Sandbox/v30: Difference between revisions

	Meningitis Main Page
Patient Information
Overview
Causes
Classification Viral Meningitis Bacterial Meningitis Fungal Meningitis
Differential Diagnosis
Diagnosis
Treatment

VisualWikitext

Revision as of 02:09, 20 January 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2], Sheng Shi, M.D. [3]

Overview

If the suspected patient complaints with fever, headache, altered level of consciousness, signs of meningeal irritationthe, blood culture or CSF should be obtained urgently, then CT. But DO NOT wait for the results of the CT scan and the lumbar puncture; empiric treatment should be started as soon as possible.

Blood cultures should be drawn before starting the antibiotic therapy, and then the antibiotic treatment should be changed once the blood culture results are out.

Empiric antibiotic treatment should be started within 30 minutes after the patient presentation.

In case of high suspicion of pneumococcal meningitis in adult patients, 0.15 mg/kg IV Q6H dexomethasone should be administered for 2 to 4 days.

The first dose of dexomethasone is given along with or 20 minutes prior to starting the antibiotics treatment.^[1]^[2]^[3]

Empiric Therapy

Community-Acquired Meningitis

Newborn, Age <1 Week
Preferred Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Cefotaxime 100—150 mg/kg/day IV q8—12h
Alternative Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Gentamicin 2.5 mg/kg IV q12h
Newborn, Age 1—4 Weeks
Preferred Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Cefotaxime 150—200 mg/kg/day IV q6—8h
Alternative Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Gentamicin 2.5 mg/kg IV q8h OR ▸Tobramycin2.5 mg/kg IV q8h OR ▸ Amikacin 10 mg/kg IV q8h
Infant and Children^†
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q6h to achieve serum trough concentrations of 15–20 μg/mL
AND
▸ Cefotaxime 225—300 mg/kg/day IV q6–8h OR ▸Ceftriaxone 80—100 mg/kg/day IV q12–24h

Adult, Age <50 Years^†
Preferred Regimen
▸ Vancomycin 30–60 mg/kg/day IV q8–12h to achieve serum trough concentrations of 15–20 μg/mL
AND
▸ Cefotaxime 8–12 g/day IV q4–6h OR ▸Ceftriaxone 2 g IV q12h
Adult, Age >50 Years
Preferred Regimen
▸ Vancomycin 30–60 mg/kg/day IV q8–12h
AND
▸ Ampicillin 2 g IV q4h
AND
▸ Cefotaxime 8–12 g/day IV q4–6h OR ▸Ceftriaxone 2 g IV q12h
Immunocompromised
Preferred Regimen
▸ Vancomycin 30–60 mg/kg/day IV q8–12h
AND
▸ Ampicillin 2 g IV q4h
AND
▸ Cefepime 2 g IV q8h OR ▸ Meropenem 2 g IV q8h
Recurrent
Preferred Regimen
▸ Vancomycin 30—60 mg/kg/day IV q8–12h
AND
▸ Cefotaxime 8–12 g/day IV q4–6h OR ▸Ceftriaxone 2 g IV q12h

^†Add Ampicillin 2 g IV q4h (50 mg/kg IV q6h for children) if meningitis caused by Listeria monocytogenes is also suspected.

Healthcare-Associated Meningitis

Basilar Skull Fracture
Preferred Regimen
▸ Vancomycin 30—60 mg/kg/day IV q8–12h
AND
▸ Cefotaxime 8–12 g/day IV q4–6h OR ▸Ceftriaxone 2 g IV q12h

Head Trauma; Post-Neurosurgery
Preferred Regimen
▸ Vancomycin 30—60 mg/kg/day IV q8–12h
AND
▸ Ceftazidime 2 g IV q8 h OR ▸ Cefepime 2 g IV q8h OR ▸ Meropenem 2 g IV q8h

Adapted from Advances in treatment of bacterial meningitis. Lancet. 2012;380(9854):1693-702.^[4]

