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Meningitis Main Page

Patient Information

Overview

Causes

Classification

Viral Meningitis
Bacterial Meningitis
Fungal Meningitis

Differential Diagnosis

Diagnosis

Treatment

Streptococcus pneumoniae

Penicillin MIC ≤0.06 μg/mL
Preferred Regimen
Penicillin G Low: 600,000–1.2 million units/day IM; High:≥ 20 million units IV q24h(=12 g)
OR
Ampicillin 150–200 mg/kg IV q3-4h
Alternative Regimen
Cefotaxime 1 g q8–12h to 2 g IV q4h
OR
Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine)
OR
Chloramphenicol 0.25–1 g po IV q6h to max. of 4 g/day
Penicillin MIC ≥0.12 μg/mL
Cefotaxime or Ceftriaxone MIC† <1.0 μg/mL
Preferred Regimen
Cefotaxime 1 g q8–12h to 2 g IV q4h
OR
Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine)
Alternative Regimen
Cefepime 1–2 g IV q12h
OR
Meropenem 2 g IV q8h
Cefotaxime or Ceftriaxone MIC† >1.0 μg/mL
Preferred Regimen
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. )
AND
Cefotaxime 1 g q8–12h to 2 g IV q4h
OR
Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine)
Alternative Regimen
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. )
AND
Moxifloxacin 400 mg po IV q24h ɸ

Neisseria meningitidis

Neisseria meningitidis
Penicillin MIC <0.1 μg/mL
Preferred Regimen
Penicillin G Low: 600,000–1.2 million units/day IM; High:≥ 20 million units IV q24h(=12 g)
OR
Ampicillin 0.25–0.5 g po q6h.150–200 mg/kg/day IV
Alternative Regimen
Cefotaxime 1 g q8–12h to 2 g IV q4h
OR

Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine)
OR
Chloramphenicol 0.25–1 g po IV q6h to max. of 4 g/day


Neisseria meningitidis
Penicillin MIC ≥0.1 μg/mL
Preferred Regimen
Cefotaxime 1 g q8–12h to 2 g IV q4h
OR
Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine)
Alternative Regimen
Cefepime 1–2 g IV q12h
OR
Chloramphenicol 0.25–1 g po IV q6h to max. of 4 g/day
OR
FluoroquinoloneΔ
OR
Meropenem 2 g IV q8h

Listeria Monocytogenes and Streptococcus agalactiae

Listeria Monocytogenes
Preferred Regimen
Ampicillin 0.25–0.5 g po q6h.150–200 mg/kg/day IV
OR
Penicillin G Low: 600,000–1.2 million units/day IM ;High:≥ 20 million units IV q24h(=12 g)£
Alternative Regimen
Trimethoprim-sulfamethoxazole 5–20 mg/kg/day q6-12h
Streptococcus agalactiae
Preferred Regimen
Ampicillin 0.25–0.5 g po q6h.150–200 mg/kg/day IV
OR
Penicillin G Low: 600,000–1.2 million units/day IM ;High:≥ 20 million units IV q24h(=12 g)£
Alternative Regimen
Cefotaxime 1 g q8–12h to 2 g IV q4h
OR

Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine)
OR
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. )

Haemophilus influenzae

Haemophilus influenzae
β-lactamase negative
Preferred Regimen
Ampicillin 0.25–0.5 g po q6h.150–200 mg/kg/day IV
Alternative Regimen
Cefotaxime 1 g q8–12h to 2 g IV q4h
OR
Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine)
OR
Cefepime 1–2 g IV q12h
OR
Chloramphenicol 0.25–1 g po IV q6h to max. of 4 g/day
OR
Aztreonam 1 g IV q8h–2 g IV q6h
OR
FluoroquinoloneΔ
β-lactamase negative, ampicillin resistant
Preferred Regimen
Meropenem 2 g IV q8h
Alternative Regimen
FluoroquinoloneΔ
Haemophilus influenzae
β-lactamase positive
Preferred Regimen
Cefotaxime 1 g q8–12h to 2 g IV q4h
OR
Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine)
Alternative Regimen
Cefepime 1–2 g IV q12h
OR
Chloramphenicol 0.25–1 g po IV q6h to max. of 4 g/day
OR
Aztreonam 1 g q8h–2 g IV q6h
OR
FluoroquinoloneΔ

