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Meningitis Main Page

Patient Information

Overview

Causes

Classification

Viral Meningitis
Bacterial Meningitis
Fungal Meningitis

Differential Diagnosis

Diagnosis

Treatment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [3], Sheng Shi, M.D. [4]

Overview

Acute bacterial meningitis is a medical emergency; commence empiric treatment after obtaining blood and/or cerebrospinal fluid (CSF) cultures if the possibility of bacterial meningitis becomes evident. Once a bacterial etiology has been identified on a CSF Gram stain, treatment regimen should be optimized accordingly. Further modifications may be required after the culture and/or in vitro susceptibility results are available. Neuroimaging (such as CT scan and MRI) or lumbar puncture must not delay antimicrobial therapy.

Principles of Therapy for Bacterial Meningitis

Factors Determining Antimicrobial Activity

  • Aminoglycosides and fluoroquinolones express a concentration-dependent manner of bactericidal activity; beta-lactams typically follow a a time-dependent antimicrobial pattern (i.e., the activity is dependent on the time that CSF concentration exceeds MIC as a proportion of the dosing interval).
Recommended Doses of Antimicrobial Agents via the Intraventricular Route.[3][4][5]
Antimicrobial Agent Daily Intraventricular Dose
 ▸ Vancomycin 5—20 mg
 ▸ Gentamicin 4—8 mg
 ▸ Tobramycin 5—20 mg
 ▸ Amikacin 5—50 mg
 ▸ Polymyxin B 5 mg
 ▸ Colistin 10 mg
 ▸ Quinupristin/Dalfopristin 2—5 mg
 ▸ Teicoplanin 5—40 mg
 ▸ Amphotericin B 0.1—0.5 mg/day

Duration of Antimicrobial Therapy

  • The duration of therapy in patients with bacterial meningitis has not been well-supported by evidence-based data.
  • The IDSA Practice Guideline provides recommendations on the duration of antimicrobial agents based on microorganisms (see table below). However, the duration of antimicrobial therapy should be individualized in accordance with patient's clinical response.
  • Maximum parenteral dosage should be maintained throughout the recommended duration of therapy to ensure adequate bactericidal concentrations are attained since antimicrobial entry attenuates as meningeal inflammation subsides, especially when dexamethasone is co-administered.
Recommended Duration of Antimicrobial Therapy Based on Isolated Pathogen.[6]
Microorganism Duration of Therapy
 ▸ Neisseria meningitidis 7 days
 ▸ Haemophilus influenzae 7 days
 ▸ Streptococcus pneumoniae 10—14 days
 ▸ Streptococcus agalactiae 14—21 days
 ▸ Aerobic Gram-negative bacilli 21 days
 ▸ Listeria monocytogenes ≥21 days

Adjunctive Dexamethasone Therapy

  • Evidences for beneficial effects of dexamethasone are variable. In some studies, adjunctive use of dexamethasone for bacterial meningitis in selected groups are associated with an improved survival or prognosis.[7][8][9][10][11][12] However, other studies fail to demonstrate a substantial reduction of death or neurological disability.[3][13][14][15] The occurrence of delayed cerebral thrombosis with dexamethasone therapy has been reported.[16]
  • In infants and children with Haemophilus influenzae type b meningitis, the IDSA Practice Guideline supports the use of adjunctive Dexamethasone at 0.15 mg/kg q6h for 2—4 days with the first dose administered 10—20 minutes prior to, or at least concomitant with, the first antimicrobial dose.[6]
  • In adults with suspected or proven Streptococcus pneumoniae meningitis, the IDSA also recommends Dexamethasone at 0.15 mg/kg q6h for 2—4 days with the first dose administered 10—20 minutes prior to, or at least concomitant with, the first antimicrobial dose. Dexamethasone should only be continued if the CSF Gram stain reveals Gram-positive diplococci, or if blood or CSF cultures are positive for S. pneumoniae. In this scenario, certain authorities advocate the addition of rifampin to the empirical combination of vancomycin plus a third-generation cephalosporin pending culture results and in vitro susceptibility testing.[6][17]
  • Dexamethasone should not be given to patients who have already received animicrobial therapy because it is unlikely to improve clinical outcome.[6]

Empiric Therapy

▸ Click on the following categories to expand treatment regimens.[3][18]