References

↑ 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
↑ Edmond K, Clark A, Korczak VS, Sanderson C, Griffiths UK, Rudan I (2010) Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis. Lancet Infect Dis 10 (5):317-28. DOI:10.1016/S1473-3099(10)70048-7 PMID: 20417414
↑ 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: 15494903
↑ 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)

[pmid16394301-1] 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

[pmid20417414-2] Edmond K, Clark A, Korczak VS, Sanderson C, Griffiths UK, Rudan I (2010) Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis. Lancet Infect Dis 10 (5):317-28. DOI:10.1016/S1473-3099(10)70048-7 PMID: 20417414

[pmid15494903-3] 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: 15494903

[van_de_Beek-2012-4] 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)

[1]

[2]

[3]

[4]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Meningitis}}
+{{CMG}}; {{AE}} {{CZ}}, {{SS}}
-{{CMG}}; {{AE}} {{CZ}}, {{SS}}
+==Overview==
-==Empiric Therapy==
+* If the suspected patient complaints with fever, headache, altered level of consciousness, signs of meningeal irritationthe, blood culture or CSF should be obtained urgently, then CT. But DO NOT wait for the results of the CT scan and the lumbar puncture; empiric treatment should be started as soon as possible.
-* If the suspected patient complaints with fever,headache,altered level of consciousness, signs of meningeal irritationthe, blood culture or CSF should be obtained urgently,then CT.But DO NOT wait for the results of the [[CT scan]] and the [[lumbar puncture]]; empiric treatment should be started as soon as possible.
 * Blood cultures should be drawn before starting the [[antibiotic]] therapy, and then the antibiotic treatment should be changed once the blood culture results are out.
 * Empiric antibiotic treatment should be started within 30 minutes after the patient presentation.
 * In case of high suspicion of pneumococcal meningitis in adult patients, 0.15 mg/kg IV Q6H dexomethasone should be administered for 2 to 4 days.
-** The first dose of dexomethasone is given along with or 20 minutes prior to starting the antibiotics treatment.<ref name="pmid16394301">van de Beek D, de Gans J, Tunkel AR, Wijdicks EF (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16394301 Community-acquired bacterial meningitis in adults.] ''N Engl J Med'' 354 (1):44-53. [http://dx.doi.org/10.1056/NEJMra052116 DOI:10.1056/NEJMra052116] PMID: [http://pubmed.gov/16394301 16394301]</ref><ref name="pmid20417414">Edmond K, Clark A, Korczak VS, Sanderson C, Griffiths UK, Rudan I (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20417414 Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis.] ''Lancet Infect Dis'' 10 (5):317-28. [http://dx.doi.org/10.1016/S1473-3099(10)70048-7 DOI:10.1016/S1473-3099(10)70048-7] PMID: [http://pubmed.gov/20417414 20417414]</ref><ref name="pmid15494903">Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15494903 Practice guidelines for the management of bacterial meningitis.] ''Clin Infect Dis'' 39 (9):1267-84. [http://dx.doi.org/10.1086/425368 DOI:10.1086/425368] PMID: [http://pubmed.gov/15494903 15494903]</ref>
+:* The first dose of dexomethasone is given along with or 20 minutes prior to starting the antibiotics treatment.<ref name="pmid16394301">van de Beek D, de Gans J, Tunkel AR, Wijdicks EF (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16394301 Community-acquired bacterial meningitis in adults.] ''N Engl J Med'' 354 (1):44-53. [http://dx.doi.org/10.1056/NEJMra052116 DOI:10.1056/NEJMra052116] PMID: [http://pubmed.gov/16394301 16394301]</ref><ref name="pmid20417414">Edmond K, Clark A, Korczak VS, Sanderson C, Griffiths UK, Rudan I (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20417414 Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis.] ''Lancet Infect Dis'' 10 (5):317-28. [http://dx.doi.org/10.1016/S1473-3099(10)70048-7 DOI:10.1016/S1473-3099(10)70048-7] PMID: [http://pubmed.gov/20417414 20417414]</ref><ref name="pmid15494903">Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15494903 Practice guidelines for the management of bacterial meningitis.] ''Clin Infect Dis'' 39 (9):1267-84. [http://dx.doi.org/10.1086/425368 DOI:10.1086/425368] PMID: [http://pubmed.gov/15494903 15494903]</ref>
