What is the recommended management for meningitis?

Management of Bacterial Meningitis

The recommended first-line treatment for suspected bacterial meningitis is immediate administration of a third-generation cephalosporin (ceftriaxone or cefotaxime) combined with vancomycin, with adjunctive dexamethasone given before or with the first antibiotic dose. 1

Initial Empiric Therapy

Antibiotic Regimens

• For patients under 60 years:

  • Ceftriaxone 2g IV every 12 hours or cefotaxime 2g IV every 6 hours
  • Plus vancomycin 15-20 mg/kg IV every 12 hours (for potential penicillin-resistant pneumococci) 1

• For patients 60 years and older:

  • Ceftriaxone 2g IV every 12 hours or cefotaxime 2g IV every 6 hours
  • Plus amoxicillin 2g IV every 4 hours (for Listeria coverage)
  • Plus vancomycin if penicillin-resistant pneumococci are suspected 1

Pediatric Dosing

• For meningitis in children: 100 mg/kg/day of ceftriaxone (not to exceed 4 grams daily) 2
• Initial therapeutic dose should be 100 mg/kg (not to exceed 4 grams) 2

Adjunctive Therapy

• Dexamethasone 0.15 mg/kg IV every 6 hours for 2-4 days
• First dose must be given 10-20 minutes before or at least concomitant with the first antimicrobial dose 1

Duration of Therapy

• Pneumococcal meningitis:

  • 10 days if recovered by day 10
  • 14 days if not recovered by day 10 or if penicillin/cephalosporin resistant 1

• Meningococcal meningitis: 7-10 days of appropriate antibiotic therapy 1

• Listeria meningitis: 3 weeks of amoxicillin, associated with gentamycin or cotrimoxazole 3

Management Based on Antibiotic Sensitivity

After Culture Results Available

• For penicillin-sensitive strains:

  • Benzylpenicillin 2.4g IV every 4 hours or
  • Continue ceftriaxone/cefotaxime 1

• For penicillin-resistant but cephalosporin-sensitive strains:

  • Continue ceftriaxone or cefotaxime 1

• For penicillin and cephalosporin-resistant strains:

  • Continue ceftriaxone/cefotaxime plus
  • Vancomycin plus
  • Rifampicin 600mg IV/oral every 12 hours 1

Supportive Care

• Maintain euvolemia; fluid restriction is not recommended
• Maintain mean arterial pressure ≥65 mmHg 1
• Monitor for signs of raised intracranial pressure
• Consider ICU admission for patients with:
  • GCS <12
  • Persistent seizures
  • Severe sepsis
  • Hypoxia 1

Critical Points to Avoid Treatment Failure

1. Never delay antimicrobial therapy - Start antibiotics immediately after blood cultures or lumbar puncture 1

2. Never use vancomycin as monotherapy - Even for highly resistant pneumococcal strains 1

3. Never miss dexamethasone timing - Must be given before or with first antibiotic dose to be effective 1, 4

4. Never restrict fluids - May worsen outcomes 1

5. Never use calcium-containing solutions with ceftriaxone - Risk of precipitation, especially in neonates 2

6. Never forget coverage for resistant organisms - Especially in patients with recent travel history 1

7. Consider combination therapy for highly resistant strains - The combination of ceftriaxone and rifampin is preferred when dexamethasone is used, as dexamethasone reduces vancomycin penetration into CSF 4

Special Considerations

• In neonates, ceftriaxone should be administered over 60 minutes to reduce the risk of bilirubin encephalopathy 2

• Ceftriaxone is contraindicated in premature neonates and neonates ≤28 days if they require calcium-containing IV solutions 2

• For areas with high rates of resistant pneumococci, initial empiric therapy should include two antibiotics: ceftriaxone and either rifampin or vancomycin 4

• A second lumbar puncture on day 2 is necessary for pneumococcal strains with MIC ≥0.5mg/L to assess treatment response 3