Meningitis medical therapy: Difference between revisions

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{{Meningitis}}


{{CMG}}; {{AE}} {{CZ}}, {{SS}}
==Principles of Therapy for Bacterial Meningitis==
====Overview====
* Acute bacterial meningitis is a medical emergency; commence empiric treatment after obtaining blood and/or [[cerebrospinal fluid|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.
====Factors Determining Antimicrobial Activity====
* Factors determine the acitivity of antimicrobial agents include [[pharmacodynamics]], [[pharmacokinetics]], penetration into the CSF, and [[bactericidal]] activity within the CSF.<ref name="Andes-1999">{{Cite journal  | last1 = Andes | first1 = DR. | last2 = Craig | first2 = WA. | title = Pharmacokinetics and pharmacodynamics of antibiotics in meningitis. | journal = Infect Dis Clin North Am | volume = 13 | issue = 3 | pages = 595-618 | month = Sep | year = 1999 | doi =  | PMID = 10470557 }}</ref>
* [[Beta-lactam]]s, [[aminoglycoside]]s, [[glycopeptide]]s, [[linezolid]], and [[daptomycin]] are considered to have poor penetration into the CSF, while [[fluoroquinolone]]s, [[chloramphenicol]], [[aztreonam]], and [[tigecycline]] generally achieve [[MIC|minimum inhibitory concentration (MIC)]] in the CSF at standard dosage.<ref name="Nau-2010">{{Cite journal  | last1 = Nau | first1 = R. | last2 = Sörgel | first2 = F. | last3 = Eiffert | first3 = H. | title = Penetration of drugs through the blood-cerebrospinal fluid/blood-brain barrier for treatment of central nervous system infections. | journal = Clin Microbiol Rev | volume = 23 | issue = 4 | pages = 858-83 | month = Oct | year = 2010 | doi = 10.1128/CMR.00007-10 | PMID = 20930076 }}</ref>
* [[Aminoglycoside]]s and [[fluoroquinolone]]s express a concentration-dependent manner of bactericidal activity; [[beta-lactam]]s 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).
* Penetration into the CSF is less prominent for drugs with a high [[molecular weight]], high protein-binding ability, low lipid solubility, and drugs that are subject to [[active transport]] in the [[choroid plexus]] such as [[penicillin]]s and [[cephalosporin]]s. Toxicity due to dose escalation may limit the usage the [[aminoglycoside]]s, [[glycopeptide]]s, and [[polymyxin]]s, thus [[intrathecal]] or [[intraventricular]] administration might be occasionally required (see table below).
{| style="border: 2px solid #696969;" align="center"
|+ <SMALL>''Recommended Doses of Antimicrobial Agents via the Intraventricular Route.''<ref name="van de Beek-2010">{{Cite journal  | last1 = van de Beek | first1 = D. | last2 = Drake | first2 = JM. | last3 = Tunkel | first3 = AR. | title = Nosocomial bacterial meningitis. | journal = N Engl J Med | volume = 362 | issue = 2 | pages = 146-54 | month = Jan | year = 2010 | doi = 10.1056/NEJMra0804573 | PMID = 20071704 }}</ref><ref name="Rodríguez Guardado-2008">{{Cite journal  | last1 = Rodríguez Guardado | first1 = A. | last2 = Blanco | first2 = A. | last3 = Asensi | first3 = V. | last4 = Pérez | first4 = F. | last5 = Rial | first5 = JC. | last6 = Pintado | first6 = V. | last7 = Bustillo | first7 = E. | last8 = Lantero | first8 = M. | last9 = Tenza | first9 = E. | title = Multidrug-resistant Acinetobacter meningitis in neurosurgical patients with intraventricular catheters: assessment of different treatments. | journal = J Antimicrob Chemother | volume = 61 | issue = 4 | pages = 908-13 | month = Apr | year = 2008 | doi = 10.1093/jac/dkn018 | PMID = 18281693 }}</ref><ref name="Cruciani-1992">{{Cite journal  | last1 = Cruciani | first1 = M. | last2 = Navarra | first2 = A. | last3 = Di Perri | first3 = G. | last4 = Andreoni | first4 = M. | last5 = Danzi | first5 = MC. | last6 = Concia | first6 = E. | last7 = Bassetti | first7 = D. | title = Evaluation of intraventricular teicoplanin for the treatment of neurosurgical shunt infections. | journal = Clin Infect Dis | volume = 15 | issue = 2 | pages = 285-9 | month = Aug | year = 1992 | doi =  | PMID = 1387805 }}</ref></SMALL>
| style="background: #A5B2D6; border: 0px solid #696969; padding: 0 5px; width: 200px"| '''Antimicrobial Agent''' || style="background: #A5B2D6; border: 0px solid #696969; padding: 0 5px; width: 200px" | '''Daily Intraventricular Dose'''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Vancomycin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''5—20 mg'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Gentamicin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''4—8 mg'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Tobramycin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''5—20 mg'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Amikacin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''5—50 mg'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Polymyxin B]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''5 mg'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Colistin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''10 mg'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Quinupristin dalfopristin|Quinupristin/Dalfopristin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''2—5 mg'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Teicoplanin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''5—40 mg'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Amphotericin B]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''0.1—0.5 mg/day'''''
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|}
====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 [[meninges|meningeal]] inflammation subsides, especially when [[dexamethasone]] is co-administered.
