Template:ID-Tuberculous meningitis: Difference between revisions

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* Tuberculous meningitis
* Tuberculous meningitis (TB meningitis)
:* '''First-line therapy (dosing information: <span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab3]</span><span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab4]</span><span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab5]</span>)'''
:* '''First-line therapy''' (dosing information: <span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab3]</span><span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab4]</span><span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab5]</span>)
::* [[Isoniazid]]
::* [[Isoniazid]]
::* [[Rifampin]]
::* [[Rifampin]]
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::* [[Ethambutol]]
::* [[Ethambutol]]


:* '''Second-line therapy (dosing information: <span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab3]</span><span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab4]</span><span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab5]</span>)'''
:* '''Second-line therapy''' (dosing information: <span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab3]</span><span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab4]</span><span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab5]</span>)
::* [[Cycloserine]]
::* [[Cycloserine]]
::* [[Ethionamide]]
::* [[Ethionamide]]
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::* '''Continuation phase (pediatric)'''
::* '''Continuation phase (pediatric)'''
:::* Preferred regimen: [[Isoniazid]] 10–15 mg/kg (max: 300 mg) for 7–10 months {{and}} [[Rifampin]] 10–20 mg/kg (max: 600 mg) for 7–10 months
:::* Preferred regimen: [[Isoniazid]] 10–15 mg/kg (max: 300 mg) for 7–10 months {{and}} [[Rifampin]] 10–20 mg/kg (max: 600 mg) for 7–10 months
:::: Note (1): World Health Organization guidelines recommend that Ethambutol should be replaced by Streptomycin in tuberculous meningitis.<ref>{{Cite book| edition = 4th| publisher = World Health Organization| isbn = 9789241547833| title = Treatment of Tuberculosis: Guidelines| location = Geneva| series = WHO Guidelines Approved by the Guidelines Review Committee| accessdate = 2015-06-08| date = 2010| url = http://www.ncbi.nlm.nih.gov/books/NBK138748/| pmid = 23741786}}</ref> Streptomycin is contraindicated in pregnancy.
:::: Note (1): World Health Organization guidelines recommend that Ethambutol should be replaced by Streptomycin (contraindicated in pregnancy) in tuberculous meningitis.<ref>{{Cite book| edition = 4th| publisher = World Health Organization| isbn = 9789241547833| title = Treatment of Tuberculosis: Guidelines| location = Geneva| series = WHO Guidelines Approved by the Guidelines Review Committee| date = 2010| url = http://www.ncbi.nlm.nih.gov/books/NBK138748/| pmid = 23741786}}</ref>
:::: Note (2): A 9– to 12–month course of treatment is recommended for tuberculous meningitis.<ref>{{Cite book| edition = 4th| publisher = World Health Organization| isbn = 9789241547833| title = Treatment of Tuberculosis: Guidelines| location = Geneva| series = WHO Guidelines Approved by the Guidelines Review Committee| accessdate = 2015-06-08| date = 2010| url = http://www.ncbi.nlm.nih.gov/books/NBK138748/| pmid = 23741786}}</ref><ref>{{Cite journal| issn = 1057-5987| volume = 52| issue = RR-11| pages = 1–77| last1 = American Thoracic Society| last2 = CDC| last3 = Infectious Diseases Society of America| title = Treatment of tuberculosis| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2003-06-20| pmid = 12836625}}</ref>
:::: Note (2): A 9– to 12–month course of treatment is recommended for tuberculous meningitis.<ref>{{Cite book| edition = 4th| publisher = World Health Organization| isbn = 9789241547833| title = Treatment of Tuberculosis: Guidelines| location = Geneva| series = WHO Guidelines Approved by the Guidelines Review Committee| date = 2010| url = http://www.ncbi.nlm.nih.gov/books/NBK138748/| pmid = 23741786}}</ref><ref>{{Cite journal| issn = 1057-5987| volume = 52| issue = RR-11| pages = 1–77| last1 = American Thoracic Society| last2 = CDC| last3 = Infectious Diseases Society of America| title = Treatment of tuberculosis| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2003-06-20| pmid = 12836625}}</ref>