+==Empiric Therapy==
+<div style="float: left;">
 <div class="mw-collapsible mw-collapsed">
@@ Line 163: / Line 170: @@
 </div></div>
-==Pathogen-Based Therapy==
+</div>
-<div class="mw-collapsible mw-collapsed">
-=====''Streptococcus pneumoniae''=====
-<div class="mw-collapsible-content">
+<div style="text-align: left;">
+<div style="margin: auto; clear: both;">
-{|
+</div>
-|-
+</div>
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|[[Penicillin]] MIC ≤0.06 μg/mL}}''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] Low: 600,000–1.2 million units/day IM; High:≥ 20 million units IV q24h(=12 g)'''''<BR>''OR''<BR>▸ '''''[[Ampicillin]] 150–200 mg/kg IV q3-4h'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR>▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''<BR>''OR''<BR>▸ '''''[[Chloramphenicol]] 0.25–1 g po IV q6h to max. of 4 g/day'''''
-|-
-|}
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|[[Penicillin]] MIC ≥0.12 μg/mL}}''
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|[[Cefotaxime]] or [[Ceftriaxone]] MIC† <1.0 μg/mL}}
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR>▸ '''''[[Ceftriaxone]] 1 g IV qd  (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 1–2 g IV q12h'''''<BR>''OR''<BR>▸ '''''[[Meropenem]] 2 g IV q8h'''''
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|[[Cefotaxime]] or [[Ceftriaxone]] MIC† >1.0 μg/mL}}
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. )'''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ''AND''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h''''' <BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''<sup>‡</sup>
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. )'''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ''AND''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Moxiﬂoxacin]] 400 mg po IV q24h '''''<sup>ɸ</sup>
-|-
-|}
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-=====''Neisseria meningitidis''=====
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Neisseria meningitidis}}''
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|[[Penicillin]] MIC <0.1 μg/mL}}
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] Low: 600,000–1.2 million units/day IM; High:≥ 20 million units IV q24h(=12 g)'''''<BR>''OR''<BR>▸ '''''[[Ampicillin]] 0.25–0.5 g po q6h.150–200 mg/kg/day IV'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''<BR>''OR''<BR>▸ '''''[[Chloramphenicol]] 0.25–1 g po IV q6h to max. of 4 g/day'''''<BR><BR><BR>
-|-
-|}
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Neisseria meningitidis}}''
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|[[Penicillin]] MIC ≥0.1 μg/mL}}
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR>▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 1–2 g IV q12h'''''<BR>''OR''<BR>▸ '''''[[Chloramphenicol]] 0.25–1 g po IV q6h to max. of 4 g/day'''''<BR>''OR''<BR>▸ '''''[[Fluoroquinolone]]'''''<sup>Δ</sup><BR>''OR''<BR>▸ '''''[[Meropenem]] 2 g IV q8h'''''
-|-
-|}
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-=====''Listeria monocytogenes'' and ''Streptococcus agalactiae''=====
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Listeria Monocytogenes}}''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 0.25–0.5 g po q6h.150–200 mg/kg/day IV'''''<BR>''OR''<BR>▸ '''''[[Penicillin G]] Low: 600,000–1.2 million units/day IM ;High:≥ 20 million units IV q24h(=12 g)'''''<sup>£</sup>
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Trimethoprim-sulfamethoxazole]] 5–20 mg/kg/day q6-12h '''''