{| style="border: 2px solid #696969;" align="center"
|+ <SMALL>''Recommended Duration of Antimicrobial Therapy Based on Isolated Pathogen.''<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/1549490315494903]</ref></SMALL>
| style="background: #A5B2D6; border: 0px solid #696969; padding: 0 5px; width: 200px"| '''''Microorganism''''' || style="background: #A5B2D6; border: 0px solid #696969; padding: 0 5px; width: 200px" | '''Duration of Therapy'''
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| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Neisseria meningitidis]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''7 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Haemophilus influenzae]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''7 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Streptococcus pneumoniae]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''10—14 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Streptococcus agalactiae]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''14—21 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Gram-negative bacteria|Aerobic Gram-negative bacilli]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |  '''''21 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Listeria monocytogenes]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''≥21 days'''''
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|}
====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.<ref name="Lebel-1988">{{Cite journal  | last1 = Lebel | first1 = MH. | last2 = Freij | first2 = BJ. | last3 = Syrogiannopoulos | first3 = GA. | last4 = Chrane | first4 = DF. | last5 = Hoyt | first5 = MJ. | last6 = Stewart | first6 = SM. | last7 = Kennard | first7 = BD. | last8 = Olsen | first8 = KD. | last9 = McCracken | first9 = GH. | title = Dexamethasone therapy for bacterial meningitis. Results of two double-blind, placebo-controlled trials. | journal = N Engl J Med | volume = 319 | issue = 15 | pages = 964-71 | month = Oct | year = 1988 | doi = 10.1056/NEJM198810133191502 | PMID = 3047581 }}</ref><ref name="Odio-1991">{{Cite journal  | last1 = Odio | first1 = CM. | last2 = Faingezicht | first2 = I. | last3 = Paris | first3 = M. | last4 = Nassar | first4 = M. | last5 = Baltodano | first5 = A. | last6 = Rogers | first6 = J. | last7 = Sáez-Llorens | first7 = X. | last8 = Olsen | first8 = KD. | last9 = McCracken | first9 = GH. | title = The beneficial effects of early dexamethasone administration in infants and children with bacterial meningitis. | journal = N Engl J Med | volume = 324 | issue = 22 | pages = 1525-31 | month = May | year = 1991 | doi = 10.1056/NEJM199105303242201 | PMID = 2027357 }}</ref><ref name="Thwaites-2004">{{Cite journal  | last1 = Thwaites | first1 = GE. | last2 = Nguyen | first2 = DB. | last3 = Nguyen | first3 = HD. | last4 = Hoang | first4 = TQ. | last5 = Do | first5 = TT. | last6 = Nguyen | first6 = TC. | last7 = Nguyen | first7 = QH. | last8 = Nguyen | first8 = TT. | last9 = Nguyen | first9 = NH. | title = Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. | journal = N Engl J Med | volume = 351 | issue = 17 | pages = 1741-51 | month = Oct | year = 2004 | doi = 10.1056/NEJMoa040573 | PMID = 15496623 }}</ref><ref name="Brouwer-2010">{{Cite journal  | last1 = Brouwer | first1 = MC. | last2 = Heckenberg | first2 = SG. | last3 = de Gans | first3 = J. | last4 = Spanjaard | first4 = L. | last5 = Reitsma | first5 = JB. | last6 = van de Beek | first6 = D. | title = Nationwide implementation of adjunctive dexamethasone therapy for pneumococcal meningitis. | journal = Neurology | volume = 75 | issue = 17 | pages = 1533-9 | month = Oct | year = 2010 | doi = 10.1212/WNL.0b013e3181f96297 | PMID = 20881273 }}</ref><ref name="Fritz-2012">{{Cite journal  | last1 = Fritz | first1 = D. | last2 = Brouwer | first2 = MC. | last3 = van de Beek | first3 = D. | title = Dexamethasone and long-term survival in bacterial meningitis. | journal = Neurology | volume = 79 | issue = 22 | pages = 2177-9 | month = Nov | year = 2012 | doi = 10.1212/WNL.0b013e31827595f7 | PMID = 23152589 }}</ref><ref name="Peltola-2007">{{Cite journal  | last1 = Peltola | first1 = H. | last2 = Roine | first2 = I. | last3 = Fernández | first3 = J. | last4 = Zavala | first4 = I. | last5 = Ayala | first5 = SG. | last6 = Mata | first6 = AG. | last7 = Arbo | first7 = A. | last8 = Bologna | first8 = R. | last9 = Miño | first9 = G. | title = Adjuvant glycerol and/or dexamethasone to improve the outcomes of childhood bacterial meningitis: a prospective, randomized, double-blind, placebo-controlled trial. | journal = Clin Infect Dis | volume = 45 | issue = 10 | pages = 1277-86 | month = Nov | year = 2007 | doi = 10.1086/522534 | PMID = 17968821 }}</ref> However, other studies fail to demonstrate a substantial reduction of death or neurological disability.