What is the management of bacterial meningitis?

From the Guidelines

Management of bacterial meningitis requires immediate empiric antibiotic therapy after obtaining blood cultures and cerebrospinal fluid (CSF) if possible, but without delaying treatment. For adults, the standard empiric regimen includes ceftriaxone (2g IV every 12 hours) plus vancomycin (15-20 mg/kg IV every 8-12 hours) to cover common pathogens including Streptococcus pneumoniae, Neisseria meningitidis, and Listeria monocytogenes, as recommended by the ESCMID guideline 1.

Key Considerations

• For patients over 50 or immunocompromised individuals, add ampicillin (2g IV every 4 hours) to cover Listeria 1.
• Dexamethasone (10 mg IV every 6 hours for 2-4 days) should be administered before or with the first antibiotic dose to reduce inflammation and improve outcomes, particularly in pneumococcal meningitis 1.
• Once culture results and sensitivities are available, therapy should be narrowed accordingly.
• Treatment duration typically ranges from 7-14 days depending on the pathogen identified.
• Supportive care includes:
  • Managing increased intracranial pressure
  • Maintaining adequate cerebral perfusion
  • Preventing seizures
  • Ensuring appropriate fluid management
• Close monitoring in an intensive care setting is often necessary due to the rapid progression and high mortality rate of bacterial meningitis.
• Prevention of secondary cases through chemoprophylaxis with rifampin, ciprofloxacin, or ceftriaxone is recommended for close contacts of patients with meningococcal meningitis. The aggressive approach to treatment reflects the need to rapidly control the infection before it causes permanent neurological damage or death, as highlighted in the update on community-acquired bacterial meningitis guidance and challenges 1.

From the FDA Drug Label

Meropenem for injection is indicated for the treatment of bacterial meningitis caused by Haemophilus influenzae, Neisseria meningitidis and penicillin-susceptible isolates of Streptococcus pneumoniae. For pediatric patients 3 months of age and older, the meropenem for injection dose is ... 40 mg/kg every 8 hours (maximum dose is 2 grams every 8 hours), depending on the type of infection (cSSSI, cIAI, intra-abdominal infection or meningitis). For pediatric patients weighing over 50 kg administer meropenem for injection at a dose of ... 2 grams every 8 hours for meningitis.

Meropenem is indicated for the management of bacterial meningitis in pediatric patients 3 months of age and older, caused by specific bacteria. The recommended dose is:

• 40 mg/kg every 8 hours (maximum dose is 2 grams every 8 hours) for patients 3 months of age and older
• 2 grams every 8 hours for patients weighing over 50 kg 2

From the Research

Management of Bacterial Meningitis

• The outcome of bacterial meningitis depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock 3.
• The choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns, with dexamethasone recommended as adjunctive therapy for community-acquired meningitis in developed countries 3.
• Ceftriaxone is a preferred drug for bacterial meningitis caused by H. influenzae, meningococci, and pneumococci, with high bactericidal titer in the cerebrospinal fluid and persistence at the site of infection longer than other beta-lactam antibiotics 4.
• Vancomycin is an effective alternate antibiotic for the treatment of bacterial meningitis, particularly in cases of resistant strains or unusual organisms, and should be included as empiric therapy for suspected bacterial meningitis 5, 6.

Antibiotic Therapy

• Ceftriaxone is effective in infants and children three months to 18 years old, but not recommended in neonates due to concerns about bilirubin displacement 4.
• Vancomycin penetrates into cerebrospinal fluid and achieves therapeutically effective levels, making it a useful option for bacterial meningitis treatment 5.
• Combination therapy with agents that act synergistically with vancomycin has been beneficial in some cases 5.

Prevention and Prophylaxis

• Prophylaxis is considered for close contacts of people with a meningococcal infection and populations with known high carriage rates 7.
• Antibiotics such as ciprofloxacin, rifampin, minocycline, and penicillin have been shown to be effective in eradicating N. meningitidis, with ceftriaxone also being effective 7.
• The use of rifampin during an outbreak may lead to the circulation of resistant isolates, and alternative agents such as ciprofloxacin, ceftriaxone, or penicillin should be considered 7.