What is the treatment for leptomeningitis?

Treatment of Leptomeningitis

The treatment of leptomeningitis requires immediate administration of appropriate intravenous antibiotics within 1 hour of presentation, with the regimen based on patient age and risk factors. 1

Initial Assessment and Stabilization

• Immediately assess airway, breathing, and circulation
• Document Glasgow Coma Scale score
• Obtain blood cultures within the first hour
• Determine if patient has signs of shock or severe sepsis
• Assess for contraindications to immediate lumbar puncture:
  • Focal neurological signs
  • Papilledema
  • Continuous or uncontrolled seizures
  • GCS ≤ 12 1

Empiric Antibiotic Therapy

Timing

• Critical: Start antibiotics within 1 hour of hospital arrival 1, 2
• If lumbar puncture is delayed (e.g., due to need for CT scan), start antibiotics immediately after blood cultures are drawn 1

Antibiotic Selection by Age Group

1. Neonates (<1 month):

   • Amoxicillin/ampicillin/penicillin PLUS cefotaxime, OR
   • Amoxicillin/ampicillin PLUS an aminoglycoside
   • Dosing: Cefotaxime 50 mg/kg q6-8h; Ampicillin 50 mg/kg q6h 1

2. Children (1 month to 18 years):

   • Ceftriaxone (100 mg/kg/day) or cefotaxime (300 mg/kg/day) PLUS
   • Vancomycin (60 mg/kg/day) if pneumococcal meningitis cannot be ruled out 1, 3

3. Adults (18-50 years) without risk factors for Listeria:

   • Ceftriaxone 2g IV q12h or cefotaxime 2g IV q4-6h
   • Add vancomycin 15-20 mg/kg IV q8-12h in areas with high pneumococcal resistance 1, 2, 4

4. Adults >50 years or immunocompromised:

   • Ceftriaxone or cefotaxime PLUS
   • Vancomycin or rifampicin PLUS
   • Amoxicillin/ampicillin 2g IV q4h (for Listeria coverage) 1, 2

Adjunctive Therapy

Dexamethasone

• Administer dexamethasone 10mg IV q6h for 4 days 1, 2
• Start before or with the first antibiotic dose
• Most beneficial in pneumococcal meningitis
• Consider stopping if the causative organism is neither H. influenzae nor S. pneumoniae 1
• For children: 0.15mg/kg IV q6h for 2-4 days 2

Supportive Care

• Maintain head elevation at 30 degrees
• Avoid hypotonic fluids that may worsen cerebral edema
• Monitor for signs of increased intracranial pressure
• Consider neurosurgical consultation if significant mass effect is present 2

Duration of Treatment

• S. pneumoniae: 10-14 days
• N. meningitidis: 7 days
• H. influenzae: 7-10 days
• L. monocytogenes: 21 days
• Culture-negative: at least 14 days 2

Treatment Adjustment Based on Culture Results

• Once pathogen is identified, narrow therapy according to susceptibility testing
• For penicillin-sensitive organisms: continue ceftriaxone/cefotaxime or switch to benzylpenicillin
• For penicillin-resistant organisms: add vancomycin and rifampicin
• For organisms resistant to both penicillin and cephalosporin: continue triple therapy with ceftriaxone/cefotaxime plus vancomycin plus rifampicin 2

Common Pitfalls to Avoid

1. Delayed antibiotic administration - significantly increases mortality risk 1, 5
2. Performing CT scan before antibiotics - if LP is delayed, start antibiotics immediately after blood cultures 1
3. Failing to cover Listeria in patients ≥50 years or immunocompromised 1, 2
4. Neglecting to add vancomycin when necessary for resistant pneumococci 1, 2
5. Stopping antibiotics too early - ensure adequate duration based on pathogen 2
6. Not adjusting therapy based on culture results and susceptibility patterns 2

Monitoring Response

• Assess clinical improvement within 48 hours
• If no improvement, consider repeat lumbar puncture and evaluation for antibiotic resistance
• For patients with persistent fever, consider complications such as subdural empyema or brain abscess 2, 6

Bacterial meningitis is a medical emergency requiring prompt recognition and treatment to reduce mortality and neurological sequelae. The organized approach outlined above enables timely administration of appropriate antibiotics and adjunctive therapy to optimize patient outcomes 7, 8.