Community-Acquired

  ▸  Newborns, Age <1 Week

  ▸  Newborns, Age 1—4 Weeks

  ▸  Infants & Children

  ▸  Adults, Age <50 Years

  ▸  Adults, Age >50 Years

  ▸  Immunocompromised

  ▸  Recurrent

Nosocomial

  ▸  Postneurosurgical Infection

  ▸  CSF Shunt Infection

  ▸  Penetrating Trauma

  ▸  Basilar Skull Fracture

Newborns, Age <1 Week
Preferred Regimen
▸ Ampicillin 50 mg/kg IV q8h
PLUS
▸ Cefotaxime 50 mg/kg IV q8—12h
Alternative Regimen
▸ Ampicillin 50 mg/kg IV q8h
PLUS
▸ Gentamicin 2.5 mg/kg IV q12h
Newborns, Age 1—4 Weeks
Preferred Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
PLUS
▸ Cefotaxime 50 mg/kg IV q6—8h
Alternative Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
PLUS
▸ Gentamicin 2.5 mg/kg IV q8h
OR
▸ Tobramycin 2.5 mg/kg IV q8h
OR
▸ Amikacin 10 mg/kg IV q8h
Infants & Children
Preferred Regimen†
▸ Vancomycin 15 mg/kg IV q6h (trough 15—20 μg/mL)
PLUS
▸ Cefotaxime 75 mg/kg IV q6—8h
OR
▸ Ceftriaxone 80—100 mg/kg/day IV q12—24h
Alternative Regimen†
▸ Vancomycin 15 mg/kg IV q6h (trough 15—20 μg/mL)
PLUS
▸ Meropenem 40 mg/kg IV q8h
† Add Ampicillin 75 mg/kg IV q6h if suspecting Listeria monocytogenes.
Adults, Age <50 Years
Preferred Regimen†
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
Alternative Regimen†
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Meropenem 2 g IV q8h
† Add Ampicillin 2 g IV q4h if suspecting Listeria monocytogenes.
Adults, Age >50 Years
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
PLUS
▸ Ampicillin 2 g IV q4h
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Aztreonam 2 g IV q6—8h
PLUS
▸ TMP/SMZ 5 mg/kg IV q6—12h (TMP component)
Immunocompromised
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Cefepime 2 g IV q8h
OR
▸ Meropenem 2 g IV q8h
PLUS
▸ Ampicillin 2 g IV q4h
Recurrent
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
Postneurosurgical Infection
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Cefepime 2 g IV q8h
OR
▸ Ceftazidime 2 g IV q8h
OR
▸ Meropenem 2 g IV q8h
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Aztreonam 2 g IV q6—8h
OR
▸ Ciprofloxacin 400 mg IV q8—12h
CSF Shunt Infection
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Cefepime 2 g IV q8h
OR
▸ Ceftazidime 2 g IV q8h
OR
▸ Meropenem 2 g IV q8h
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Aztreonam 2 g IV q6—8h
OR
▸ Ciprofloxacin 400 mg IV q8—12h
Penetrating Trauma
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Cefepime 2 g IV q8h
OR
▸ Ceftazidime 2 g IV q8h
OR
▸ Meropenem 2 g IV q8h
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Aztreonam 2 g IV q6—8h
OR
▸ Ciprofloxacin 400 mg IV q8—12h
Basilar Skull Fracture
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Aztreonam 2 g IV q6—8h
OR
▸ Ciprofloxacin 400 mg IV q8—12h


CSF Gram Stain-Based Therapy

▸ Click on the following categories to expand treatment regimens.[6][18]

Gram-Positive

  ▸  Gram-Positive Cocci in Chains

  ▸  Gram-Positive Cocci in Pairs

  ▸  Gram-Positive (Cocco-)Bacilli

Gram-Negative

  ▸  Gram-Negative Cocci in Pairs

  ▸  Gram-Negative Coccobacilli

  ▸  Gram-Negative Bacilli

Gram-Positive Cocci in Chains
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q8—12h (trough 15—20 μg/mL)
PLUS
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
Alternative Regimen
▸ Meropenem 2 g IV q8h
OR
▸ Moxifloxacin 400 mg IV q24h
Gram-Positive Cocci in Pairs
Preferred Regimen
▸ Ampicillin 2 g IV q4h
OR
▸ Penicillin G 4 MU IV q4h
PLUS
▸ Gentamicin 1.7 mg/kg IV q8h
Alternative Regimen
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
Gram-Positive (Cocco-)Bacilli
Preferred Regimen
▸ Ampicillin 2 g IV q4h
OR
▸ Penicillin G 4 MU IV q4h
PLUS
▸ Gentamicin 1.7 mg/kg IV q8h
Alternative Regimen
▸ TMP/SMZ 5 mg/kg IV q6—12h (TMP component)
OR
▸ Meropenem 2 g IV q8h
Gram-Negative Cocci in Pairs
Preferred Regimen
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
Alternative Regimen
▸ Penicillin G 4 MU IV q4h
OR
▸ Ampicillin 2 g IV q4h
OR
▸ Chloramphenicol 1—1.5 g IV q6h
OR
▸ Moxifloxacin 400 mg IV q24h
OR
▸ Aztreonam 2 g IV q6—8h
Gram-Negative Coccobacilli
Preferred Regimen
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
Alternative Regimen
▸ Chloramphenicol 1—1.5 g IV q6h
OR
▸ Cefepime 2 g IV q8h
OR
▸ Meropenem 2 g IV q8h
OR
▸ Moxifloxacin 400 mg IV q24h
Gram-Negative Bacilli
Preferred Regimen
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
Alternative Regimen
▸ Cefepime 2 g IV q8h
OR
▸ Meropenem 2 g IV q8h
OR
▸ Aztreonam 2 g IV q6—8h
OR
▸ Moxifloxacin 400 mg IV q24h
OR
▸ TMP/SMZ 5 mg/kg IV q6—12h (TMP component)


