What is the recommended treatment for Streptococcus pneumoniae (S. pneumoniae) meningitis?

From the Guidelines

The recommended treatment for Streptococcus pneumoniae meningitis is high-dose intravenous antibiotics, specifically ceftriaxone (2g IV every 12 hours) or cefotaxime (2g IV every 4-6 hours) plus vancomycin (15-20 mg/kg IV every 8-12 hours), as stated in the most recent guideline 1.

This combination therapy should be initiated immediately after obtaining blood cultures and cerebrospinal fluid, without waiting for test results.

• Dexamethasone (0.15 mg/kg IV every 6 hours for 2-4 days) should be administered before or with the first dose of antibiotics to reduce inflammation and improve outcomes, as suggested by the ESCMID guideline 1.
• Treatment typically continues for 10-14 days, depending on clinical response, with the possibility of extension to 14 days if the patient has not recovered by day 10, or 21 days in certain cases, as outlined in the UK joint specialist societies guideline 1.
• Supportive care including management of increased intracranial pressure, seizures, and maintenance of adequate cerebral perfusion is essential.
• The dual antibiotic approach is necessary because of increasing pneumococcal resistance to beta-lactam antibiotics, as highlighted in the update on community-acquired bacterial meningitis guidance 1.
• Once susceptibility results are available, therapy can be narrowed if the isolate proves sensitive, as recommended by the UK joint specialist societies guideline 1.
• Prompt treatment is critical as S. pneumoniae meningitis has a high mortality rate and significant risk of neurological sequelae among survivors.

Key considerations in the treatment of S. pneumoniae meningitis include:

• The use of ceftriaxone or cefotaxime as the primary antibiotic therapy, with vancomycin added in cases of suspected penicillin resistance, as stated in the UK joint specialist societies guideline 1.
• The administration of dexamethasone to reduce inflammation and improve outcomes, as suggested by the ESCMID guideline 1.
• The importance of supportive care, including management of increased intracranial pressure and seizures, to improve patient outcomes.

From the FDA Drug Label

Meropenem for injection, USP (I.V.) is indicated for the treatment of bacterial meningitis caused by Haemophilus influenzae, Neisseria meningitidis and penicillin-susceptible isolates of Streptococcus pneumoniae. The recommended treatment for Streptococcus pneumoniae (S. pneumoniae) meningitis is Meropenem for injection, USP (I.V.), but only for penicillin-susceptible isolates.

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

From the Research

Treatment Options for Streptococcus pneumoniae Meningitis

• The recommended treatment for Streptococcus pneumoniae (S. pneumoniae) meningitis involves the use of antibiotics, with the specific choice depending on the susceptibility of the strain to various antimicrobial agents 3, 4, 5, 6, 7.
• For strains resistant to extended-spectrum cephalosporins, combinations such as vancomycin and ceftriaxone or ceftriaxone and rifampin have been suggested as effective treatments 3, 4, 7.
• Vancomycin has been shown to penetrate reliably into the cerebrospinal fluid (CSF) of children with acute meningitis, making it a useful addition to ceftriaxone for treating cephalosporin-resistant pneumococcal meningitis 4.
• In cases where the strain is relatively resistant to cefotaxime, treatment with cefotaxime should be used with caution, and consideration should be given to changing therapy to intravenous and intrathecal vancomycin if therapeutic failure is suspected 5.
• The use of rifampicin in combination with ceftriaxone has been found to be as effective as vancomycin and ceftriaxone in treating penicillin-resistant S. pneumoniae meningitis in an experimental rabbit model 7.

Key Considerations

• The choice of antibiotic treatment should be guided by the results of susceptibility studies, and empiric therapy may need to be adjusted based on these results 3, 4, 5.
• The emergence of multi-drug resistant S. pneumoniae strains highlights the need for careful selection of antibiotic therapy and consideration of combination regimens 6.
• The administration of dexamethasone may be beneficial in the treatment of pneumococcal meningitis, based on favorable experience with its use 6.