From the Guidelines
For community-acquired nursing home-associated (CNNA) meningitis with persistent fever despite ceftriaxone therapy, I recommend broadening antibiotic coverage immediately to cover potential resistant organisms, considering the patient's age and risk factors for Listeria monocytogenes.
Management Approach
Based on the most recent guidelines 1, the management approach should prioritize the patient's age, clinical presentation, and potential risk factors for resistant organisms.
- For patients older than 50 years or those with risk factors for Listeria monocytogenes, the recommended empiric treatment includes ceftriaxone or cefotaxime plus vancomycin or rifampicin, along with amoxicillin or ampicillin.
- The dosage for ceftriaxone is 2g every 12 hours or 4g every 24 hours, while vancomycin should be administered at 10-20 mg/kg every 8-12 hours to achieve serum trough concentrations of 15-20 μg/mL.
Considerations
- The addition of dexamethasone to the treatment regimen should be considered, especially if the patient is suspected to have Streptococcus pneumoniae or Haemophilus influenzae infection 1.
- However, recent observational data suggest that dexamethasone treatment may be associated with increased mortality in patients with Listeria monocytogenes infection, and its use should be carefully evaluated on a case-by-case basis 1.
Monitoring and Adjustment
- Close monitoring of the patient's clinical response, including temperature, mental status, and laboratory parameters, is essential to adjust the treatment regimen as needed.
- If the patient's condition does not improve or worsens, consideration should be given to alternative diagnoses, such as non-infectious causes of fever or resistant organisms, and the treatment regimen should be adjusted accordingly.
Additional Recommendations
- Obtain new cultures (blood, cerebrospinal fluid, and possibly other relevant specimens) before changing antibiotics to identify potential resistant organisms or healthcare-associated pathogens.
- Evaluate for potential complications, such as brain abscess or empyema, with imaging studies and consider drainage if present.
- Reassess the patient within 48-72 hours of the new regimen; if fever persists, investigate non-central nervous system sources of infection or non-infectious causes of fever.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Management of Coagulase-Negative Staphylococcal (CNNA) Infections with Persistent Fever on Ceftriaxone
- The provided studies do not directly address the management of CNNA infections with persistent fever on ceftriaxone 2, 3, 4, 5, 6.
- However, study 2 evaluates the effectiveness and safety of ceftriaxone for the treatment of methicillin-susceptible Staphylococcus aureus (MSSA) bloodstream infections, which may be relevant to CNNA infections.
- Study 3 discusses the treatment of Staphylococcus aureus meningitis, including the use of nafcillin or vancomycin, which may be applicable to CNNA infections.
- Study 4 reviews the epidemiology, clinical features, and treatment of Staphylococcus aureus central nervous system infections in children, including the use of nafcillin or vancomycin.
- Study 5 reports on the use of combination therapy with vancomycin and ceftaroline for refractory methicillin-resistant Staphylococcus aureus bacteremia, which may be relevant to CNNA infections that are resistant to ceftriaxone.
- Study 6 provides an update on the use of ceftriaxone in the management of community-acquired and nosocomial infections, including its activity against various pathogens and its tolerability profile.
Treatment Options
- Nafcillin or vancomycin may be considered as treatment options for CNNA infections, depending on the susceptibility of the isolate 3, 4.
- Combination therapy with vancomycin and ceftaroline may be considered for refractory CNNA infections 5.
- Ceftriaxone may still be effective against some CNNA isolates, but its use should be guided by susceptibility testing 2, 6.