Pathogen-Based Therapy — Bacteria

▸ Click on the following categories to expand treatment regimens.[6][18]

Bacteria

  ▸  Acinetobacter baumannii

  ▸  Enterobacteriaceae

  ▸  Haemophilus influenzae

  ▸  Listeria monocytogenes

  ▸  Neisseria meningitidis

  ▸  Pseudomonas aeruginosa

  ▸  Staphylococcus aureus

  ▸  Staphylococcus epidermidis

  ▸  Streptococcus agalactiae

  ▸  Streptococcus pneumoniae

Mycobacteria

  ▸  Mycobacterium tuberculosis

Spirochetes

  ▸  Borrelia burgdorferi

  ▸  Treponema pallidum

Acinetobacter baumannii
Preferred Regimen
▸ Meropenem 2 g IV q8h
Alternative Regimen
▸ Colistin 1.25 mg/kg IV q6—12h
OR
▸ Polymyxin B 0.75—1.25 mg/kg IV q12h
Enterobacteriaceae
Preferred Regimen
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
Alternative Regimen
▸ Aztreonam 2 g IV q6—8h
OR
▸ Moxifloxacin 400 mg IV q24h
OR
▸ TMP/SMZ 5 mg/kg IV q6—12h (TMP component)
OR
▸ Meropenem 2 g IV q8h
OR
▸ Ampicillin 2 g IV q4h
H. influenzae, β-lactamase Negative
Preferred Regimen
▸ Ampicillin 2 g IV q4h
Alternative Regimen
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
OR
▸ Cefepime 2 g IV q8h
OR
▸ Chloramphenicol 1—1.5 g IV q6h
OR
▸ Aztreonam 2 g IV q6—8h
OR
▸ Moxifloxacin 400 mg IV q24h
H. influenzae, β-lactamase Positive
Preferred Regimen
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
Alternative Regimen
▸ Cefepime 2 g IV q8h
OR
▸ Chloramphenicol 1—1.5 g IV q6h
OR
▸ Aztreonam 2 g IV q6—8h
OR
▸ Moxifloxacin 400 mg IV q24h
H. influenzae, β-lactamase Negative, Ampicillin Resistant
Preferred Regimen
▸ Meropenem 2 g IV q8h
Alternative Regimen
▸ Moxifloxacin 400 mg IV q24h
Listeria monocytogenes
Preferred Regimen
▸ Ampicillin 2 g IV q4h
OR
▸ Penicillin G 4 MU IV q4h
PLUS
▸ Gentamicin 1.7 mg/kg IV q8h
Alternative Regimen
▸ TMP/SMZ 5 mg/kg IV q6—12h (TMP component)
N. meningitidis, Penicillin MIC <0.1 μg/mL
Preferred Regimen
▸ Penicillin G 4 MU IV q4h
OR
▸ Ampicillin 2 g IV q4h
Alternative Regimen
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
OR
▸ Chloramphenicol 1—1.5 g IV q6h
N. meningitidis, Penicillin MIC ≥0.1 μg/mL
Preferred Regimen
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
Alternative Regimen
▸ Cefepime 2 g IV q8h
OR
▸ Chloramphenicol 1—1.5 g IV q6h
OR
▸ Moxifloxacin 400 mg IV q24h
OR
▸ Meropenem 2 g IV q8h
Pseudomonas aeruginosa
Preferred Regimen
▸ Ceftazidime 2 g IV q8h
OR
▸ Cefepime 2 g IV q8h
PLUS
▸ Gentamicin 1.7 mg/kg IV q8h
Alternative Regimen
▸ Aztreonam 2 g IV q6—8h
OR
▸ Meropenem 2 g IV q8h
OR
▸ Ciprofloxacin 400 mg IV q8—12h
PLUS
▸ Gentamicin 1.7 mg/kg IV q8h
Staphylococcus aureus, Methicillin sensitive
Preferred Regimen
▸ Nafcillin 1.5—2 g IV q4h
OR
▸ Oxacillin 1.5—2 g IV q4h
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q6h (trough 15—20 μg/mL)
OR
▸ Linezolid 600 mg IV q12h
OR
▸ Daptomycin 6 mg/kg IV q24h
Staphylococcus aureus, Methicillin resistant
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q6h (trough 15—20 μg/mL)