Staphylococcus aureus

Staphylococcus aureus
Meticillin sensitive
Preferred Regimen
Nafcillin 1–2 g IV/IM q4h
OR
Oxacillin 1–2 g IV/IM q4h
Alternative Regimen
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. )
OR
linezolid 600 mg IV/PO q12h
OR
Daptomycin 6 mg/kg IV q24h
Staphylococcus aureus
Meticillin resistant
Preferred Regimen
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. )
Alternative Regimen
Trimethoprim-sulfamethoxazole 5–20 mg/kg/day q6-12h
OR
linezolid 600 mg IV/PO q12h
OR
Daptomycin 6 mg/kg IV q24h


Staphylococcus epidermidis and Acinetobacter baumanniiΩ

Staphylococcus epidermidis
Preferred Regimen
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. )
Alternative Regimen
Linezolid 600 mg IV/PO q12h




Acinetobacter baumannii
Preferred Regimen
Meropenem 2 g IV q8h
Alternative Regimen
Colistin
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);
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).

OR
Polymyxin B 15,000–25,000 units/kg/day q12hǂ

Enterobacteriaceae and Pseudomonas aeruginosa

EnterobacteriaceaeΩ
Preferred Regimen
Cefotaxime 1 g q8–12h to 2 g IV q4h
OR
Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine)
Alternative Regimen
Aztreonam 1 g q8h–2 g IV q6h
OR

FluoroquinoloneΔ
OR
Trimethoprim-sulfamethoxazole 5–20 mg/kg/day q6-12h
OR
Meropenem 2 g IV q8h
OR
Ampicillin 150–200 mg/kg/day IV

Pseudomonas aeruginosa
Preferred Regimen
Ceftazidime 1–2 g IV/IM q8–12h
OR
Cefepime 1–2 g IV q12h£
Alternative Regimen
Aztreonam 1 g q8h–2 g IV q6h
OR
Meropenem 2 g IV q8h
OR
Ciprofloxacin 500-750 mg po bid£



†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/mLorganism is susceptible, the expected clinical or bacteriological response is delayed, or the cefotaxime/ceftriaxone MIC.ΦNo clinical data exist for use of this agent in patients with pneumococcal meningitis; recommendation is based on cerebrospinal fl uid penetration and in-vitro activity against S pneumoniae.£Addition of an aminoglycoside should be considered; might need intraventricular or intrathecal administration in Gram-negative meningitis. ||Addition of rifampicin should be considered.Ω Choice of a specifi c agent should be based on in-vitro susceptibility testing. ††Might also need to be administered by the intraventricular or intrathecal routes. ǂ Might also need to be administered by the intraventricular or intrathecal routes. ₦ Addition of rifampicin should be considered.Δ The fluoroquinolones gatifl oxacin and moxifl oxacin pene trate the CSF eff ectively and have greater in-vitro activity against Gram-positive bacteria than do their earlier counterparts (eg, ciprofl oxacin). Findings from experi mental meningitis models suggested their effi cacy 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 gatifl oxacin or moxifl oxacin to treat bacterial meningitis in human beings. Trovafl oxacin and gatifl oxacin have been asso ciated with serious hepatic toxicity and dysglycaemia, respectively, and were with drawn from many markets.51 The IDSA guidelines recom mend moxifl oxacin as an alternative to third-generation cephalosporins plus vancomycin for menin-gitis 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 cephalo sporin), because of the absence of clinical data supporting its use.