-|-
-|}
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Streptococcus agalactiae}}''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 0.25–0.5 g po q6h.150–200 mg/kg/day IV'''''<BR>''OR''<BR>▸ '''''[[Penicillin G]] Low: 600,000–1.2 million units/day IM ;High:≥ 20 million units IV q24h(=12 g)'''''<sup>£</sup>
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR>
-▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''<BR>''OR''<BR>▸ '''''[[Vancomycin]] give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. )'''''
-|-
-|}
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-=====''Haemophilus inﬂuenzae''=====
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Haemophilus inﬂuenzae <BR> β-lactamase negative}}''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 0.25–0.5 g po q6h.150–200 mg/kg/day IV'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR>▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''<BR>''OR''<BR>▸ '''''[[Cefepime]] 1–2 g IV q12h'''''<BR>''OR''<BR>▸ '''''[[Chloramphenicol]] 0.25–1 g po IV q6h to max. of 4 g/day'''''<BR>''OR''<BR>▸ '''''[[Aztreonam]] 1 g IV q8h–2 g IV q6h'''''<BR>''OR''<BR>▸ '''''[[Fluoroquinolone]]'''''<sup>Δ</sup>
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|β-lactamase negative, ampicillin resistant}}
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Meropenem]] 2 g IV q8h'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Fluoroquinolone]]'''''<sup>Δ</sup>
-|}
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Haemophilus inﬂuenzae <BR> β-lactamase positive}}''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR>▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 1–2 g IV q12h'''''<BR>''OR''<BR>▸ '''''[[Chloramphenicol]] 0.25–1 g po IV q6h to max. of 4 g/day'''''<BR>''OR''<BR>▸ '''''[[Aztreonam]] 1 g q8h–2 g IV q6h'''''<BR>''OR''<BR>▸ '''''[[Fluoroquinolone]]'''''<sup>Δ</sup>
-|-
-|}
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-=====''Staphylococcus aureus''=====
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Staphylococcus aureus <BR> Meticillin sensitive}}''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nafcillin]] 1–2 g IV/IM q4h<BR>''OR''<BR>▸ '''''[[Oxacillin]] 1–2 g IV/IM q4h
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. )'''''<BR>''OR''<BR>▸ '''''[[linezolid]] 600 mg IV/PO q12h<BR>''OR''<BR>▸ '''''[[Daptomycin]] 6 mg/kg IV q24h'''''
-|-
-|}
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Staphylococcus aureus <BR> Meticillin resistant}}<sup>₦</sup>
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. )'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Trimethoprim-sulfamethoxazole]]  5–20 mg/kg/day q6-12h<BR>''OR''<BR>▸ '''''[[linezolid]] 600 mg IV/PO q12h<BR>''OR''<BR>▸ '''''[[Daptomycin]] 6 mg/kg IV q24h '''''<BR><BR><BR>
-|-
-|}
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-=====''Staphylococcus epidermidis'' and ''Acinetobacter baumannii''<sup>Ω</sup>=====
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Staphylococcus epidermidis}}<sup>₦</sup>
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. )'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]] 600 mg IV/PO q12h<BR><BR><BR><BR><BR>
-|-
-|}
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Acinetobacter baumannii}}
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Meropenem]] 2 g IV q8h'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Colistin]] <BR>in US:2.5-5 mg/kg/day q6-12h( 6.7-13.3 mg/kg/day of colistimethate sodium (CMS),max 800 mg/day); <BR>Elsewhere: ≤60 kg, 50,000-75,000 IU/kg/day IV q8h (=4-6 mg/kg per day of CMS). >60 kg, 1-2 mill IU IV q8h (= 80-160 mg IV tid).''''' <BR>''OR''<BR>▸ '''''[[Polymyxin B]] 15,000–25,000 units/kg/day q12h<sup>ǂ</sup>
-|-
-|}
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-=====''Enterobacteriaceae'' and ''Pseudomonas aeruginosa''=====