:::: Note (3): Adjuvant [[Dexamethasone]] 0.3–0.4 mg/kg/day (max: 24 mg) is recommended unless drug resistance is suspected.<ref>{{Cite journal| doi = 10.1056/NEJMoa040573| issn = 1533-4406| volume = 351| issue = 17| pages = 1741–1751| last1 = Thwaites| first1 = Guy E.| last2 = Nguyen| first2 = Duc Bang| last3 = Nguyen| first3 = Huy Dung| last4 = Hoang| first4 = Thi Quy| last5 = Do| first5 = Thi Tuong Oanh| last6 = Nguyen| first6 = Thi Cam Thoa| last7 = Nguyen| first7 = Quang Hien| last8 = Nguyen| first8 = Tri Thuc| last9 = Nguyen| first9 = Ngoc Hai| last10 = Nguyen| first10 = Thi Ngoc Lan| last11 = Nguyen| first11 = Ngoc Lan| last12 = Nguyen| first12 = Hong Duc| last13 = Vu| first13 = Ngoc Tuan| last14 = Cao| first14 = Huu Hiep| last15 = Tran| first15 = Thi Hong Chau| last16 = Pham| first16 = Phuong Mai| last17 = Nguyen| first17 = Thi Dung| last18 = Stepniewska| first18 = Kasia| last19 = White| first19 = Nicholas J.| last20 = Tran| first20 = Tinh Hien| last21 = Farrar| first21 = Jeremy J.| title = Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults| journal = The New England Journal of Medicine| date = 2004-10-21| pmid = 15496623}}</ref><ref>{{Cite journal| doi = 10.1016/j.jinf.2009.06.011| issn = 1532-2742| volume = 59| issue = 3| pages = 167–187| last1 = Thwaites| first1 = Guy| last2 = Fisher| first2 = Martin| last3 = Hemingway| first3 = Cheryl| last4 = Scott| first4 = Geoff| last5 = Solomon| first5 = Tom| last6 = Innes| first6 = John| last7 = British Infection Society| title = British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children| journal = The Journal of Infection| date = 2009-09| pmid = 19643501}}</ref>
:::: Note (3): Adjuvant [[Dexamethasone]] 0.3–0.4 mg/kg/day (max: 24 mg) is recommended unless drug resistance is suspected.<ref>{{Cite journal| doi = 10.1056/NEJMoa040573| issn = 1533-4406| volume = 351| issue = 17| pages = 1741–1751| last1 = Thwaites| first1 = Guy E.| last2 = Nguyen| first2 = Duc Bang| last3 = Nguyen| first3 = Huy Dung| last4 = Hoang| first4 = Thi Quy| last5 = Do| first5 = Thi Tuong Oanh| last6 = Nguyen| first6 = Thi Cam Thoa| last7 = Nguyen| first7 = Quang Hien| last8 = Nguyen| first8 = Tri Thuc| last9 = Nguyen| first9 = Ngoc Hai| last10 = Nguyen| first10 = Thi Ngoc Lan| last11 = Nguyen| first11 = Ngoc Lan| last12 = Nguyen| first12 = Hong Duc| last13 = Vu| first13 = Ngoc Tuan| last14 = Cao| first14 = Huu Hiep| last15 = Tran| first15 = Thi Hong Chau| last16 = Pham| first16 = Phuong Mai| last17 = Nguyen| first17 = Thi Dung| last18 = Stepniewska| first18 = Kasia| last19 = White| first19 = Nicholas J.| last20 = Tran| first20 = Tinh Hien| last21 = Farrar| first21 = Jeremy J.| title = Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults| journal = The New England Journal of Medicine| date = 2004-10-21| pmid = 15496623}}</ref><ref>{{Cite journal| doi = 10.1016/j.jinf.2009.06.011| issn = 1532-2742| volume = 59| issue = 3| pages = 167–187| last1 = Thwaites| first1 = Guy| last2 = Fisher| first2 = Martin| last3 = Hemingway| first3 = Cheryl| last4 = Scott| first4 = Geoff| last5 = Solomon| first5 = Tom| last6 = Innes| first6 = John| last7 = British Infection Society| title = British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children| journal = The Journal of Infection| date = 2009-09| pmid = 19643501}}</ref>
:::: Note (4): Liaise with microbiology laboratory about genotype testing for drug resistance if there is high risk for MDR-TB.<ref>{{Cite journal| doi = 10.1016/j.jinf.2009.06.011| issn = 1532-2742| volume = 59| issue = 3| pages = 167–187| last1 = Thwaites| first1 = Guy| last2 = Fisher| first2 = Martin| last3 = Hemingway| first3 = Cheryl| last4 = Scott| first4 = Geoff| last5 = Solomon| first5 = Tom| last6 = Innes| first6 = John| last7 = British Infection Society| title = British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children| journal = The Journal of Infection| date = 2009-09| pmid = 19643501}}</ref>
:::: Note (4): Liaise with microbiology laboratory about genotype testing for drug resistance if there is high risk for MDR-TB.<ref>{{Cite journal| doi = 10.1016/j.jinf.2009.06.011| issn = 1532-2742| volume = 59| issue = 3| pages = 167–187| last1 = Thwaites| first1 = Guy| last2 = Fisher| first2 = Martin| last3 = Hemingway| first3 = Cheryl| last4 = Scott| first4 = Geoff| last5 = Solomon| first5 = Tom| last6 = Innes| first6 = John| last7 = British Infection Society| title = British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children| journal = The Journal of Infection| date = 2009-09| pmid = 19643501}}</ref>
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:::* Consult infectious disease specialist.
:::* Consult infectious disease specialist.