PLUS
▸ Rifampin 600 mg IV q24h
Alternative Regimen
▸ TMP/SMZ 5 mg/kg IV q6—12h (TMP component)
OR
▸ Linezolid 600 mg IV q12h
OR
▸ Daptomycin 6 mg/kg IV q24h
PLUS
▸ Rifampin 600 mg IV q24h
Staphylococcus epidermidis
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q6h (trough 15—20 μg/mL)
PLUS
▸ Rifampin 600 mg IV q24h
Alternative Regimen
▸ Linezolid 600 mg IV q12h
PLUS
▸ Rifampin 600 mg IV q24h
Streptococcus agalactiae
Preferred Regimen
▸ Ampicillin 2 g IV q4h
OR
▸ Penicillin G 4 MU IV q4h
PLUS
▸ Gentamicin 1.7 mg/kg IV q8h
Alternative Regimen
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
OR
▸ Vancomycin 15 mg/kg IV q6h (trough 15—20 μg/mL)
S. pneumoniae, Penicillin MIC ≤0.06 μg/mL
Preferred Regimen
▸ Penicillin G 4 MU IV q4h
OR
▸ Ampicillin 2 g IV q4h
Alternative Regimen
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
OR
▸ Chloramphenicol 1—1.5 g IV q6h
S. pneumoniae, Penicillin MIC ≥0.12 μg/mL, Cefotaxime/Ceftriaxone MIC <1.0 μg/mL
Preferred Regimen
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
Alternative Regimen
▸ Cefepime 2 g IV q8h
OR
▸ Meropenem 2 g IV q8h
S. pneumoniae, Penicillin MIC ≥0.12 μg/mL, Cefotaxime/Ceftriaxone MIC ≥1.0 μg/mL
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q6h (trough 15—20 μg/mL)
PLUS
▸ Cefotaxime 2 g IV q4—6h
OR
▸ Ceftriaxone 2 g IV q12h
PLUS
▸ Rifampin 600 mg IV q24h
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q6h (trough 15—20 μg/mL)
PLUS
▸ Moxifloxacin 400 mg IV q24h
Mycobacterium tuberculosis (New Patients)
Intensive Phase
▸ Isoniazid 5 mg/kg PO qd × 2 months
OR
▸ Isoniazid 10 mg/kg PO 3 times per week × 2 months
PLUS
▸ Rifampicin 10 mg/kg PO qd × 2 months
OR
▸ Rifampicin 10 mg/kg PO 3 times per week × 2 months
PLUS
▸ Pyrazinamide 25 mg/kg PO qd × 2 months
OR
▸ Pyrazinamide 35 mg/kg PO 3 times per week × 2 months
PLUS
▸ Streptomycin 15 mg/kg PO qd × 2 months
OR
▸ Streptomycin 15 mg/kg PO 3 times per week × 2 months
Continuation Phase
▸ Isoniazid 5 mg/kg PO qd × 4 months
OR
▸ Isoniazid 10 mg/kg PO 3 times per week × 2 months
PLUS
▸ Rifampicin 10 mg/kg PO qd × 4 months
OR
▸ Rifampicin 10 mg/kg PO 3 times per week × 2 months
Adapted from Treatment of Tuberculosis: Guidelines.[19]
Borrelia burgdorferi
Preferred Regimen
▸ Ceftriaxone 2 g IV q24h × 10—28 days
Alternative Regimen
▸ Cefotaxime 2 g IV q8h × 10—28 days
OR
▸ Penicillin G 3—4 MU IV q4h × 10—28 days
OR
▸ Doxycycline 100—200 mg PO q12h × 10—28 days
Adapted from Clin Infect Dis. 2006;43(9):1089-134.[20]
Treponema pallidum
Preferred Regimen
▸ Penicillin G 3—4 MU IV q4h × 10—14 days
Alternative Regimen
▸ Procaine penicillin 2.4 MU IM q24h × 10—14 days
PLUS
▸ Probenecid 500 mg PO q6h × 10—14 days
Adapted from MMWR Recomm Rep. 2006;55(RR-11):1-94.[21]


Pathogen-Based Therapy — Fungi, Helminths, and Protozoan

▸ Click on the following categories to expand treatment regimens.

Fungi

  ▸  Blastomyces dermatitidis

  ▸  Candida spp.

