group dropped by nearly 80%.

    Importantly, vaccines not only confer protection on an individual level but also, on a broader scale, help control the spread of these bacteria in the community, contributing to herd immunity.

    Herd Immunity: This is a form of immunity that occurs when a significant portion of the community is immune to a disease, which protects individuals who aren't immune from infection, as there are fewer opportunities for an outbreak.

    Knowledge about the available vaccines and their schedules can empower you against bacterial meningitis. It's essential to consult with a healthcare practitioner to clarify any doubts and ensure you and your close contacts are protected suitably.

    Precautions against Bacterial Meningitis

    Besides vaccines, incorporating specific precautions into your life can significantly mitigate the risk of bacterial meningitis. Precautionary measures often revolve around maintaining high standards of personal hygiene and being cautious in environments where the bacteria may spread easily.

    • Maintain good hygiene: As the bacteria are usually spread from person to person via respiratory secretions, good hygiene practices are fundamental. Regular hand washing, especially before meals, after using the toilet or changing diapers, can make a difference.
    • Avoid sharing personal items: Items like utensils, toothbrushes, or drink bottles, which can carry respiratory secretions, should not be shared.
    • Healthy lifestyle: A strong immune system can resist infections better. Maintain a balanced diet, ensure adequate sleep, regular exercise, and avoid smoking.

    Best Practices to Avoid Contracting Bacterial Meningitis

    Knowing how bacterial meningitis spreads, several practical strategies can be implemented to reduce the risk further.

    Practice 'respiratory etiquette' - that is, covering the mouth and nose while coughing or sneezing, ideally using a tissue, which must be disposed of correctly. Furthermore, avoid close contact with sick individuals where possible, particularly if they exhibit respiratory symptoms.

    Consider avoiding crowded places during an active outbreak of bacterial meningitis. If travelling to a country where meningococcal disease is prevalent, especially the 'meningitis belt' of sub-Saharan Africa, seeking advice about receiving the relevant vaccines prior to the trip is crucial.

    A school is an example of an environment where close contact can occur, and the bacteria causing meningitis can potentially spread. The school can ensure hand washing facilities are available and functional. They should have a sickness policy, ensuring pupils and staff affected by respiratory illnesses refrain from attending school until fully recovered. As a parent or student, you should be vaccinated as per guidelines, and practice good hygiene

    In essence, a combination of vaccination and effective daily precautions can provide substantial protection against bacterial meningitis. It's not just about protecting yourself, but also about contributing to the broader control of bacterial meningitis spread within your community.

    Viral vs Bacterial Meningitis

    Meningitis can be instigated by various pathogens, prominently including viruses and bacteria. While sharing some common characteristics, viral and bacterial meningitis have distinct differences in causes, symptoms, severity, treatment, and prevention strategies.

    Distinction between Viral and Bacterial Meningitis

    As first-order causatives, viral and bacterial meningitis are delineated by the type of organism involved. Viral meningitis, also known as aseptic meningitis, is typically less severe and most patients recover on their own without specific treatment. It's often caused by common viruses called enteroviruses that are primarily transmitted via the fecal-oral route.

    Contrastingly, bacterial meningitis is a result of bacterial infections, commonly occurring due to bacteria like Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae infecting the protective lining of the brain and spinal cord. It's generally more severe and can lead to significant complications or even be fatal. Therefore, bacterial meningitis necessitates immediate medical attention and treatment.

    Enteroviruses: These are a group of viruses that primarily live in the intestines and are often linked to infections with symptoms ranging from mild to severe.

    The symptoms for both types can seem very similar initially – for example, high fever, severe headache, and neck stiffness. However, bacterial meningitis symptoms often intensify swiftly and could include symptoms such as altered mental status or a rash in meningococcal disease. While viral meningitis could also offer a similar presentation, the course is usually milder.

    Understanding Differences: Viral Meningitis vs Bacterial Meningitis

    Early diagnosis of the type of meningitis – viral or bacterial – is crucial due to the differences in their treatment options and potential outcomes. Hence, distinguishing between the two is necessary.

    Bacterial meningitis requires immediate treatment with antibiotics to eliminate the bacteria. Antiviral drugs exist for some viruses that cause meningitis, but most of the time, specific treatment is not available for viral meningitis. Instead, care focuses on relieving symptoms and supporting the body's immune response.