====Septic thrombosis of cavernous or dural venous sinus {{ID-returntotop-organ}}====
==References==
 
{{reflist|2}}
* Septic thrombosis of cavernous or dural venous sinus
:* '''Empiric antimicrobial therapy'''<ref>{{Cite journal| doi = 10.1161/STR.0b013e31820a8364| issn = 1524-4628| volume = 42| issue = 4| pages = 1158–1192| last1 = Saposnik| first1 = Gustavo| last2 = Barinagarrementeria| first2 = Fernando| last3 = Brown| first3 = Robert D.| last4 = Bushnell| first4 = Cheryl D.| last5 = Cucchiara| first5 = Brett| last6 = Cushman| first6 = Mary| last7 = deVeber| first7 = Gabrielle| last8 = Ferro| first8 = Jose M.| last9 = Tsai| first9 = Fong Y.| last10 = American Heart Association Stroke Council and the Council on Epidemiology and Prevention| title = Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association| journal = Stroke; a Journal of Cerebral Circulation| date = 2011-04| pmid = 21293023}}</ref><ref>{{Cite journal| issn = 0003-9926| volume = 161| issue = 22| pages = 2671–2676| last1 = Ebright| first1 = J. R.| last2 = Pace| first2 = M. T.| last3 = Niazi| first3 = A. F.| title = Septic thrombosis of the cavernous sinuses| journal = Archives of Internal Medicine| date = 2001-12-10| pmid = 11732931}}</ref><ref>{{Cite journal| issn = 0022-2151| volume = 107| issue = 9| pages = 803–808| last = Singh| first = B.| title = The management of lateral sinus thrombosis| journal = The Journal of Laryngology and Otology| date = 1993-09| pmid = 8228594}}</ref><ref>{{Cite journal| issn = 0025-7974| volume = 65| issue = 2| pages = 82–106| last1 = Southwick| first1 = F. S.| last2 = Richardson| first2 = E. P.| last3 = Swartz| first3 = M. N.| title = Septic thrombosis of the dural venous sinuses| journal = Medicine| date = 1986-03| pmid = 3512953}}</ref>
::* Preferred regimen: ([[Nafcillin]] 2 g IV q4h or [[Oxacillin]] 2 g IV q4h) {{and}} ([[Ceftriaxone]] 2 g IV q12h or [[Cefotaxime]] 8–12 g/day IV q4–6h) {{and}} [[Metronidazole]] 7.5 mg/kg IV q6h
::: Note (1): [[Vancomycin]] 30–45 mg/kg IV q8–12h could be substituted for nafcillin or oxacillin if the risk of MRSA is high.
::: Note (2): The optimal duration of therapy remains unclear.  A 3– to 4–week course of treatment is usually recommended.
 
:* Specific anatomic considerations
::* '''Cavernous sinus'''
:::* Preferred regimen: [[Vancomycin]] 30–45 mg/kg IV q8–12h {{and}} ([[Ceftriaxone]] 2 g IV q12h or [[Cefotaxime]] 8–12 g/day IV q4–6h) {{and}} [[Metronidazole]] 7.5 mg/kg IV q6h
:::: Note: [[Daptomycin]] 8–12 mg/kg IV q24h {{or}} [[Linezolid]] 600 mg IV q12h could be considered for patients unable to tolerate vancomycin.
 
