What is the management of meningitis?

From the Guidelines

Management of meningitis requires prompt recognition and treatment to prevent serious complications, and the standard empiric regimen for adults includes ceftriaxone (2g IV every 12 hours) plus vancomycin (15-20 mg/kg IV every 8-12 hours), with ampicillin (2g IV every 4 hours) added for patients over 50 years or immunocompromised to cover Listeria, as recommended by the most recent guidelines 1. The choice of empiric antibiotic therapy depends on the age of the patient, risk factors for L. monocytogenes, and the regional rate of decreased susceptibility to penicillin and third-generation cephalosporins of S. pneumoniae, the most common pathogen 1.

• For children and adults aged <50 years without risk factors for L. monocytogenes, a third-generation cephalosporin (ceftriaxone or cefotaxime) is advised if local S. pneumoniae resistance rate to penicillin is low 1.
• If local resistance rates of S. pneumoniae to penicillin are elevated, vancomycin or rifampin is advised in addition to ceftriaxone or cefotaxime 1.
• The ESCMID guideline advises to treat all patients with risk factors and those aged >50 years to cover for listeria 1. Dexamethasone (0.15 mg/kg IV every 6 hours for 2-4 days) should be administered before or with the first antibiotic dose to reduce inflammation and improve outcomes, particularly in pneumococcal meningitis, as recommended by the UK joint specialist societies guideline 1. Supportive care includes managing increased intracranial pressure, maintaining adequate cerebral perfusion, preventing seizures, and ensuring proper fluid and electrolyte balance, with stabilization of the patient’s airway, breathing, and circulation as an immediate priority 1. Viral meningitis is typically self-limiting and requires supportive care, though acyclovir (10 mg/kg IV every 8 hours) should be given if herpes simplex virus is suspected, and close monitoring for neurological deterioration and complications is essential throughout treatment 1.

From the FDA Drug Label

In the treatment of meningitis, it is recommended that the initial therapeutic dose be 100 mg/kg (not to exceed 4 grams). Thereafter, a total daily dose of 100 mg/kg/day (not to exceed 4 grams daily) is recommended. Ceftriaxone for Injection is indicated for the treatment of the following infections when caused by susceptible organisms: ... MENINGITIS Caused by Haemophilus influenzae, Neisseria meningitidis or Streptococcus pneumoniae Bacterial Meningitis caused by E. coli, Group B Streptococci, and other Gram-negative bacteria (Listeria monocytogenes, N. meningitidis).

The management of meningitis includes the administration of antibiotics, such as ceftriaxone or ampicillin, in doses specific to the patient's condition and weight.

• The recommended dose for ceftriaxone is an initial therapeutic dose of 100 mg/kg (not to exceed 4 grams), followed by a total daily dose of 100 mg/kg/day (not to exceed 4 grams daily) 2.
• Ampicillin may also be used to treat bacterial meningitis, particularly when caused by susceptible Gram-negative bacteria, and its use may be enhanced by the addition of an aminoglycoside 3. Key considerations in the management of meningitis include:
• Identifying the causative organism and its susceptibility to antibiotics
• Selecting an appropriate antibiotic regimen based on the causative organism and local epidemiology
• Administering antibiotics in a timely and effective manner to reduce the risk of complications and improve outcomes 2

From the Research

Management of Meningitis

The management of meningitis involves the use of antibiotic therapy, with the choice of antibiotics depending on the causative pathogen and its susceptibility to different antibiotics.

• The initial empirical therapy for bacterial meningitis in infants and children should be based on direct cerebrospinal fluid (CSF) examination and rapid therapeutic adaptation according to bacterial identification and susceptibility 4.
• Combination treatment including cefotaxim or ceftriaxone and vancomycine remains the standard first line if pneumococcal meningitis cannot be ruled out 4.
• A simple treatment with third generation cephalosporin can be used for Neisseria meningitidis or Haemophilus influenzae meningitis, while aminoglycosides must be added in case of Enterobacteriacae, mainly before 3 months of age 4.
• Second line antibiotic therapy is adapted according to the clinical and bacteriological response on Day 2, with the possibility of adding rifampicin to the initial regimen 4.

Antibiotic Resistance

The increasing incidence of antibiotic-resistant pathogens requires the choice of an optimum initial empirical antibiotic regimen to be significant 5.

• The resistance rates of Streptococcus pneumoniae to penicillin G, ceftriaxone, and vancomycin have been evaluated, with moderate to penicillin, low to cephalosporin, and neutral to vancomycin resistance rates found 6.
• The use of antibiotics that are bactericidal but do not lyse bacteria may emerge as a therapeutic option for bacterial meningitis 5.
• The role of corticosteroids as adjunctive therapy may decline due to the increasing antibiotic resistance of bacteria causing meningitis 5.

Treatment of Specific Pathogens

The treatment of meningitis caused by specific pathogens, such as Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis, has been evaluated.

• Ceftriaxone and dexamethasone therapy has been evaluated in experimental cephalosporin-resistant pneumococcal meningitis, with increasing doses of ceftriaxone found to be effective, but concomitant use of dexamethasone associated with a higher failure rate 7.
• Cephalosporins, such as cefotaxime and ceftriaxone, have been found to be effective in treating meningitis due to various pathogens, including pneumococci, H. influenzae, and N. meningitidis 8.