Bacterial Meningitis Management

See Also

Bacterial Meningitis
Neisseria Meningitidis
1. Includes prophylaxis for exposures
Viral Meningitis
Aseptic Meningitis
Encephalitis
Brain Abscess

Management
General

ABC Management
Initiate droplet precautions (for first 24 hours of management)
Obtain Blood Cultures
Obtain Lumbar Puncture (and Head CT if indicated)
Initiate empiric Antibiotics as below
1. Do not delay Antibiotics and Dexamethasone if LP cannot be immediately obtained
2. Door to Antibiotic delay >6 hours is associated with significantly increased mortality (OR 8.4)
  1. Proulx (2005) QJM 98(4): 291-8 [PubMed]
Consider atypical organisms (e.g. travel history, skin lesions, underlying HIV Infection, Immunocompromised status)
1. Consider Acyclovir if HSV Meningitis (or Encephalitis) is suspected
2. Consider Tuberculous Meningitis, Cryptococcal Meningitis, fungal Meningitis
Indications for repeat Lumbar Puncture
1. No clinical improvement in 48 hours
Consider testing after Bacterial Meningitis episode
1. Audiology for Hearing Testing (esp. children)
2. Screening for neurologic sequelae including Developmental Delay
3. Complement deficiency (if recurrent Meningitis or other serious infection)

Management
Antibiotic and adjunctive medication Doses

See Dexamethasone below
Ampicillin (typically used for Listeria coverage in newborns, debilitated adults)
1. Age under 1 month: 50 mg/kg IV q8-12 hours
2. Age over 1 month: 50 mg/kg IV q6 hours
3. Adult: 2g IV q4 hours
Cefotaxime
1. <1 month old: 50 mg/kg IV q8-12 hours
2. >1 month old: 200 mg/kg/d IV divide q6-8 hours
3. Adult: 2g IV q6 hours
Ceftriaxone
1. <1 month old: 50-75 mg/kg IV divide q12-24 hours
2. >1 month old: 100 mg/kg/d IV divide q12 hours
3. Adult: 2g IV q12 hours
Gentamycin
1. Peds: 2-2.5 mg/kg q8 hours
2. Adult: 1 mg/kg IV/IM q8h OR 5 mg/kg IV q24 hours
3. Therapeutic Window
  1. Peak: 5-10 ug/ml
  2. Trough: <2 ug/ml
Vancomycin
1. Peds: 15 mg/kg q6 hours IV
2. Adult: 1g IV q6-12 hours
Meropenem
1. Peds: 40 mg/kg IV q8 hours
2. Adult: 1g IV q8 hours

Management
Empiric Antibiotic Therapy

Precautions
1. Consider Acyclovir if HSV Meningitis (or Encephalitis) is suspected
2. Penicillin and Ceftriaxone resistant Pneumococcus is common (therefore Vancomycin is added to regimens)
Low Birth Weight or Preterm Infant
1. Vancomycin AND
2. Ceftazidime OR Amikacin
Age < 1 month old
1. Ampicillin (for Listeria coverage) AND
2. Cefotaxime OR Gentamicin, or if shortages, Ceftazidime or Cefepime (for Group B Strep, E coli coverage)
3. Consider Vancomycin only for MRSA risk
4. Consider Dexamethasone immediately before Antibiotics (for HaemophilusInfluenzae, pneumococcal Meningitis)
  1. Stop Dexamethasone if Listeria positive
Age 1 month to 50 years old
1. Vancomycin AND
2. Cefotaxime OR Ceftriaxone (or Meropenem) AND
3. In severe Penicillin/Cephalosporin allergy
  1. Chloramphenicol with TMP-SMZ may be used instead of Ampicillin and Cephalosporin
4. Consider Dexamethasone immediately before Antibiotics
  1. Indicated for pneumococcal Meningitis (or in unimmunized children, H. Influenzae)
5. Consider adding Rifampin
6. Consider adding Ampicillin if Listeria monocytogenes risk
Age >50 years (or Immunocompromised or Alcoholism)
1. Ampicillin (Listeria coverage) AND
2. Vancomycin AND
3. Ceftriaxone OR Cefotaxime (or in Immunocompromised patients, Cefepime or Meropenem) AND
4. In severe Penicillin/Cephalosporin allergy
  1. Meropenem (or Aztreonam) with TMP-SMZ may be used instead of Ampicillin and Cephalosporin
5. Consider Dexamethasone immediately before Antibiotics (for pneumococcal Meningitis)
  1. Stop Dexamethasone if Listeria positive
6. Consider adding Rifampin
Comorbid CNS conditions
1. Head Trauma with Basilar Skull Fracture (or Cochlear impant)
  1. Vancomycin AND
  2. Ceftriaxone or Cefotaxime (or Meropenem) AND
  3. Dexamethasone
  4. In severe Penicillin/Cephalosporin allergy
    1. Meropenem (or Aztreonam) OR Chloramphenicol may be used instead of Ampicillin and Cephalosporin
2. Head Trauma with Penetrating Trauma
  1. Vancomycin AND
  2. Cefepime or Ceftazidime (or Meropenem)
3. Post-Neurosurgery or CSF Shunt
  1. Vancomycin AND
  2. Cefepime or Ceftazidime (or Meropenem)
  3. Add Dexamethasone for recurrent Meningitis
  4. In severe Penicillin/Cephalosporin allergy
    1. Aztreonam OR Ciprofloxacin may be used instead of Cephalosporin
4. CSF Shunt
  1. Remove infected shunt and replace with external ventricular catheter
  2. Vancomycin AND
    1. Used alone in children if Gram Positive infection
    2. Check Gram Stain to confirm no Gram Negative Rods
  3. Cefepime or Ceftazidime or Meropenem
    1. Typically started with Vancomycin initially
    2. Added in adults and in Gram Negative infection
  4. Intraventricular shunt Antibiotics may be used if shunt not able to be removed
    1. Options: Amikacin, Gentamicin, Polymixin E, Tobramycin, Vancomycin, Daptomycin, Quinupristin-Dalf.