<ref name="van de Beek-2010">{{Cite journal  | last1 = van de Beek | first1 = D. | last2 = Farrar | first2 = JJ. | last3 = de Gans | first3 = J. | last4 = Mai | first4 = NT. | last5 = Molyneux | first5 = EM. | last6 = Peltola | first6 = H. | last7 = Peto | first7 = TE. | last8 = Roine | first8 = I. | last9 = Scarborough | first9 = M. | title = Adjunctive dexamethasone in bacterial meningitis: a meta-analysis of individual patient data. | journal = Lancet Neurol | volume = 9 | issue = 3 | pages = 254-63 | month = Mar | year = 2010 | doi = 10.1016/S1474-4422(10)70023-5 | PMID = 20138011 }}</ref><ref name="Peltola-2010">{{Cite journal  | last1 = Peltola | first1 = H. | last2 = Roine | first2 = I. | last3 = Fernández | first3 = J. | last4 = González Mata | first4 = A. | last5 = Zavala | first5 = I. | last6 = Gonzalez Ayala | first6 = S. | last7 = Arbo | first7 = A. | last8 = Bologna | first8 = R. | last9 = Goyo | first9 = J. | title = Hearing impairment in childhood bacterial meningitis is little relieved by dexamethasone or glycerol. | journal = Pediatrics | volume = 125 | issue = 1 | pages = e1-8 | month = Jan | year = 2010 | doi = 10.1542/peds.2009-0395 | PMID = 20008417 }}</ref><ref name="Nguyen-2007">{{Cite journal  | last1 = Nguyen | first1 = TH. | last2 = Tran | first2 = TH. | last3 = Thwaites | first3 = G. | last4 = Ly | first4 = VC. | last5 = Dinh | first5 = XS. | last6 = Ho Dang | first6 = TN. | last7 = Dang | first7 = QT. | last8 = Nguyen | first8 = DP. | last9 = Nguyen | first9 = HP. | title = Dexamethasone in Vietnamese adolescents and adults with bacterial meningitis. | journal = N Engl J Med | volume = 357 | issue = 24 | pages = 2431-40 | month = Dec | year = 2007 | doi = 10.1056/NEJMoa070852 | PMID = 18077808 }}</ref><ref name="Molyneux-2002">{{Cite journal  | last1 = Molyneux | first1 = EM. | last2 = Walsh | first2 = AL. | last3 = Forsyth | first3 = H. | last4 = Tembo | first4 = M. | last5 = Mwenechanya | first5 = J. | last6 = Kayira | first6 = K. | last7 = Bwanaisa | first7 = L. | last8 = Njobvu | first8 = A. | last9 = Rogerson | first9 = S. | title = Dexamethasone treatment in childhood bacterial meningitis in Malawi: a randomised controlled trial. | journal = Lancet | volume = 360 | issue = 9328 | pages = 211-8 | month = Jul | year = 2002 | doi =  | PMID = 12133656 }}</ref> The occurrence of delayed [[cerebral thrombosis]] with dexamethasone therapy has been reported.<ref name="Schut-2009">{{Cite journal  | last1 = Schut | first1 = ES. | last2 = Brouwer | first2 = MC. | last3 = de Gans | first3 = J. | last4 = Florquin | first4 = S. | last5 = Troost | first5 = D. | last6 = van de Beek | first6 = D. | title = Delayed cerebral thrombosis after initial good recovery from pneumococcal meningitis. | journal = Neurology | volume = 73 | issue = 23 | pages = 1988-95 | month = Dec | year = 2009 | doi = 10.1212/WNL.0b013e3181c55d2e | PMID = 19890068 }}</ref>
* '''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.<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>
* '''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 ''[[Streptococcus pneumoniae|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]].<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><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>
* [[Dexamethasone]] should not be given to patients who have already received animicrobial therapy because it is unlikely to improve clinical outcome.<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 <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from ''Lancet. 2012;380(9854):1693-702.''<ref name="van de Beek-2012">{{Cite journal  | last1 = van de Beek | first1 = D. | last2 = Brouwer | first2 = MC. | last3 = Thwaites | first3 = GE. | last4 = Tunkel | first4 = AR. | title = Advances in treatment of bacterial meningitis. | journal = Lancet | volume = 380 | issue = 9854 | pages = 1693-702 | month = Nov | year = 2012 | doi = 10.1016/S0140-6736(12)61186-6 | PMID = 23141618 }}</ref> and ''N Engl J Med. 2010;362(2):146-54.''<ref name="van de Beek-2010">{{Cite journal  | last1 = van de Beek | first1 = D. | last2 = Drake | first2 = JM. | last3 = Tunkel | first3 = AR. | title = Nosocomial bacterial meningitis. | journal = N Engl J Med | volume = 362 | issue = 2 | pages = 146-54 | month = Jan | year = 2010 | doi = 10.1056/NEJMra0804573 | PMID = 20071704 }}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
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<div style="height: 30px; line-height: 30px; width: 225px; background: #A5B2D6; border: 2px solid #696969; border-bottom: 0px; text-align: center;">'''Community-Acquired'''</div>
<div class="mw-customtoggle-table01" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Newborns, Age <1 Week'''</font></div>
<div class="mw-customtoggle-table02" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Newborns, Age 1—4 Weeks'''</font></div>
<div class="mw-customtoggle-table03" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Infants & Children'''</font></div>
<div class="mw-customtoggle-table04" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Adults, Age <50 Years'''</font></div>
<div class="mw-customtoggle-table05" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Adults, Age >50 Years'''</font></div>
<div class="mw-customtoggle-table06" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Immunocompromised'''</font></div>
<div class="mw-customtoggle-table07" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Recurrent'''</font></div>
<div style="height: 30px; line-height: 30px; width: 225px; background: #A5B2D6; border: 2px solid #696969; border-bottom: 0px; text-align: center;">&nbsp;&nbsp;'''Nosocomial'''</div>
<div class="mw-customtoggle-table08" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Postneurosurgical Infection'''</font></div>
<div class="mw-customtoggle-table09" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''CSF Shunt Infection'''</font></div>
<div class="mw-customtoggle-table10" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Penetrating Trauma'''</font></div>
<div class="mw-customtoggle-table11" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid#696969;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Basilar Skull Fracture'''</font></div>
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! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Newborns, Age <1 Week}}