    Antiviral drugs: These are a type of medication used specifically for treating viral infections. They work by inhibiting the development of the virus, and unlike antibiotics, they are not effective against bacterial infections.

    Another key distinction lies in prevention. Vaccines are available against several of the bacteria and viruses that can cause meningitis. High-risk individuals are advised to receive vaccines, particularly those against the common bacteria causing meningitis. While there are vaccines against some viruses causing meningitis, such as mumps or measles, there is no vaccine for enteroviruses, the most common cause of viral meningitis.

    Did you know? Human immunodeficiency virus (HIV) can also cause meningitis in its initial stages. However, it's unique in that it can also make the body more susceptible to other types of meningitis by weakening the immune system.

    Type Common Causative Agents Typical Treatment Vaccination Available
    Viral Meningitis Enteroviruses, Mumps virus Symptomatic treatment, occasionally antivirals For some viruses
    Bacterial Meningitis Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae Antibiotics Yes

    Imagine two patients, both presenting with fever, headache, and neck stiffness. Patient A's symptoms are escalating rapidly, with evidence of a purpuric rash (a clue towards meningococcal septicaemia), while Patient B's symptoms are milder and stable over a couple of days. Patient A would likely be suspected of bacterial meningitis and treated urgently with antibiotics, while patient B might have viral meningitis, necessitating different management.

    Both viral and bacterial meningitis unequivocally demand timely detection and appropriate management. Distinguishing between these two is vital given their severities, treatment modalities, and preventive measures. Hence, healthcare professionals are trained to differentiate between viral and bacterial meningitis and treat each case as per its specific needs.

    Bacterial Meningitis - Key takeaways

    • Bacterial Meningitis is a severe, rapidly progressing infection that primarily infects via bacteria like Streptococcus pneumoniae. Early detection significantly improves treatment outcomes.
    • Symptoms of Bacterial Meningitis include a high fever, a stiff neck, and a severe headache that develop over several hours or a couple of days. Other symptoms may include nausea, vomiting, sensitivity to light (photophobia), and confusion or difficulty concentrating.
    • If bacterial meningitis progresses to septicemia, symptoms may include joint or muscle pain, a rash, and cold hands and feet. In infants, symptoms might manifest as drowsiness, a high-pitched cry, or a bulge in the soft spot on the baby's head.
    • Treatment options for bacterial meningitis are predominantly supportive care and antibiotic therapy initiated prior to definitive diagnosis. Once the specific bacterium is identified, the antibiotics are refined and typically continued for around 7-21 days.
    • Vaccination is the primary defense against bacterial meningitis, with specific vaccines available against the most common strains. Even though vaccines do not offer 100% protection, they significantly reduce the prevalence of the condition. Awareness of symptoms and early diagnosis are equally crucial.
    Frequently Asked Questions about Bacterial Meningitis
    What are the initial symptoms of bacterial meningitis?
    Initial symptoms of bacterial meningitis include sudden high fever, severe headache, stiff neck, vomiting or nausea with headache, confusion or difficulty concentrating, seizures, sleepiness or difficulty waking up, and sensitivity to light.
    Can bacterial meningitis be prevented through vaccination?
    Yes, certain types of bacterial meningitis can be prevented through vaccination. Vaccines such as the meningococcal vaccine and pneumococcal vaccine are generally effective against some forms of the disease.
    How is bacterial meningitis transmitted from one person to another?
    Bacterial meningitis is transmitted from person to person through respiratory droplets or throat secretions. This can occur during close contact, such as kissing, sharing eating utensils or coughing in close proximity to someone.
    What are the potential complications of bacterial meningitis?
    Potential complications of bacterial meningitis can include hearing loss, memory difficulty, learning disabilities, brain damage, motor deficits, seizures, gangrene, or shock. In severe cases, it can lead to death.
    What is the treatment process for bacterial meningitis?
    The treatment process for bacterial meningitis involves hospitalisation, administering intravenous antibiotics, corticosteroids to reduce brain swelling, and sometimes anticonvulsants to prevent or control seizures. Fluids may be provided to combat dehydration.

    Test your knowledge with multiple choice flashcards

    Can vomiting be a sign of bacterial meningitis?

    If someone has acute meningitis, is confused, has seizures, and high fever, is it appropriate to give empiric or specific treatment before getting results from blood cultures?

    Phonophobia is aversion to ______ while photophobia is aversion to ________


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