  ▸  Coccidioides immitis

  ▸  Cryptococcus neoformans

  ▸  Histoplasma capsulatum

Helminths

  ▸  Angiostrongylus cantonensis

  ▸  Baylisascaris procyonis

  ▸  Gnathostoma spinigerum

Protozoan

  ▸  Naegleria fowleri

Blastomyces dermatitidis
Preferred Regimen
▸ Liposomal Amphotericin B 5 mg/kg/day IV × 4—6 weeks
FOLLOWED BY
▸ Fluconazole 800 mg PO qd × ≥12 months until CSF abnl resolves
OR
▸ Itraconazole 200 mg PO bid—tid × ≥12 months until CSF abnl resolves
OR
▸ Voriconazole 200—400 mg PO bid × ≥12 months until CSF abnl resolves
Adapted from Clin Infect Dis. 2008;46(12):1801-12.[22]
Candida spp.
Preferred Regimen
▸ Liposomal Amphotericin B 3—5 mg/kg/day IV
WITH OR WITHOUT
▸ Flucytosine 25 mg/kg PO qid
Alternative Regimen
▸ Fluconazole 400—800 mg PO qd (6—12 mg/kg IV q24h)
OR
▸ Voriconazole 400 mg PO bid × 2 doses FOLLOWED BY 200 mg PO bid
OR
▸ Voriconazole 6 mg/kg IV q12h × 2 doses FOLLOWED BY 3 mg/kg IV q12h
Adapted from Clin Infect Dis. 2009;48(5):503-35.[23]
Coccidioides immitis
Preferred Regimen
▸ Fluconazole 400 mg PO qd
Alternative Regimen
▸ Itraconazole 200 mg PO bid—tid
Adapted from Clin Infect Dis. 2005;41(9):1217-23.[24]
C. neoformans, HIV–infected
Induction Therapy: Preferred Regimen 1
▸ Amphotericin B 0.7—1.0 mg/kg IV q24h for ≥2 weeks
OR
▸ Liposomal Amphotericin B 3—4 mg/kg IV q24h for ≥2 weeks
OR
▸ Amphotericin B lipid complex 5 mg/kg IV q24h for ≥2 weeks
PLUS
▸ Flucytosine 25 mg/kg PO q6h for ≥2 weeks
Induction Therapy: Preferred Regimen 2
▸ Amphotericin B 0.7—1.0 mg/kg IV q24h for 4—6 weeks
OR
▸ Liposomal Amphotericin B 3—4 mg/kg IV q24h for 4—6 weeks
OR
▸ Amphotericin B lipid complex 5 mg/kg IV q24h for 4—6 weeks
Induction Therapy: Alternative Regimen 1
▸ Amphotericin B 0.7 mg/kg IV q24h for 2 weeks
PLUS
▸ Fluconazole 800 mg PO q24h for 2 weeks
Induction Therapy: Alternative Regimen 2
▸ Fluconazole 1200 mg PO q24h for 6 weeks
PLUS
▸ Flucytosine 100 mg/kg PO q24h for 6 weeks
Induction Therapy: Alternative Regimen 3
▸ Fluconazole 800—2000 mg PO q24h for 10—12 weeks
Induction Therapy: Alternative Regimen 4
▸ Itraconazole 200 mg PO q12h for 10—12 weeks
Consolidation Therapy
▸ Fluconazole 400 mg PO q24h for 8 weeks
Maintenance Therapy
▸ Fluconazole 200 mg PO q24h for ≥1 year
OR
▸ Itraconazole 400 mg PO q24h for ≥1 year
OR
▸ Amphotericin B 1.0 mg/kg/week IV for ≥1 year
C. neoformans, Organ Transplant Recipients
Induction Therapy: Preferred Regimen
▸ Liposomal Amphotericin B 3—4 mg/kg IV q24h for ≥2 weeks
OR
▸ Amphotericin B lipid complex 5 mg/kg IV q24h for ≥2 weeks
PLUS
▸ Flucytosine 25 mg/kg PO q6h for ≥2 weeks
Induction Therapy: Alternative Regimen