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! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
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| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 50 mg/kg IV q8h'''''
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| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
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| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 50 mg/kg IV q8—12h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 50 mg/kg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q12h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Newborns, Age 1—4 Weeks}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 50 mg/kg IV q6—8h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Tobramycin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Amikacin]] 10 mg/kg IV q8h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Infants & Children}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''<sup>†</sup>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q6h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 75 mg/kg IV q6—8h''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 80—100 mg/kg/day IV q12—24h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''<sup>†</sup>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q6h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Meropenem]] 40 mg/kg IV q8h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | <SMALL><sup>†</sup> Add '''''[[Ampicillin]] 75 mg/kg IV q6h''''' if suspecting ''[[Listeria monocytogenes]]''.</SMALL>
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table04" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Adults, Age <50 Years}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''<sup>†</sup>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''<sup>†</sup>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | <SMALL><sup>†</sup> Add '''''[[Ampicillin]] 2 g IV q4h''''' if suspecting ''[[Listeria monocytogenes]]''.</SMALL>
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table05" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Adults, Age >50 Years}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Aztreonam]] 2 g IV q6—8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[TMP/SMZ]] 5 mg/kg IV q6—12h''''' <SMALL>(TMP component)</SMALL>
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table06" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Immunocompromised}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table07" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Recurrent}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table08" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Postneurosurgical Infection}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Ceftazidime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Aztreonam]] 2 g IV q6—8h'''''<BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 400 mg IV q8—12h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table09" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|CSF Shunt Infection}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Ceftazidime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Aztreonam]] 2 g IV q6—8h'''''<BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 400 mg IV q8—12h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table10" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Penetrating Trauma}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Ceftazidime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Aztreonam]] 2 g IV q6—8h'''''<BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 400 mg IV q8—12h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table11" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Basilar Skull Fracture}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Aztreonam]] 2 g IV q6—8h'''''<BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 400 mg IV q8—12h'''''
|-
|}
|}
|}
==CSF Gram Stain-Based Therapy <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from ''Lancet. 2012;380(9854):1693-702.''<ref name="van de Beek-2012">{{Cite journal  | last1 = van de Beek | first1 = D. | last2 = Brouwer | first2 = MC. | last3 = Thwaites | first3 = GE. | last4 = Tunkel | first4 = AR. | title = Advances in treatment of bacterial meningitis. | journal = Lancet | volume = 380 | issue = 9854 | pages = 1693-702 | month = Nov | year = 2012 | doi = 10.1016/S0140-6736(12)61186-6 | PMID = 23141618 }}</ref> and ''Clin Infect Dis. 2004;39(9):1267-84.''<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/1549490315494903]</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
{|
| valign=top |
<div style="height: 30px; line-height: 30px; width: 225px; background: #A5B2D6; border: 2px solid #696969; border-bottom: 0px; text-align: center;">'''Gram-Positive'''</div>
<div class="mw-customtoggle-table12" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Gram-Positive Cocci in Chains'''</font></div>
<div class="mw-customtoggle-table13" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Gram-Positive Cocci in Pairs'''</font></div>
<div class="mw-customtoggle-table14" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Gram-Positive (Cocco-)Bacilli'''</font></div>
<div style="height: 30px; line-height: 30px; width: 225px; background: #A5B2D6; border: 2px solid #696969; border-bottom: 0px; text-align: center;">&nbsp;&nbsp;'''Gram-Negative'''</div>
<div class="mw-customtoggle-table15" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Gram-Negative Cocci in Pairs'''</font></div>
