What is the treatment for meningitis?

Treatment of Meningitis

Immediate empiric antibiotic therapy should be started within 1 hour of clinical suspicion of bacterial meningitis, even before lumbar puncture if it will be delayed, as any delay in treatment is strongly associated with poor outcomes and death. 1

Initial Assessment and Diagnostic Approach

• Lumbar puncture (LP) is the cornerstone diagnostic procedure for meningitis

• When to perform CT before LP: Only in patients with:

  • Focal neurologic deficits (excluding cranial nerve palsies)
  • New-onset seizures
  • Severely altered mental status (Glasgow Coma Scale score <10)
  • Severely immunocompromised state 1

• Critical timing: If LP will be delayed (e.g., due to CT), blood cultures must be drawn and empiric antibiotics started immediately 1

Empiric Antibiotic Treatment

Adults <60 years:

• First-line: Ceftriaxone 2g IV q12h OR Cefotaxime 2g IV q6h 1, 2
• PLUS: Vancomycin 15-20mg/kg IV q8-12h (to achieve serum trough concentrations of 15-20 μg/mL) 1
• Consider adding: Rifampicin 600mg IV/oral q12h if high suspicion of penicillin-resistant pneumococci 1

Adults ≥60 years or immunocompromised:

• First-line: Ceftriaxone 2g IV q12h OR Cefotaxime 2g IV q6h 1
• PLUS: Vancomycin 15-20mg/kg IV q8-12h 1
• PLUS: Ampicillin/Amoxicillin 2g IV q4h (for Listeria coverage) 1, 2

Pediatric patients:

• For meningitis: 100mg/kg/day of ceftriaxone or cefotaxime (not exceeding 4g daily) 3
• Duration: 7-14 days typically 3

Adjunctive Therapy

• Dexamethasone: 10mg IV q6h for 4 days, started before or with first antibiotic dose 2
  • Most beneficial in pneumococcal meningitis 1
  • Should be given to adults with suspected or proven pneumococcal meningitis 1

Pathogen-Specific Treatment (After Culture Results)

Streptococcus pneumoniae:

• If penicillin-sensitive (MIC ≤0.06 mg/L): Continue ceftriaxone/cefotaxime OR switch to benzylpenicillin 2.4g IV q4h 1
• If penicillin-resistant but cephalosporin-sensitive: Continue ceftriaxone/cefotaxime 1
• If both penicillin and cephalosporin resistant: Continue ceftriaxone/cefotaxime PLUS vancomycin PLUS rifampicin 1
• Duration: 10 days if stable, up to 14 days if slower response or resistant strains 1

Neisseria meningitidis:

• Treatment: Continue ceftriaxone/cefotaxime OR benzylpenicillin 2.4g IV q4h 1
• Duration: 5 days if recovered 1

Listeria monocytogenes:

• Treatment: Amoxicillin/Ampicillin 2g IV q4h 1
• Alternative: Co-trimoxazole 10-20mg/kg (trimethoprim component) in 4 divided doses 1
• Duration: 21 days 1

Common Pitfalls to Avoid

1. Delaying antibiotics: Never delay antibiotic administration for imaging or LP - start within 1 hour of suspicion 1, 4

2. Unnecessary CT scans: Too many patients undergo unnecessary CT scans before LP, causing critical delays in diagnosis and treatment 5, 6

3. Missing adjunctive dexamethasone: Only 39% of patients receive appropriate adjunctive corticosteroids in some studies 6

4. Inadequate monitoring: Patients require close monitoring for neurological deterioration and complications, which occur in a large proportion of cases 1

Duration of Treatment

• Pneumococcal meningitis: 10 days if recovered, 14 days if slower response or resistant strains 1
• Meningococcal meningitis: 5 days if recovered 1
• Listeria meningitis: 21 days 1

Follow-up Considerations

• Hearing loss occurs in 5-35% of bacterial meningitis patients and should be evaluated 1
• Neuropsychological evaluation may be needed for cognitive deficits, which are common sequelae 1
• Other potential sequelae include seizures (13%), motor deficits (12%), and hydrocephalus (7%) 1

Bacterial meningitis remains a medical emergency with high mortality and morbidity despite advances in treatment. The key to improving outcomes is rapid diagnosis and immediate initiation of appropriate antimicrobial therapy, with careful attention to adjunctive treatments and monitoring for complications.