::* '''Lateral sinus'''
:::* Preferred regimen: [[Cefepime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8h {{and}} [[Vancomycin]] 15-20 IV mg/kg
:::* Alternative regimen: [[Meropenem]] 1-2 g IV q8h {{and}} [[Linezolid]] 600 mg IV q12h
 
::* '''Superior sagittal sinus'''
:::* Preferred regimen: [[Ceftriaxone]] 2 g IV q12h {{and}} [[Vancomycin]] 15–20 mg/kg {{and}} [[Dexamethasone]]
:::* Alternative regimen: [[Meropenem]] 1–2 g IV q8h {{and}} [[Vancomycin]] 15–20 mg/kg {{and}} [[Dexamethasone]]
 
:* Pathogen-directed antimicrobial therapy
::* '''Staphylococcus aureus, methicillin-resistant (MRSA)'''<ref>{{Cite journal| doi = 10.1093/cid/ciq146| issn = 1537-6591| volume = 52| issue = 3| pages = –18-55| last1 = Liu| first1 = Catherine| last2 = Bayer| first2 = Arnold| last3 = Cosgrove| first3 = Sara E.| last4 = Daum| first4 = Robert S.| last5 = Fridkin| first5 = Scott K.| last6 = Gorwitz| first6 = Rachel J.| last7 = Kaplan| first7 = Sheldon L.| last8 = Karchmer| first8 = Adolf W.| last9 = Levine| first9 = Donald P.| last10 = Murray| first10 = Barbara E.| last11 = J Rybak| first11 = Michael| last12 = Talan| first12 = David A.| last13 = Chambers| first13 = Henry F.| last14 = Infectious Diseases Society of America| title = Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 2011-02-01| pmid = 21208910}}</ref>
:::* Preferred regimen: [[Vancomycin]] 15–20 mg/kg/dose IV q8–12h for 4–6 weeks
:::* Alternative regimen: [[Linezolid]] 600 mg PO/IV q12h for 4–6 weeks {{or}} [[TMP-SMX]] 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
:::* Pediatric dose: [[Vancomycin]] 15 mg/kg/dose IV q6h {{or}} [[Linezolid]] 10 mg/kg/dose PO/IV q8h
:::: Note (1): Surgical evaluation for incision and drainage of contiguous sites of infection or abscess is recommended whenever possible.
:::: Note (2): Consider the addition of [[Rifampin]] 600 mg qd or 300–450 mg bid to vancomycin.
 
====Subdural empyema {{ID-returntotop-organ}}====
 
* Subdural empyema<ref>{{Cite journal| doi = 10.1016/S1473-3099(06)70688-0| issn = 1473-3099| volume = 7| issue = 1| pages = 62–67| last1 = Osborn| first1 = Melissa K.| last2 = Steinberg| first2 = James P.| title = Subdural empyema and other suppurative complications of paranasal sinusitis| journal = The Lancet. Infectious Diseases| date = 2007-01| pmid = 17182345}}</ref><ref>{{Cite journal| issn = 1092-8480| volume = 5| issue = 1| pages = 13–22| last = Greenlee| first = John E.| title = Subdural Empyema| journal = Current Treatment Options in Neurology| date = 2003-01| pmid = 12521560}}</ref>
:* Causative pathogens
::* More common
:::* Streptococcus milleri
:::* Other streptococci and enterococci
:::* Aerobic Gram-negative bacilli (Haemophilus influenzae, Proteus, Escherichia coli, Pseudomonas, Klebsiella, Acinetobacter, Salmonella, Morganella, Eikenella)
:::* No growth
::* Less common
:::* Streptococcus pneumoniae
:::* Staphylococcus aureus, coagulase-negative staphylococci
:::* Anaerobic Gram-positive cocci (Veillonella, Peptostreptococcus, others)
:::* Anaerobic Gram-negative bacilli (Bacteroides, Fusobacterium, Prevotella)
 
