Should meropenem be stopped and an antiepileptic medication, such as levetiracetam, be added for a patient with meningitis who is experiencing seizures after a decompressive craniectomy?

From the Guidelines

No, meropenem should not be stopped for a patient with meningitis experiencing seizures after decompressive craniectomy, but levetiracetam should be added to manage the seizures. Meropenem is a critical antibiotic for treating the underlying meningitis infection and discontinuing it could worsen the patient's condition, as it has been shown to have clinical and microbiologic outcomes similar to those of cefotaxime or ceftriaxone in the treatment of bacterial meningitis 1. Levetiracetam is recommended at an initial loading dose of 20-40 mg/kg IV (typically 1000-2000 mg in adults), followed by maintenance dosing of 500-1500 mg twice daily, adjusted based on clinical response and renal function, as it has been shown to be effective in managing status epilepticus 1. Seizures in this context are likely multifactorial, resulting from the meningitis infection, surgical intervention, and possibly meropenem itself, which can lower seizure threshold, although the risk of seizure with meropenem is considered lower compared to other carbapenems like imipenem 1. While meropenem can contribute to seizure risk, the benefit of treating the infection outweighs this risk, especially when seizures can be managed with antiepileptic medication. Close neurological monitoring should continue, with EEG monitoring if persistent seizures occur. The treatment team should also ensure therapeutic levels of the antibiotic while managing seizure control. Alternatively, valproate could also be considered for seizure management, given its efficacy in status epilepticus as demonstrated in several studies 1, but levetiracetam is chosen here due to its favorable profile and the specific context of this patient.

From the FDA Drug Label

5.3 Seizure Potential Seizures and other adverse CNS experiences have been reported during treatment with Meropenem for injection (I.V.). These experiences have occurred most commonly in patients with CNS disorders (e.g., brain lesions or history of seizures) or with bacterial meningitis and/or compromised renal function [see Adverse Reactions(6.1)and Drug Interactions(7.2)]. If focal tremors, myoclonus, or seizures occur, evaluate neurologically, placed on anti-convulsant therapy if not already instituted, and re-examine the dosage of Meropenem for injection (I.V.) to determine whether it should be decreased or discontinued.

Meropenem should not be stopped solely based on the occurrence of seizures. However, the patient should be evaluated neurologically, and anti-convulsant therapy, such as levetiracetam, should be considered if not already instituted. The dosage of meropenem should be re-examined to determine whether it should be decreased or discontinued 2.

From the Research

Meropenem and Seizures in Meningitis

• Meropenem is a carbapenem antibiotic used to treat bacterial meningitis, and it has been shown to be effective and well-tolerated in several studies 3, 4, 5, 6.
• The occurrence of seizures in patients treated with meropenem for meningitis is not commonly reported, and when seizures do occur, they are not typically thought to be drug-related 3, 6.
• In one study, seizures occurred in 6% of patients receiving meropenem and 1% of patients receiving cefotaxime, but none were thought to be drug-related 6.
• Another study found that meropenem has a low propensity for inducing seizures, making it suitable for treating bacterial meningitis 5.

Management of Seizures in Meningitis

• If a patient with meningitis is experiencing seizures while being treated with meropenem, it may be necessary to add an antiepileptic medication, such as levetiracetam, to control the seizures.
• However, there is no evidence to suggest that meropenem should be stopped in this situation, as it is an effective treatment for bacterial meningitis and the seizures are not typically thought to be drug-related 3, 4, 5, 6.
• The treatment of seizures in meningitis should be individualized and based on the specific needs of the patient.

Use of Meropenem in Meningitis

• Meropenem is a broad-spectrum antibiotic that is effective against a wide range of bacterial pathogens, including those that cause meningitis 3, 4, 5.
• It has been shown to be effective in treating meningitis caused by N. meningitidis, H. influenzae, and pneumococci sensitive to penicillin, as well as nosocomial meningitis caused by multiresistant gram-negative bacilli 4, 5.
• Meropenem may also be useful in the treatment of meningitis caused by Pseudomonas aeruginosa, especially when other treatments have failed 4.