Meningitis medical therapy

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Meningitis Main Page

Patient Information

Overview

Causes

Classification

Viral Meningitis
Bacterial Meningitis
Fungal Meningitis

Differential Diagnosis

Diagnosis

Treatment

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

Principles of Therapy for Bacterial Meningitis

  • Acute bacterial meningitis is a medical emergency; commence empiric treatment after obtaining blood and/or cerebrospinal fluid (CSF) cultures once the possibility of bacterial meningitis becomes evident. Antibiotic regimen should be adjusted according to the culture results.

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).
  • Adequate parenteral dosage should be maintained throughout the course to ensure adequate bactericidal concentration since antimicrobial entry attenuates as meningeal inflammation subsides, especially when adjunctive dexamethasone is co-administered.


Recommended Doses of Selected Antimicrobial Agents Administered by the Intraventricular Route.[3][4][5]
Antimicrobial Agent Daily Intraventricular Dose
 ▸ Vancomycin 5—20 mg/day; 10—20 mg/day has been used in most studies
 ▸ Gentamicin 4—8 mg/day in adults; 1—2 mg/day in infants and children
 ▸ Tobramycin 5—20 mg/day
 ▸ Amikacin 5—50 mg/day; the usual daily dose is 30 mg/day
 ▸ Polymyxin B 5 mg/day in adults; 1—2 mg/day in infants and children
 ▸ Colistimethate sodium 10 mg q24h or 5—10 mg q12h
 ▸ Quinupristin/Dalfopristin 2—5 mg/day
 ▸ Teicoplanin 5—40 mg/day; 5—10 mg q48—72h in one study
 ▸ Amphotericin B 0.1—0.5 mg/day for Candida shunt infection


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.[6][7][8][9][10][11] However, other studies fail to demonstrate a substantial reduction of death or neurological disability.[3][12][13][14] The occurrence of delayed cerebral thrombosis with dexamethasone therapy has been reported.[15]
  • 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.[16]
  • Dexamethasone should not be given to patients who have already receive animicrobial therapy because it is unlikely to improve clinical outcome.[16]

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

Community-Acquired Meningitis
 ▸   Newborn, Age <1 Week
 ▸   Newborn, Age 1—4 Weeks
 ▸   Infant & Children
 ▸   Adult, Age <50 Years
 ▸   Adult, Age >50 Years
 ▸   Immunocompromised
 ▸   Recurrent
  Nosocomial Meningitis
 ▸   Postneurosurgical Infection
 ▸   CSF Shunt Infection
 ▸   Penetrating Trauma
 ▸   Basilar Skull Fracture
Newborn, Age <1 Week
Preferred Regimen
Ampicillin 50 mg/kg IV q8h
PLUS
Cefotaxime 100—150 mg/kg/day IV q8—12h
Alternative Regimen
Ampicillin 50 mg/kg IV q8h
PLUS
Gentamicin 2.5 mg/kg IV q12h
Newborn, Age 1—4 Weeks
Preferred Regimen
Ampicillin 200 mg/kg/day IV q6—8h
PLUS
Cefotaxime 150—200 mg/kg/day 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
Infant & Children
Preferred Regimen
Vancomycin 15 mg/kg IV q6h (trough level: 15—20 μg/mL)
PLUS
Cefotaxime 225—300 mg/kg/day IV q6—8h
OR
Ceftriaxone 80—100 mg/kg/day IV q12—24h
Alternative Regimen
Vancomycin 15 mg/kg IV q6h (trough level: 15—20 μg/mL)
PLUS
Meropenem 40 mg/kg IV q8h
  Add Ampicillin 50 mg/kg IV q6h if suspecting Listeria monocytogenes.
Adult, Age <50 Years
Preferred Regimen
Vancomycin 30—60 mg/kg/day IV q8—12h (trough level: 15—20 μg/mL)
PLUS
Cefotaxime 8—12 g/day IV q4—6h
OR
Ceftriaxone 2 g IV q12h
Alternative Regimen
Vancomycin 30—60 mg/kg/day IV q8—12h (trough level: 15—20 μg/mL)
PLUS
Meropenem 2 g IV q8h
  Add Ampicillin 2 g IV q4h if suspecting Listeria monocytogenes.
Adult, Age >50 Years
Preferred Regimen
Vancomycin 30—60 mg/kg/day IV q8—12h (trough level: 15—20 μg/mL)
PLUS
Ampicillin 2 g IV q4h
PLUS
Cefotaxime 8—12 g/day IV q4—6h
OR
Ceftriaxone 2 g IV q12h
Alternative Regimen
Vancomycin 30—60 mg/kg/day IV q8—12h (trough level: 15—20 μg/mL)
PLUS
Aztreonam 6—8 g/day IV q6—8h
PLUS
TMP/SMZ 10—20 mg/kg/day IV q6—12h (trimethoprim component)
Immunocompromised
Preferred Regimen
Vancomycin 30—60 mg/kg/day IV q8—12h (trough level: 15—20 μg/mL)
PLUS
Ampicillin 2 g IV q4h
PLUS
Cefepime 2 g IV q8h
OR
Meropenem 2 g IV q8h
Recurrent
Preferred Regimen
Vancomycin 30—60 mg/kg/day IV q8—12h (trough level: 15—20 μg/mL)
PLUS
Cefotaxime 8—12 g/day IV q4—6h
OR
Ceftriaxone 2 g IV q12h
Postneurosurgical Infection
Preferred Regimen
Vancomycin 15 mg/kg IV q8—12h (trough level: 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 level: 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 level: 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 level: 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 level: 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 level: 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 level: 15—20 μg/mL)
PLUS
Ceftriaxone 2 g IV q12h
OR
Cefotaxime 2 g IV q4—6h
Alternative Regimen
Vancomycin 15 mg/kg IV q8—12h (trough level: 15—20 μg/mL)
PLUS
Aztreonam 2 g IV q6—8h
OR
Ciprofloxacin 400 mg IV q8—12h

References

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  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)
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  15. Schut, ES.; Brouwer, MC.; de Gans, J.; Florquin, S.; Troost, D.; van de Beek, D. (2009). "Delayed cerebral thrombosis after initial good recovery from pneumococcal meningitis". Neurology. 73 (23): 1988–95. doi:10.1212/WNL.0b013e3181c55d2e. PMID 19890068. Unknown parameter |month= ignored (help)
  16. 16.0 16.1 16.2 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
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  18. 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)