:* Empiric antimicrobial therapy
:: Note (1): The choice of antimicrobial agent should be based on Gram stain results and directed against the likely causative microorganisms in the specific clinical setting.
:: Note (2): Metronidazole is recommended if anaerobes are suspected.  Metronidazole is not necessary for antianaerobic activity if Meropenem is used.
:: Note (3): For coverage of aerobic Gram-negative bacilli, empiric therapy with Cefepime, Ceftazidime, or Meropenem is appropriate.
:: Note (4): Depending on the clinical response, parenteral antimicrobial therapy should be administered for 3 to 4 weeks after drainage.  Parenteral or oral therapy is frequently continued for up to a total of 6 weeks of therapy.
:: Note (5): A longer course of treatment (minimum of 6–8 weeks) may be required if the patient has accompanying osteomyelitis.
:: Note (6): Consider adjunctive medications including prophylactic anticonvulsants, corticosteroids, and mannitol if clinically indicated.
 
::* '''Intracranial subdural empyema with unclear source of infection'''
:::* Preferred regimen: ([[Nafcillin]] 2 g IV q4h or [[Oxacillin]] 2 g IV q4h) {{and}} ([[Ceftriaxone]] 2 g IV q12h or [[Cefotaxime]] 8–12 g/day IV q4–6h) {{and}} [[Metronidazole]] 7.5 mg/kg IV q6h
:::: Note: [[Vancomycin]] should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.
 
::* '''Intracranial subdural empyema associated with sinusitis or otitis media'''
:::* Preferred regimen: ([[Nafcillin]] 2 g IV q4h or [[Oxacillin]] 2 g IV q4h) {{and}} ([[Ceftriaxone]] 2 g IV q12h or [[Cefotaxime]] 8–12 g/day IV q4–6h) {{and}} [[Metronidazole]] 7.5 mg/kg IV q6h
:::: Note: [[Vancomycin]] should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.
 
::* '''Intracranial subdural empyema after cranial trauma'''
:::* Preferred regimen: [[Nafcillin]] 2 g IV q4h or [[Oxacillin]] 2 g IV q4h
:::: Note: [[Vancomycin]] should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.
 
::* '''Intracranial subdural empyema after neurosurgical procedures'''
:::* Preferred regimen: [[Vancomycin]] 30–45 mg/kg/day IV q8–12h {{and}} [[Ceftazidime]] 2 g IV q8h
 
::* '''Intracranial subdural empyema in neonates (usually associated with meningitis)'''
:::* '''Infants &lt; 1 month'''
::::* Preferred regimen: [[Ampicillin]] 200 mg/kg/day IV q4h {{and}} [[Cefotaxime]] 200 mg/kg/day IV q6h
 
:::* '''Infants 1–3 months'''
::::* Preferred regimen: [[Ampicillin]] 200 mg/kg/day IV q4h {{and}} ([[Cefotaxime]] 200 mg/kg/day IV q6h {{or}} [[Ceftriaxone]] 100 mg/kg/day IV q12h)
 
:::* '''Infants &gt; 3 months'''
::::* Preferred regimen: [[Vancomycin]] 60 mg/kg/day IV q6h {{and}} ([[Cefotaxime]] 200 mg/kg/day IV q6h {{or}} [[Ceftriaxone]] 100 mg/kg/day IV q12h {{or}} [[Cefepime]] 150 mg/kg/day IV q8h)
 
::* '''Spinal subdural empyema'''
:::* Preferred regimen: [[Nafcillin]] 2 g IV q4h or [[Oxacillin]] 2 g IV q4h
:::: Note: [[Vancomycin]] should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.
 
:* Pathogen-directed antimicrobial therapy
::* '''Staphylococcus aureus, methicillin-resistant (MRSA)'''
:::* Preferred regimen: [[Vancomycin]] 30–45 mg/kg/day IV q8–12h for 4–6 weeks
:::* Alternative regimen: [[Linezolid]] 600 mg PO/IV q12h for 4–6 weeks {{or}} [[TMP-SMX]] 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
:::* Pediatric dose: [[Vancomycin]] 15 mg/kg/dose IV q6h {{or}} [[Linezolid]] 10 mg/kg/dose PO/IV q8h
:::: Note: Consider the addition of [[Rifampin]] 600 mg qd or 300–450 mg bid to vancomycin.