<div class="mw-customtoggle-table16" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Gram-Negative Coccobacilli'''</font></div>
<div class="mw-customtoggle-table17" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid#696969;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''Gram-Negative Bacilli'''</font></div>
| valign=top |
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table12" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Gram-Positive Cocci in Chains}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q8—12h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Meropenem]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table13" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Gram-Positive Cocci in Pairs}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h'''''<BR> OR <BR> ▸ '''''[[Penicillin G]] 4 MU IV q4h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1.7 mg/kg IV q8h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table14" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Gram-Positive (Cocco-)Bacilli}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h'''''<BR> OR <BR> ▸ '''''[[Penicillin G]] 4 MU IV q4h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1.7 mg/kg IV q8h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[TMP/SMZ]] 5 mg/kg IV q6—12h''''' <SMALL>(TMP component)</SMALL><BR> OR <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table15" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Gram-Negative Cocci in Pairs}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 4 MU IV q4h'''''<BR> OR <BR> ▸ '''''[[Ampicillin]] 2 g IV q4h'''''<BR> OR <BR> ▸ '''''[[Chloramphenicol]] 1—1.5 g IV q6h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Aztreonam]] 2 g IV q6—8h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table16" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Gram-Negative Coccobacilli}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Chloramphenicol]] 1—1.5 g IV q6h'''''<BR> OR <BR> ▸ '''''[[Cefepime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table17" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|Gram-Negative Bacilli}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Aztreonam]] 2 g IV q6—8h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[TMP/SMZ]] 5 mg/kg IV q6—12h''''' <SMALL>(TMP component)</SMALL>
|-
|}
|}
|}
==Pathogen-Based Therapy <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from ''Lancet. 2012;380(9854):1693-702.''<ref name="van de Beek-2012">{{Cite journal  | last1 = van de Beek | first1 = D. | last2 = Brouwer | first2 = MC. | last3 = Thwaites | first3 = GE. | last4 = Tunkel | first4 = AR. | title = Advances in treatment of bacterial meningitis. | journal = Lancet | volume = 380 | issue = 9854 | pages = 1693-702 | month = Nov | year = 2012 | doi = 10.1016/S0140-6736(12)61186-6 | PMID = 23141618 }}</ref> and ''Clin Infect Dis. 2004;39(9):1267-84.''<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/1549490315494903]</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
{|
| valign=top |
<div style="height: 30px; line-height: 30px; width: 225px; background: #A5B2D6; border: 2px solid #696969; border-bottom: 0px; text-align: center;">'''Bacteria'''</div>
<div class="mw-customtoggle-table18" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''''Acinetobacter baumannii'''''</font></div>
<div class="mw-customtoggle-table19" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''''Enterobacteriaceae'''''</font></div>
<div class="mw-customtoggle-table20" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''''Haemophilus influenzae'''''</font></div>
<div class="mw-customtoggle-table21" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''''Listeria monocytogenes'''''</font></div>
<div class="mw-customtoggle-table22" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''''Neisseria meningitidis'''''</font></div>
<div class="mw-customtoggle-table23" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''''Pseudomonas aeruginosa'''''</font></div>
<div class="mw-customtoggle-table24" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''''Staphylococcus aureus'''''</font></div>
<div class="mw-customtoggle-table25" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''''Staphylococcus epidermidis'''''</font></div>
<div class="mw-customtoggle-table26" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid #696969; border-bottom: 0px;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''''Streptococcus agalactiae'''''</font></div>
<div class="mw-customtoggle-table27" style="cursor:pointer; height: 30px; line-height: 30px; width: 225px; background: #F8F8FF; border: 2px solid#696969;">&nbsp;&nbsp;▸&nbsp;&nbsp;<font color="#1F4099">'''''Streptococcus pneumoniae'''''</font></div>
| valign=top |
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table18" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''Acinetobacter baumannii''}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Colistin]] 1.25 mg/kg IV q6—12h'''''<BR> OR <BR> ▸ '''''[[Polymyxin B]] 0.75—1.25 mg/kg IV q12h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table19" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''Enterobacteriaceae''}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Aztreonam]] 2 g IV q6—8h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[TMP/SMZ]] 5 mg/kg IV q6—12h''''' <SMALL>(TMP component)</SMALL><BR> OR <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Ampicillin]] 2 g IV q4h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table20" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''H. influenzae'', β-lactamase Negative}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''<BR> OR <BR> ▸ '''''[[Cefepime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Chloramphenicol]] 1—1.5 g IV q6h'''''<BR> OR <BR> ▸ '''''[[Aztreonam]] 2 g IV q6—8h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h'''''
