Treatment Protocol and Duration for Different Etiologies of Meningitis
The first-line treatment for bacterial meningitis is intravenous ceftriaxone 2g every 12 hours or cefotaxime 2g every 6 hours for 5-7 days in patients who have clinically recovered, with specific modifications based on the suspected pathogen. 1
Bacterial Meningitis Treatment Protocols
Meningococcal Meningitis
- First-line treatment: Ceftriaxone 2g IV every 12 hours or cefotaxime 2g IV every 6 hours 1
- Duration: 5 days if clinically recovered (7 days per ESCMID recommendations) 1
- Alternative options:
- Benzylpenicillin 2.4g IV every 4 hours (may require additional ciprofloxacin for throat carriage eradication)
- Chloramphenicol 25mg/kg IV every 6 hours (for severe beta-lactam allergies) 1
Pneumococcal Meningitis
- First-line treatment: Combination of ceftriaxone and vancomycin is recommended for empiric therapy due to increasing penicillin and cephalosporin resistance 2, 3
- Duration: 10-14 days 1
- For resistant strains:
Haemophilus influenzae Meningitis
Listeria Meningitis
- Treatment: Amoxicillin 2g IV every 4 hours (should be added for patients ≥60 years) 1
- Duration: 3 weeks, associated with gentamycin or cotrimoxazole 4
Enterobacteriaceae Meningitis (common in neonates)
- Treatment: Third-generation cephalosporins plus aminoglycosides, especially in infants under 3 months 4
- Duration: 14-21 days
Pediatric Dosing Considerations
- Meningitis dosing: 100 mg/kg/day of ceftriaxone (not to exceed 4 grams daily) 5
- Duration: 7-14 days is the usual duration of therapy 5
- Administration: Intravenous doses should be given over 60 minutes in neonates to reduce the risk of bilirubin encephalopathy 5
Adjunctive Therapy
Dexamethasone: 10 mg IV every 6 hours started with or before the first dose of antibiotics and continued for 4 days in confirmed cases 1
Not recommended: Routine adjuvant therapy with mannitol, acetaminophen, antiepileptic drugs, or hypertonic saline 1
Contraindicated: Therapeutic hypothermia and glycerol in bacterial meningitis 1
Treatment Monitoring and Follow-up
- Monitor clinical response within the first 24-48 hours 1
- Consider repeat lumbar puncture, evaluation for complications, or assessment for antibiotic resistance if no improvement or clinical deterioration occurs 1
- For culture-negative meningitis with clinical suspicion, continue empiric treatment for at least 2 weeks 1
Special Considerations
- Penicillin resistance: Approximately 10.3% of isolates show intermediate susceptibility to penicillin G, though all isolates in U.S. surveillance studies remain susceptible to ceftriaxone 1
- Outpatient therapy: May be considered when the patient is afebrile and clinically improving, has received 5 days of inpatient therapy, has reliable IV access, can access medical care 24/7, and has no other acute medical needs 1
- Prophylaxis: Close contacts of patients with meningococcal disease should receive prophylaxis to prevent secondary cases 1
Common Pitfalls to Avoid
- Incomplete treatment: Ensure full course of antibiotics even if rapid clinical improvement occurs 1
- Calcium-containing solutions: Do not use diluents containing calcium with ceftriaxone due to risk of precipitation 5
- Neonatal considerations: Ceftriaxone is contraindicated in premature neonates and neonates ≤28 days if they require calcium-containing IV solutions 5
- Inadequate coverage: For patients ≥60 years, always add amoxicillin to cover Listeria 1
- Delayed adjunctive therapy: Dexamethasone should be started with or before the first dose of antibiotics for maximum benefit 1