Latest revision as of 20:16, 11 August 2015

  • Tuberculous meningitis (TB meningitis)
  • First-line therapy (dosing information: [1][2][3])
  • Second-line therapy (dosing information: [4][5][6])
  • Tuberculous meningitis caused by susceptible Mycobacterium tuberculosis[1][2][3][4]
  • Intensive phase (adult)
  • Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) for 2 months AND Rifampin 10 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months
  • Continuation phase (adult)
  • Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) for 7–10 months AND Rifampin 10 mg/kg (max: 600 mg) for 7–10 months
  • Intensive phase (pediatric)
  • Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 2 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months
  • Continuation phase (pediatric)
  • Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 7–10 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 7–10 months
Note (1): World Health Organization guidelines recommend that Ethambutol should be replaced by Streptomycin (contraindicated in pregnancy) in tuberculous meningitis.[5]
Note (2): A 9– to 12–month course of treatment is recommended for tuberculous meningitis.[6][7]
Note (3): Adjuvant Dexamethasone 0.3–0.4 mg/kg/day (max: 24 mg) is recommended unless drug resistance is suspected.[8][9]
Note (4): Liaise with microbiology laboratory about genotype testing for drug resistance if there is high risk for MDR-TB.[10]
  • Tuberculous meningitis caused by Mycobacterium tuberculosis resistant to isoniazid or rifampin
  • Isoniazid monoresistance[11]
  • Substitute fluoroquinolone for isoniazid in intensive phase regimen.
  • Continue treatment with rifampin, pyrazinamide, and fluoroquinolone for 12 months.
  • Rifampin monoresistance[12]
  • Substitute Fluoroquinolones for Rifampin in intensive phase regimen.
  • Continue treatment with isoniazid, pyrazinamide, and fluoroquinolone for 18 months.
  • MDR-TB (resistant to Isoniazid and Rifampin)[13]
  • MDR tuberculosis therapy should be considered if there is a history of prior tuberculosis treatment, contact with a patient with MDR tuberculosis, or a poor clinical response to first-line TB therapy within 2 weeks despite a firm diagnosis and an adequate adherence to treatment.
  • Second-line agents such as Aminoglycosides penetrate the BBB only in the presence of inflamed meninges, and Fluoroquinolones, while able to penetrate into the CNS, have lower CSF levels than in the serum or brain parenchyma.
  • Consult infectious disease specialist.
  • XDR-TB (resistant to Isoniazid, Rifampin, Fluoroquinolones, and either Capreomycin, Kanamycin, or Amikacin)[14]
  • Consider Ethionamide or Cycloserine to build the treatment regimen.
  • Consult infectious disease specialist.