|-
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''H. influenzae'', β-lactamase Positive}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Chloramphenicol]] 1—1.5 g IV q6h'''''<BR> OR <BR> ▸ '''''[[Aztreonam]] 2 g IV q6—8h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h'''''
|-
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''H. influenzae'', β-lactamase Negative, Ampicillin Resistant}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Moxifloxacin]] 400 mg IV q24h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table21" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''Listeria monocytogenes''}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h'''''<BR> OR <BR> ▸ '''''[[Penicillin G]] 4 MU IV q4h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1.7 mg/kg IV q8h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[TMP/SMZ]] 5 mg/kg IV q6—12h''''' <SMALL>(TMP component)</SMALL>
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table22" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''N. meningitidis'', Penicillin MIC <0.1 μg/mL}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 4 MU IV q4h'''''<BR> OR <BR> ▸ '''''[[Ampicillin]] 2 g IV q4h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''<BR> OR <BR> ▸ '''''[[Chloramphenicol]] 1—1.5 g IV q6h'''''
|-
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''N. meningitidis'', Penicillin MIC ≥0.1 μg/mL}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Chloramphenicol]] 1—1.5 g IV q6h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table23" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''Pseudomonas aeruginosa''}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftazidime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Cefepime]] 2 g IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1.7 mg/kg IV q8h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Aztreonam]] 2 g IV q6—8h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 400 mg IV q8—12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1.7 mg/kg IV q8h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table24" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''Staphylococcus aureus'', Methicillin sensitive}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nafcillin]] 1.5—2 g IV q4h'''''<BR> OR <BR> ▸ '''''[[Oxacillin]] 1.5—2 g IV q4h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q6h''''' <SMALL>(trough 15—20 μg/mL)</SMALL><BR> OR <BR> ▸ '''''[[Linezolid]] 600 mg IV q12h'''''<BR> OR <BR> ▸ '''''[[Daptomycin]] 6 mg/kg IV q24h'''''
|-
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''Staphylococcus aureus'', Methicillin resistant}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q6h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 600 mg IV q24h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[TMP/SMZ]] 5 mg/kg IV q6—12h''''' <SMALL>(TMP component)</SMALL><BR> OR <BR> ▸ '''''[[Linezolid]] 600 mg IV q12h'''''<BR> OR <BR> ▸ '''''[[Daptomycin]] 6 mg/kg IV q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 600 mg IV q24h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table25" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''Staphylococcus epidermidis''}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q6h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 600 mg IV q24h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]] 600 mg IV q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 600 mg IV q24h'''''
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table26" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''Streptococcus agalactiae''}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h'''''<BR> OR <BR> ▸ '''''[[Penicillin G]] 4 MU IV q4h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1.7 mg/kg IV q8h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''<BR> OR <BR> ▸ '''''[[Vancomycin]] 15 mg/kg IV q6h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
|}
|}
{| class="wikitable mw-collapsible mw-collapsed" id="mw-customcollapsible-table27" style="border: 2px solid #696969;"
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 0px; float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''S. pneumoniae'', Penicillin MIC ≤0.06 μg/mL}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 4 MU IV q4h'''''<BR> OR <BR> ▸ '''''[[Ampicillin]] 2 g IV q4h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''<BR> OR <BR> ▸ '''''[[Chloramphenicol]] 1—1.5 g IV q6h'''''
|-
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''S. pneumoniae'', Penicillin MIC ≥0.12 μg/mL, Cefotaxime/Ceftriaxone MIC <1.0 μg/mL}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''
|-
! style="padding: 0 5px; border: 0px; font-size: 100%; background: #F8F8FF" align=center | {{fontcolor|#1F4099|''S. pneumoniae'', Penicillin MIC ≥0.12 μg/mL, Cefotaxime/Ceftriaxone MIC ≥1.0 μg/mL}}
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q6h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 600 mg IV q24h'''''
|-
! style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q6h''''' <SMALL>(trough 15—20 μg/mL)</SMALL>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Moxifloxacin]] 400 mg IV q24h'''''
|-
|}
|}
|}
==References==
{{Reflist|2}}
[[Category:Wikinfect]]
[[Category:Infectious disease]]
[[Category:Primary care]]
[[Category:Neurology]]
[[Category:Emergency medicine]]

