What is the treatment protocol for meningitis?

Meningitis Treatment Protocol

For bacterial meningitis, the first-line empiric treatment is ceftriaxone 2g IV every 12 hours, with specific adjustments based on patient age and suspected pathogens. 1

Initial Empiric Treatment

Standard Adult Therapy

• Ceftriaxone 2g IV every 12 hours OR Cefotaxime 2g IV every 6 hours 2, 1
• Treatment duration: 5-14 days depending on pathogen and clinical response 1

Age-Specific Considerations

• Adults ≥60 years old: Add Amoxicillin 2g IV every 4 hours to cover Listeria monocytogenes 1
  • Alternative if penicillin allergic: Co-trimoxazole 10-20mg/kg (of trimethoprim component) in four divided doses 2

Suspected Penicillin Resistance

• Add Vancomycin 15-20mg/kg IV twice daily (aim for trough levels 15-20 μg/mL) 2
• Consider adding Rifampicin 600mg twice daily 2, 1

Pathogen-Specific Treatment

Neisseria meningitidis

• Continue ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 2
• Alternative: Benzylpenicillin 2.4g IV every 4 hours 2, 1
• Duration: 5 days if clinical improvement 2, 1
• Add single dose of ciprofloxacin 500mg orally before discharge to eradicate nasopharyngeal carriage 2, 1

Streptococcus pneumoniae

• Continue ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 2
• Duration: 10-14 days 1
• For penicillin/cephalosporin-resistant strains:
  • Continue ceftriaxone/cefotaxime AND add vancomycin AND rifampicin 2
  • Treatment duration: 14 days 2

Haemophilus influenzae

• Continue ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 2
• Duration: 10 days 2

Listeria monocytogenes

• Amoxicillin 2g IV every 4 hours 2
• Alternative: Co-trimoxazole 10-20mg/kg (of trimethoprim component) in four divided doses 2
• Duration: 21 days 2

Enterobacteriaceae

• Continue ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 2
• For suspected ESBL-producing organisms: Meropenem 2g IV every 8 hours 2
• Duration: 21 days 2

No Identified Pathogen

• If recovered by day 10, treatment can be discontinued 2

Adjunctive Therapy

Dexamethasone

• Dexamethasone 10mg IV every 6 hours 1
• Start with or before first antibiotic dose
• Continue for 4 days in confirmed cases
• Do not start if antibiotics have been given for >12 hours 1

Monitoring and Follow-up

Treatment Failure Assessment

• Evaluate for treatment failure if:
  • Persistent fever after 48-72 hours of appropriate therapy
  • Worsening neurological status or GCS score
  • Persistent or recurrent positive CSF cultures 1

Intensive Care Referral Criteria

• GCS ≤12
• Rapidly evolving rash
• Cardiovascular instability
• Respiratory compromise
• Uncontrolled seizures 1

Before Discharge

• Assess for potential long-term sequelae (physical and psychological)
• Perform hearing tests if hearing loss is suspected 1

Special Considerations

Outpatient Therapy

• Consider outpatient parenteral antibiotic therapy for clinically stable patients requiring extended treatment 2, 1
• Requirements:
  • Afebrile and clinically improving
  • Reliable IV access
  • No other acute medical needs 1

Prophylaxis for Close Contacts

• Required for contacts of patients with Neisseria meningitidis
• Options:
  • Ciprofloxacin: single oral dose
  • Ceftriaxone: single intramuscular dose
  • Rifampicin: oral administration for 2 days 1

Clinical Pearls and Pitfalls

• Single daily dosing of ceftriaxone (50 mg/kg/day, max 4g) is effective for bacterial meningitis 3
• For cephalosporin-resistant pneumococci, higher doses of ceftriaxone (100 mg/kg/day) may be needed 4
• Dexamethasone may reduce mortality and neurological sequelae, particularly in pneumococcal meningitis 5
• Never use calcium-containing solutions with ceftriaxone due to risk of precipitation 6
• Vancomycin should never be used alone due to concerns about CSF penetration, especially when dexamethasone is given 2