What is the treatment for meningitis?

Treatment of Meningitis

Immediate antibiotic therapy must be started within 1 hour of clinical suspicion of bacterial meningitis, even before diagnostic confirmation, as delayed treatment is strongly associated with poor outcomes and death. 1

Initial Assessment and Diagnostic Approach

• Perform blood cultures before starting antibiotics

• Lumbar puncture (LP) should be performed promptly unless contraindications exist:

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

• If LP must be delayed (e.g., for CT scan), start empiric antibiotics immediately after drawing blood cultures 1, 2

• CSF analysis should include cell count, protein, glucose, Gram stain, culture, and consider PCR for bacterial and viral pathogens 2

Empiric Antibiotic Treatment

Adults <60 years:

• Ceftriaxone 2g IV q12h OR Cefotaxime 2g IV q6h
• PLUS Vancomycin 10-20 mg/kg IV q8-12h (to achieve serum trough levels of 15-20 μg/mL) 1, 2

Adults ≥60 years or immunocompromised:

• Ceftriaxone 2g IV q12h OR Cefotaxime 2g IV q6h
• PLUS Vancomycin 10-20 mg/kg IV q8-12h
• PLUS Ampicillin/Amoxicillin 2g IV q4h (for Listeria coverage) 1, 2

Adjunctive Therapy

• Dexamethasone 10mg IV q6h for 4 days, with first dose administered 10-20 minutes before or at least concomitant with first antibiotic dose 1, 2
• Most beneficial in pneumococcal meningitis and in patients with moderate-to-severe disease 1

Pathogen-Specific Treatment (after identification)

Streptococcus pneumoniae:

• If penicillin sensitive (MIC ≤0.06 mg/L): Benzylpenicillin 2.4g IV q4h OR continue ceftriaxone/cefotaxime
• If penicillin resistant but cephalosporin sensitive: Continue ceftriaxone/cefotaxime
• If both penicillin and cephalosporin resistant: Continue ceftriaxone/cefotaxime PLUS vancomycin PLUS rifampicin 600mg IV/PO q12h 1
• Duration: 10 days if stable, 14 days if not recovered by day 10 or resistant strains 1

Neisseria meningitidis:

• Continue ceftriaxone/cefotaxime OR benzylpenicillin 2.4g IV q4h
• If not treated with ceftriaxone, add single dose ciprofloxacin 500mg PO for prophylaxis
• Duration: 5 days if recovered 1

Listeria monocytogenes:

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

Treatment Duration

• Meningococcal meningitis: 5 days (if recovered) 1
• Pneumococcal meningitis: 10-14 days 1
• Listeria meningitis: 21 days 1

Common Pitfalls to Avoid

1. Delaying antibiotics for imaging or LP - Start antibiotics within 1 hour of clinical suspicion 1, 3
2. Unnecessary CT scans - Only perform if specific contraindications to immediate LP exist 4
3. Omitting dexamethasone - Should be given with or before first antibiotic dose 1, 3
4. Inadequate vancomycin dosing - Maintain serum trough concentrations of 15-20 μg/mL 1
5. Forgetting Listeria coverage in adults >50 years or immunocompromised patients 1

Supportive Care

• Maintain mean arterial pressure ≥65 mmHg
• Target euvolemia (avoid fluid restriction)
• Consider intubation for GCS <12
• Monitor for signs of raised intracranial pressure
• Provide antipyretics and analgesics as needed 2

Monitoring and Complications

• Monitor for neurological deterioration
• Watch for seizures, cerebral infarctions, hydrocephalus
• Consider repeat neuroimaging if clinical deterioration occurs
• Common sequelae include hearing loss, cognitive deficits, and focal neurological deficits 1

Early antibiotic administration is the most critical intervention in bacterial meningitis management, with each hour of delay associated with worse outcomes. The recommended empiric regimen provides coverage against the most common pathogens while awaiting culture results.