▸ Liposomal Amphotericin B 3—4 mg/kg IV q24h for 4—6 weeks
OR
▸ Amphotericin B lipid complex 5 mg/kg IV q24h for 4—6 weeks
Consolidation Therapy
▸ Fluconazole 400—800 mg PO q24h for 8 weeks
Maintenance Therapy
▸ Fluconazole 200—400 mg PO q24h for 6—12 months
C. neoformans, Non–HIV-Infected and Nontransplant Hosts
Induction Therapy: Preferred Regimen
▸ Amphotericin B 0.7—1.0 mg/kg IV q24h for 4—6 weeks
OR
▸ Liposomal Amphotericin B 3—4 mg/kg IV q24h for 4—6 weeks
OR
▸ Amphotericin B lipid complex 5 mg/kg IV q24h for 4—6 weeks
PLUS
▸ Flucytosine 25 mg/kg PO q6h for 4—6 weeks
Consolidation Therapy
▸ Fluconazole 400—800 mg PO q24h for 8 weeks
Maintenance Therapy
▸ Fluconazole 200 mg PO q24h for 6—12 months
Adapted from Clin Infect Dis. 2010;50(3):291-322.[25]
Histoplasma capsulatum
Preferred Regimen
▸ Liposomal Amphotericin B 5 mg/kg IV q24h for 4—6 weeks
FOLLOWED BY
▸ Itraconazole 200 mg PO bid—tid for ≥12 months
Adapted from Clin Infect Dis. 2007;45(7):807-25.[26]
Angiostrongylus cantonensis
Preferred Regimen
▸ Albendazole 15–20 mg/kg/day PO qd–bid for 10–20 days
PLUS
▸ Dexamethasone 10–20 mg PO qd for 10–20 days
Alternative Regimen
▸ Mebendazole 100 mg PO bid for 10–20 days
PLUS
▸ Dexamethasone 10–20 mg PO qd for 10–20 days
Adapted from Lancet Infect Dis. 2008;8(10):621-30. and Clin Infect Dis. 2009;48(3):322-7.[27][28]
Baylisascaris procyonis
Preferred Regimen
▸ Albendazole 25–50 mg/kg PO qd or 400 mg PO bid for 10 days
PLUS
▸ Dexamethasone 10–20 mg PO qd for 10 days
Alternative Regimen
▸ Thiabendazole 50 mg/kg/day PO bid for 10 days
PLUS
▸ Dexamethasone 10–20 mg PO qd for 10 days
Adapted from Clin Microbiol Rev. 2005;18(4):703-18. and Clin Infect Dis. 2004;15;39(10):1484-92.[29][30]
Gnathostoma spinigerum
Preferred Regimen
▸ Albendazole 400 mg PO bid for 3 weeks
PLUS
▸ Dexamethasone 10–20 mg PO qd for 3 weeks
Alternative Regimen
▸ Ivermectin 0.2 mg/kg PO qd for 2 days
PLUS
▸ Dexamethasone 10–20 mg PO qd for 3 weeks
Adapted from Clin Microbiol Rev. 2009;22(3):484-92. and Clin Infect Dis. 2009;48(3):322-7.[31][28]
Gnathostoma spinigerum
Preferred Regimen
▸ Amphotericin B 1.5 mg/kg/day IV q12h for 3 days
FOLLOWED BY
▸ Amphotericin B 1 mg/kg/day IV for 6 days
PLUS
▸ Amphotericin B 1.5 mg/kg/day intrathecal for 2 days
FOLLOWED BY
▸ Amphotericin B 1 mg/kg/day intrathecal qod for 8 days
Alternative Regimen
▸ Amphotericin B 0.25–1 mg/kg/day IV q24h for 2 weeks
PLUS
▸ Fluconazole 10 mg/kg IV q24h for 30 days
PLUS
▸ Rifampicin 10 mg/kg PO qd for 30 days
PLUS
▸ Dexamethasone 0.15 mg/kg IV q6h for 30 days
Adapted from MMWR Morb Mortal Wkly Rep. 2008;57(21):573-7. and Arch Med Res. 2005;36(1):83-6.[32][33]