Management
Antibiotics based on CSF Gram Stain Results

Gram Positive Diplococci (Pneumococcus)
1. All cases receive Dexamethasone for 4 days
2. Antibiotics for 10-14 days
  1. Vancomycin AND
  2. Cefotaxime OR Ceftriaxone (or Meropenem or Moxifloxacin) AND
Gram Negative Cocci (Meningococcus)
1. Cefotaxime or Ceftriaxone or Pencillin G or Ampicillin or Moxifloxacin or Chloramphenicol
Gram Positive Bacilli (Listeria monocytogenes)
1. Ampicillin AND Gentamycin OR (TMP-SMZ or Meropenem)
Gram Negative Bacilli (H. flu, E. coli, Pseudomonas)
1. Ceftazidime OR Cefepime (or Meropenem) AND
2. Gentamycin

Management
Known Etiology

Infant
1. Group B Streptococcus (Treat for 14-21 days)
  1. Ampicillin AND
  2. Consider Gentamycin
2. Coliforms (Treat for 21 days)
  1. Cefotaxime AND
  2. Gentamycin
3. Pseudomonas
  1. Ceftazidime AND
  2. Gentamycin
4. Listeria (Treat for 7 days)
  1. Ampicillin AND
  2. Consider Gentamycin
Children and Adults
1. Pneumococcal Meningitis (Treat for 10-14 days)
  1. All cases receive Dexamethasone for 4 days
  2. Course: 10-14 days of Antibiotics
  3. Coverage until culture sensitivities available
    1. Ceftriaxone or Cefotaxime (or Meropenem) AND
    2. Vancomycin AND
    3. Dexamethasone
  4. Penicillin MIC <0.1 mcg per ml
    1. Penicillin or Ampicillin (or Cefotaxime or Chloramphenicol)
  5. Penicllin MIC 0.1 to 1 mcg/ml
    1. Ceftriaxone or Cefotaxime (or Cefopime or Meropenem)
  6. Penicillin MIC >2 mcg/ml (or Ceftriaxone MIC >1 mcg/ml)
    1. Vancomycin AND
    2. Ceftriaxone or Cefotaxime (or Moxifloxacin)
    3. Add Rifampin if Ceftriaxone MIC >2 mcg/ml or clinical response after 24-36 hours
2. HaemophilusInfluenzae (Treat for 7 days)
  1. Dexamethasone started prior to first Antibiotic dose
  2. Preferred regimen
    1. Ceftriaxone (or Meropenem)
    2. May substitute Ampicillin if Beta-Lactamase negative AND Ampicillin sensitive
  3. Severe Penicillin/Cephalosporin allergy
    1. Aztreonam (adults)
    2. Chloramphenicol (children, but higher resistance rates)
3. Neisseria Meningitidis (Treat for 7 days)
  1. Ceftriaxone OR Cefotaxime (or Aztreonam or Meropenem or Moxifloxacin)
  2. Chloramphenicol may be used if no other alternative, but higher resistance rates
4. Listeria monocytogenes
  1. Ampicillin (or Meropenem) AND
  2. Aminoglycoside (Gentamicin or Tobramycin)