References

  1. ↑ Blumberg, Henry M.; Burman, William J.; Chaisson, Richard E.; Daley, Charles L.; Etkind, Sue C.; Friedman, Lloyd N.; Fujiwara, Paula; Grzemska, Malgosia; Hopewell, Philip C.; Iseman, Michael D.; Jasmer, Robert M.; Koppaka, Venkatarama; Menzies, Richard I.; O'Brien, Richard J.; Reves, Randall R.; Reichman, Lee B.; Simone, Patricia M.; Starke, Jeffrey R.; Vernon, Andrew A.; American Thoracic Society, Centers for Disease Control and Prevention and the Infectious Diseases Society (2003-02-15). "American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis". American Journal of Respiratory and Critical Care Medicine. 167 (4): 603–662. doi:10.1164/rccm.167.4.603. ISSN 1073-449X. PMID 12588714.
  2. ↑ Rock, R. Bryan; Olin, Michael; Baker, Cristina A.; Molitor, Thomas W.; Peterson, Phillip K. (2008-04). "Central nervous system tuberculosis: pathogenesis and clinical aspects". Clinical Microbiology Reviews. 21 (2): 243–261, table of contents. doi:10.1128/CMR.00042-07. ISSN 1098-6618. PMC 2292571. PMID 18400795. Check date values in: |date= (help)
  3. ↑ Thwaites, Guy; Fisher, Martin; Hemingway, Cheryl; Scott, Geoff; Solomon, Tom; Innes, John; British Infection Society (2009-09). "British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children". The Journal of Infection. 59 (3): 167–187. doi:10.1016/j.jinf.2009.06.011. ISSN 1532-2742. PMID 19643501. Check date values in: |date= (help)
  4. ↑ American Thoracic Society; CDC; Infectious Diseases Society of America (2003-06-20). "Treatment of tuberculosis". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 52 (RR-11): 1–77. ISSN 1057-5987. PMID 12836625.
  5. ↑ Treatment of Tuberculosis: Guidelines. WHO Guidelines Approved by the Guidelines Review Committee (4th ed.). Geneva: World Health Organization. 2010. ISBN 9789241547833. PMID 23741786.
  6. ↑ Treatment of Tuberculosis: Guidelines. WHO Guidelines Approved by the Guidelines Review Committee (4th ed.). Geneva: World Health Organization. 2010. ISBN 9789241547833. PMID 23741786.
  7. ↑ American Thoracic Society; CDC; Infectious Diseases Society of America (2003-06-20). "Treatment of tuberculosis". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 52 (RR-11): 1–77. ISSN 1057-5987. PMID 12836625.
  8. ↑ Thwaites, Guy E.; Nguyen, Duc Bang; Nguyen, Huy Dung; Hoang, Thi Quy; Do, Thi Tuong Oanh; Nguyen, Thi Cam Thoa; Nguyen, Quang Hien; Nguyen, Tri Thuc; Nguyen, Ngoc Hai; Nguyen, Thi Ngoc Lan; Nguyen, Ngoc Lan; Nguyen, Hong Duc; Vu, Ngoc Tuan; Cao, Huu Hiep; Tran, Thi Hong Chau; Pham, Phuong Mai; Nguyen, Thi Dung; Stepniewska, Kasia; White, Nicholas J.; Tran, Tinh Hien; Farrar, Jeremy J. (2004-10-21). "Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults". The New England Journal of Medicine. 351 (17): 1741–1751. doi:10.1056/NEJMoa040573. ISSN 1533-4406. PMID 15496623.
  9. ↑ Thwaites, Guy; Fisher, Martin; Hemingway, Cheryl; Scott, Geoff; Solomon, Tom; Innes, John; British Infection Society (2009-09). "British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children". The Journal of Infection. 59 (3): 167–187. doi:10.1016/j.jinf.2009.06.011. ISSN 1532-2742. PMID 19643501. Check date values in: |date= (help)
  10. ↑ Thwaites, Guy; Fisher, Martin; Hemingway, Cheryl; Scott, Geoff; Solomon, Tom; Innes, John; British Infection Society (2009-09). "British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children". The Journal of Infection. 59 (3): 167–187. doi:10.1016/j.jinf.2009.06.011. ISSN 1532-2742. PMID 19643501. Check date values in: |date= (help)
  11. ↑ Thwaites, Guy; Fisher, Martin; Hemingway, Cheryl; Scott, Geoff; Solomon, Tom; Innes, John; British Infection Society (2009-09). "British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children". The Journal of Infection. 59 (3): 167–187. doi:10.1016/j.jinf.2009.06.011. ISSN 1532-2742. PMID 19643501. Check date values in: |date= (help)
  12. ↑ Thwaites, Guy; Fisher, Martin; Hemingway, Cheryl; Scott, Geoff; Solomon, Tom; Innes, John; British Infection Society (2009-09). "British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children". The Journal of Infection. 59 (3): 167–187. doi:10.1016/j.jinf.2009.06.011. ISSN 1532-2742. PMID 19643501. Check date values in: |date= (help)
  13. ↑ Rock, R. Bryan; Olin, Michael; Baker, Cristina A.; Molitor, Thomas W.; Peterson, Phillip K. (2008-04). "Central nervous system tuberculosis: pathogenesis and clinical aspects". Clinical Microbiology Reviews. 21 (2): 243–261, table of contents. doi:10.1128/CMR.00042-07. ISSN 1098-6618. PMC 2292571. PMID 18400795. Check date values in: |date= (help)
  14. ↑ Rock, R. Bryan; Olin, Michael; Baker, Cristina A.; Molitor, Thomas W.; Peterson, Phillip K. (2008-04). "Central nervous system tuberculosis: pathogenesis and clinical aspects". Clinical Microbiology Reviews. 21 (2): 243–261, table of contents. doi:10.1128/CMR.00042-07. ISSN 1098-6618. PMC 2292571. PMID 18400795. Check date values in: |date= (help)
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