References

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  2. ↑ Nau, R.; Sörgel, F.; Eiffert, H. (2010). "Penetration of drugs through the blood-cerebrospinal fluid/blood-brain barrier for treatment of central nervous system infections". Clin Microbiol Rev. 23 (4): 858–83. doi:10.1128/CMR.00007-10. PMID 20930076. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 3.2 van de Beek, D.; Drake, JM.; Tunkel, AR. (2010). "Nosocomial bacterial meningitis". N Engl J Med. 362 (2): 146–54. doi:10.1056/NEJMra0804573. PMID 20071704. Unknown parameter |month= ignored (help)
  4. ↑ Rodríguez Guardado, A.; Blanco, A.; Asensi, V.; Pérez, F.; Rial, JC.; Pintado, V.; Bustillo, E.; Lantero, M.; Tenza, E. (2008). "Multidrug-resistant Acinetobacter meningitis in neurosurgical patients with intraventricular catheters: assessment of different treatments". J Antimicrob Chemother. 61 (4): 908–13. doi:10.1093/jac/dkn018. PMID 18281693. Unknown parameter |month= ignored (help)
  5. ↑ Cruciani, M.; Navarra, A.; Di Perri, G.; Andreoni, M.; Danzi, MC.; Concia, E.; Bassetti, D. (1992). "Evaluation of intraventricular teicoplanin for the treatment of neurosurgical shunt infections". Clin Infect Dis. 15 (2): 285–9. PMID 1387805. Unknown parameter |month= ignored (help)
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM et al. (2004) Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 39 (9):1267-84. DOI:10.1086/425368 PMID: [1]
  7. ↑ Lebel, MH.; Freij, BJ.; Syrogiannopoulos, GA.; Chrane, DF.; Hoyt, MJ.; Stewart, SM.; Kennard, BD.; Olsen, KD.; McCracken, GH. (1988). "Dexamethasone therapy for bacterial meningitis. Results of two double-blind, placebo-controlled trials". N Engl J Med. 319 (15): 964–71. doi:10.1056/NEJM198810133191502. PMID 3047581. Unknown parameter |month= ignored (help)
  8. ↑ Odio, CM.; Faingezicht, I.; Paris, M.; Nassar, M.; Baltodano, A.; Rogers, J.; Sáez-Llorens, X.; Olsen, KD.; McCracken, GH. (1991). "The beneficial effects of early dexamethasone administration in infants and children with bacterial meningitis". N Engl J Med. 324 (22): 1525–31. doi:10.1056/NEJM199105303242201. PMID 2027357. Unknown parameter |month= ignored (help)
  9. ↑ Thwaites, GE.; Nguyen, DB.; Nguyen, HD.; Hoang, TQ.; Do, TT.; Nguyen, TC.; Nguyen, QH.; Nguyen, TT.; Nguyen, NH. (2004). "Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults". N Engl J Med. 351 (17): 1741–51. doi:10.1056/NEJMoa040573. PMID 15496623. Unknown parameter |month= ignored (help)
  10. ↑ Brouwer, MC.; Heckenberg, SG.; de Gans, J.; Spanjaard, L.; Reitsma, JB.; van de Beek, D. (2010). "Nationwide implementation of adjunctive dexamethasone therapy for pneumococcal meningitis". Neurology. 75 (17): 1533–9. doi:10.1212/WNL.0b013e3181f96297. PMID 20881273. Unknown parameter |month= ignored (help)
  11. ↑ Fritz, D.; Brouwer, MC.; van de Beek, D. (2012). "Dexamethasone and long-term survival in bacterial meningitis". Neurology. 79 (22): 2177–9. doi:10.1212/WNL.0b013e31827595f7. PMID 23152589. Unknown parameter |month= ignored (help)
  12. ↑ Peltola, H.; Roine, I.; Fernández, J.; Zavala, I.; Ayala, SG.; Mata, AG.; Arbo, A.; Bologna, R.; Miño, G. (2007). "Adjuvant glycerol and/or dexamethasone to improve the outcomes of childhood bacterial meningitis: a prospective, randomized, double-blind, placebo-controlled trial". Clin Infect Dis. 45 (10): 1277–86. doi:10.1086/522534. PMID 17968821. Unknown parameter |month= ignored (help)
  13. ↑ Peltola, H.; Roine, I.; Fernández, J.; González Mata, A.; Zavala, I.; Gonzalez Ayala, S.; Arbo, A.; Bologna, R.; Goyo, J. (2010). "Hearing impairment in childhood bacterial meningitis is little relieved by dexamethasone or glycerol". Pediatrics. 125 (1): e1–8. doi:10.1542/peds.2009-0395. PMID 20008417. Unknown parameter |month= ignored (help)
  14. ↑ Nguyen, TH.; Tran, TH.; Thwaites, G.; Ly, VC.; Dinh, XS.; Ho Dang, TN.; Dang, QT.; Nguyen, DP.; Nguyen, HP. (2007). "Dexamethasone in Vietnamese adolescents and adults with bacterial meningitis". N Engl J Med. 357 (24): 2431–40. doi:10.1056/NEJMoa070852. PMID 18077808. Unknown parameter |month= ignored (help)
  15. ↑ Molyneux, EM.; Walsh, AL.; Forsyth, H.; Tembo, M.; Mwenechanya, J.; Kayira, K.; Bwanaisa, L.; Njobvu, A.; Rogerson, S. (2002). "Dexamethasone treatment in childhood bacterial meningitis in Malawi: a randomised controlled trial". Lancet. 360 (9328): 211–8. PMID 12133656. Unknown parameter |month= ignored (help)