Management
Reducing Intracranial Pressure

Indications
1. Meningitis with Pressure >260mm H2O
Methods
1. Elevate head of bed to 30 degrees
2. Hyperosmolar agents (Mannitol, Glycerol)
3. High Dose Barbiturates
4. Avoid Hyperventilation
  1. May reduce ICP at expense of cerebral Blood Flow

Management
Dexamethasone

Use is controversial in Bacterial Meningitis
1. Some providers consider using only if Lumbar Puncture fluid cloudy (expert opinion only)
2. Greatest benefit in moderate to seriously ill patients (GCS 8-11) or if CSF WBCs >1000/hpf
3. Primarily effective for H. Influenzae (neonates), S. Pneumoniae (adults) and Tuberculosis (non-HIV related)
  1. Decreases mortality (NNT 18)
  2. Decreases Hearing Loss risk (NNT 21)
  3. Brouwer (2015) Cochrane Database Syst Rev (9):CD004405 [PubMed]
Technique
1. First dose 15 minutes before Antibiotic
Benefits
1. Reduces subarachnoid space inflammation (associated with Antibiotic-induced Bacterial lysis)
2. Decreases edema, Vasculitis, Neuronitis
Risks
1. Risk of apoptosis
2. May lower Vancomycin efficacy in CNS
3. Consider using Rifampin with Dexamethasone
  1. Specifically indicated for Pneumococcal Meningitis
Children
1. Dosing
  1. Dexamethasone 0.4 mg/kg q12h IV for 2 days OR
  2. Dexamethasone 0.15 mg/kg q6h IV for 4 days
2. Efficacy
  1. Protective against bilateral Hearing Loss
  2. Must be given prior to first dose of Antibiotic
Adults
1. Dosing
  1. Dexamethasone 10 mg IV q6 hours for 4 days
  2. Start 15 minutes before first Antibiotic dose
2. Efficacy
  1. Significantly better outcomes with Dexamethasone
  2. Decreased neurologic sequelae
  3. Improved survival
3. References
  1. De Gans (2002) N Engl J Med 347:1549-56 [PubMed]

Prevention
Post-exposure Prophylaxis

See Bacterial Meningitis for primary prevention Vaccinations
Group B Streptococcus
1. See GBS Prophylaxis intrapartum if maternal GBS positive
Meningococcal Meningitis
1. See Meningococcal Meningitis for specific Antibiotic prophylaxis
2. Indications
  1. Close contacts for >8 hours OR
  2. Unprotected droplet or nasopharyngeal secretion exposure
3. Adult
  1. Preferred: Ciprofloxacin 500 mg or Ceftriaxone 250 mg IM (125 mg if age <15) for 1 dose
  2. Other options (risk of higher resistance)
    1. Rifampin 600 mg every 12 hours for 2 days OR
    2. Spiramycin for 5 days
4. Child
  1. Preferred: Ceftriaxone
  2. Other options (risk of higher resistance)
    1. Rifampin 10 mg/kg (5 mg/kg if age <1 month) for 2 days OR
    2. Spiramycin for 5 days
Haemophilus Influenzae
1. Indications
  1. Household contact
    1. Contact for at least 4 hours
    2. Unvaccinated or under-vaccinated children under age 4 years
  2. Child care
    1. Contact for at least 4 hours AND
    2. Attended same day care for 5-7 days before symptom onset AND
    3. One case and unvaccinated children <2 years old at center OR
      1. Two or more cases in last 60 days and unvaccinated children
2. Dosing
  1. Child: Rifampin 20 mg/kg/day up to 600 mg/day for up to 4 days
  2. Adult: Rifampin 600 mg daily for 4 days

Reference

Gilbert (2016) Sanford Guide to Antimicrobial Therapy, accessed 4/11/2016
Wilson (1991) Harrison's Internal Medicine, p. 651-2
Bamberger (2010) Am Fam Physician 82(12): 1491-8 [PubMed]
Choi (2001) Clin Infect Dis 33:1380-5 [PubMed]
Mount (2017) Am Fam Physician 96(5): 314-22 [PubMed]
Tunkel (1997) Am Fam Physician 56(5):1355-62 [PubMed]
Tunkel (2004) Clin Infect Dis 39 [PubMed]