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em; height: 25em;" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Enterobacteriaceae}}<sup>Ω</sup>
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 1 g IV qd (2 g IV q12h for Purulent meningitis  also IM in 1% lidocaine)'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Aztreonam]] 1 g q8h–2 g IV q6h''''' <BR> ''OR'' <BR> ▸ '''''[[Fluoroquinolone]]'''''<sup>Δ</sup><BR> ''OR'' <BR> ▸ '''''[[Trimethoprim-sulfamethoxazole]] 5–20 mg/kg/day q6-12h''''' <BR> ''OR'' <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''<BR> ''OR'' <BR>▸ '''''[[Ampicillin]] 150–200 mg/kg/day IV'''''
-|-
-|}
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:39em; height: 25em;" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pseudomonas aeruginosa}}''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftazidime ]] 1–2 g IV/IM q8–12h'''''<BR>''OR''<BR>▸ '''''[[Cefepime]] 1–2 g IV q12h'''''<sup>£</sup>
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Aztreonam]] 1 g q8h–2 g IV q6h'''''<BR>''OR''<BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''<BR>''OR''<BR> ▸ '''''[[Ciproﬂoxacin]] 500-750 mg po bid'''''<sup>£</sup><BR><BR><BR><BR><BR>
-|-
-|}
-|}
-<BR><SMALL><sup>†</sup> MIC = minimum inhibitory concentration.‡Addition of rifampicin can be considered if the organism is susceptible, the expected clinical or bacteriological response is delayed, or the cefotaxime/ceftriaxone MIC of the pneumococcal isolate is >4.0 μg/mL organism is susceptible, the expected clinical or bacteriological response is delayed, or the cefotaxime/ceftriaxone MIC.
-<sup>Φ</sup> No clinical data exist for use of this agent in patients with pneumococcal meningitis; recommendation is based on cerebrospinal ﬂuid penetration and in-vitro activity against S. pneumoniae.
-<sup>£</sup> Addition of an aminoglycoside should be considered; might need intraventricular or intrathecal administration in Gram-negative meningitis.
-<sup>ǁ</sup> Addition of rifampicin should be considered.
-<sup>Ω</sup> Choice of a speciﬁc agent should be based on in-vitro susceptibility testing.
-<sup>††</sup> Might also need to be administered by the intraventricular or intrathecal routes.
-<sup>ǂ</sup> Might also need to be administered by the intraventricular or intrathecal routes.
-<sup>₦</sup> Addition of rifampicin should be considered.
-<sup>Δ</sup> The ﬂuoroquinolones gatiﬂoxacin and moxiﬂoxacin pene trate the CSF eﬀectively and have greater in-vitro activity against Gram-positive bacteria than do their earlier counterparts (eg, ciprofloxacin). Findings from experi mental meningitis models suggested their eﬃcacy in S. pneumoniae meningitis, including that caused by penicillin-resistant and cephalosporin-resistant strains. Although one controlled trial suggested the ﬂuoroquinolone trovaﬂ -oxacin mesilate to be as eﬀ  ective as ceftriaxone, with or without the addition of vancomycin, for paediatric bacterial meningitis, no clinical trials describe the use of gatiﬂoxacin or moxiﬂoxacin to treat bacterial meningitis in human beings. Trovaﬂoxacin and gatiﬂoxacin have been asso ciated with serious hepatic toxicity and dysglycaemia, respectively, and were with drawn from many markets. The IDSA guidelines recommend moxiﬂoxacin as an alternative to third-generation cephalosporins plus vancomycin for meningitis caused by S. pneumoniae strains resistant to penicillin and third-generation cephalosporins, although some experts recom mend that this agent should not be used alone but rather should be combined with another drug (either vancomycin or a third-generation cephalosporin), because of the absence of clinical data supporting its use.
-</SMALL>
-</div></div>
 ==References==
-{{reflist|2}}
+{{Reflist|2}}
-[[Category:Needs overview]]
 [[Category:Primary care]]
 [[Category:Disease]]
@@ Line 496: / Line 188: @@
 [[Category:Inflammations]]
 [[Category:Neurological disorders]]
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