  16. ↑ Schut, ES.; Brouwer, MC.; de Gans, J.; Florquin, S.; Troost, D.; van de Beek, D. (2009). "Delayed cerebral thrombosis after initial good recovery from pneumococcal meningitis". Neurology. 73 (23): 1988–95. doi:10.1212/WNL.0b013e3181c55d2e. PMID 19890068. Unknown parameter |month= ignored (help)
  17. ↑ van de Beek D, de Gans J, Tunkel AR, Wijdicks EF (2006) Community-acquired bacterial meningitis in adults. N Engl J Med 354 (1):44-53. DOI:10.1056/NEJMra052116 PMID: 16394301
  18. ↑ 18.0 18.1 18.2 van de Beek, D.; Brouwer, MC.; Thwaites, GE.; Tunkel, AR. (2012). "Advances in treatment of bacterial meningitis". Lancet. 380 (9854): 1693–702. doi:10.1016/S0140-6736(12)61186-6. PMID 23141618. Unknown parameter |month= ignored (help)
  19. ↑ Treatment of tuberculosis : guidelin. Geneva: World Health Organization. 2010. ISBN 978-92-4-154783-3.
  20. ↑ Wormser, GP.; Dattwyler, RJ.; Shapiro, ED.; Halperin, JJ.; Steere, AC.; Klempner, MS.; Krause, PJ.; Bakken, JS.; Strle, F. (2006). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clin Infect Dis. 43 (9): 1089–134. doi:10.1086/508667. PMID 17029130. Unknown parameter |month= ignored (help)
  21. ↑ Workowski, KA.; Berman, SM. (2006). "Sexually transmitted diseases treatment guidelines, 2006". MMWR Recomm Rep. 55 (RR-11): 1–94. PMID 16888612. Unknown parameter |month= ignored (help)
  22. ↑ Chapman, SW.; Dismukes, WE.; Proia, LA.; Bradsher, RW.; Pappas, PG.; Threlkeld, MG.; Kauffman, CA. (2008). "Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America". Clin Infect Dis. 46 (12): 1801–12. doi:10.1086/588300. PMID 18462107. Unknown parameter |month= ignored (help)
  23. ↑ Pappas, PG.; Kauffman, CA.; Andes, D.; Benjamin, DK.; Calandra, TF.; Edwards, JE.; Filler, SG.; Fisher, JF.; Kullberg, BJ. (2009). "Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America". Clin Infect Dis. 48 (5): 503–35. doi:10.1086/596757. PMID 19191635. Unknown parameter |month= ignored (help)
  24. ↑ Galgiani, JN.; Ampel, NM.; Blair, JE.; Catanzaro, A.; Johnson, RH.; Stevens, DA.; Williams, PL. (2005). "Coccidioidomycosis". Clin Infect Dis. 41 (9): 1217–23. doi:10.1086/496991. PMID 16206093. Unknown parameter |month= ignored (help)
  25. ↑ Perfect, JR.; Dismukes, WE.; Dromer, F.; Goldman, DL.; Graybill, JR.; Hamill, RJ.; Harrison, TS.; Larsen, RA.; Lortholary, O. (2010). "Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america". Clin Infect Dis. 50 (3): 291–322. doi:10.1086/649858. PMID 20047480. Unknown parameter |month= ignored (help)
  26. ↑ Wheat, LJ.; Freifeld, AG.; Kleiman, MB.; Baddley, JW.; McKinsey, DS.; Loyd, JE.; Kauffman, CA. (2007). "Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America". Clin Infect Dis. 45 (7): 807–25. doi:10.1086/521259. PMID 17806045. Unknown parameter |month= ignored (help)
  27. ↑ Wang, QP.; Lai, DH.; Zhu, XQ.; Chen, XG.; Lun, ZR. (2008). "Human angiostrongyliasis". Lancet Infect Dis. 8 (10): 621–30. doi:10.1016/S1473-3099(08)70229-9. PMID 18922484. Unknown parameter |month= ignored (help)
  28. ↑ 28.0 28.1 Ramirez-Avila, L.; Slome, S.; Schuster, FL.; Gavali, S.; Schantz, PM.; Sejvar, J.; Glaser, CA. (2009). "Eosinophilic meningitis due to Angiostrongylus and Gnathostoma species". Clin Infect Dis. 48 (3): 322–7. doi:10.1086/595852. PMID 19123863. Unknown parameter |month= ignored (help)
  29. ↑ Gavin, PJ.; Kazacos, KR.; Shulman, ST. (2005). "Baylisascariasis". Clin Microbiol Rev. 18 (4): 703–18. doi:10.1128/CMR.18.4.703-718.2005. PMID 16223954. Unknown parameter |month= ignored (help)
  30. ↑ Murray, WJ.; Kazacos, KR. (2004). "Raccoon roundworm encephalitis". Clin Infect Dis. 39 (10): 1484–92. doi:10.1086/425364. PMID 15546085. Unknown parameter |month= ignored (help)
  31. ↑ Herman, JS.; Chiodini, PL. (2009). "Gnathostomiasis, another emerging imported disease". Clin Microbiol Rev. 22 (3): 484–92. doi:10.1128/CMR.00003-09. PMID 19597010. Unknown parameter |month= ignored (help)
  32. ↑ "Primary amebic meningoencephalitis--Arizona, Florida, and Texas, 2007". MMWR Morb Mortal Wkly Rep. 57 (21): 573–7. 2008. PMID 18509301. Unknown parameter |month= ignored (help)
  33. ↑ Vargas-Zepeda, J.; Gómez-Alcalá, AV.; Vásquez-Morales, JA.; Licea-Amaya, L.; De Jonckheere, JF.; Lares-Villa, F. "Successful treatment of Naegleria fowleri meningoencephalitis by using intravenous amphotericin B, fluconazole and rifampicin". Arch Med Res. 36 (1): 83–6. PMID 15900627.
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