Revision as of 15:26, 24 January 2014

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]

Principles of Therapy for Bacterial Meningitis

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.


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]
  • Dexamethasone should not be given to patients who have already received animicrobial therapy because it is unlikely to improve clinical outcome.[6]


Empiric Therapy Adapted from Lancet. 2012;380(9854):1693-702.[18] and N Engl J Med. 2010;362(2):146-54.[3]

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 Adapted from Lancet. 2012;380(9854):1693-702.[18] and Clin Infect Dis. 2004;39(9):1267-84.[6]

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 Adapted from Lancet. 2012;380(9854):1693-702.[18] and Clin Infect Dis. 2004;39(9):1267-84.[6]

Bacteria
  ▸  Acinetobacter baumannii
  ▸  Enterobacteriaceae
  ▸  Haemophilus influenzae
  ▸  Listeria monocytogenes
  ▸  Neisseria meningitidis
  ▸  Pseudomonas aeruginosa
  ▸  Staphylococcus aureus
  ▸  Staphylococcus epidermidis
  ▸  Streptococcus agalactiae
  ▸  Streptococcus pneumoniae
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


References

  1. Andes, DR.; Craig, WA. (1999). "Pharmacokinetics and pharmacodynamics of antibiotics in meningitis". Infect Dis Clin North Am. 13 (3): 595–618. PMID 10470557. Unknown parameter |month= ignored (help)
  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]
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