What is the management of Bacterial Meningitis?

From the Guidelines

Bacterial meningitis requires immediate empiric antibiotic therapy after obtaining blood cultures and cerebrospinal fluid (CSF) if possible, without delaying treatment, with the most recent and highest quality study recommending vancomycin plus a third-generation cephalosporin such as ceftriaxone or cefotaxime, as outlined in the 2017 ESCMID guideline 1. The choice of empiric antibiotic therapy depends on the patient's age and underlying health conditions.

• For neonates less than 1 month old, the recommended treatment is amoxicillin/ampicillin/penicillin plus cefotaxime, or amoxicillin/ampicillin plus an aminoglycoside, with specific dosing guidelines provided in the 2017 ESCMID guideline 1.
• For patients between 1 month and 18 years old, cefotaxime or ceftriaxone plus vancomycin or rifampicin is recommended, with dosing guidelines also provided in the 2017 ESCMID guideline 1.
• For adults between 18 and 50 years old, cefotaxime or ceftriaxone plus vancomycin or rifampicin is recommended, with specific dosing guidelines provided in the 2017 ESCMID guideline 1.
• For adults over 50 years old or those with risk factors for Listeria monocytogenes, cefotaxime or ceftriaxone plus vancomycin or rifampicin plus amoxicillin/ampicillin/penicillin G is recommended, as outlined in the 2017 ESCMID guideline 1. Dexamethasone should be administered before or with the first antibiotic dose to reduce inflammation and improve outcomes, particularly in pneumococcal meningitis, as recommended in the 2016 UK joint specialist societies guideline 1. The duration of antibiotic therapy depends on the identified pathogen, with recommendations ranging from 5-10 days for meningococcal disease and 10-14 days for pneumococcal disease, as outlined in the 2016 UK joint specialist societies guideline 1. Supportive care includes airway management, seizure control, intracranial pressure monitoring if needed, and ICU admission for close monitoring, as bacterial meningitis can cause severe inflammation of the meninges, leading to increased intracranial pressure and potential neurological damage. Prompt treatment is crucial as mortality increases significantly with delayed antibiotic administration, highlighting the importance of immediate empiric antibiotic therapy after obtaining blood cultures and CSF if possible, without delaying treatment, as recommended in the 2017 ESCMID guideline 1.

From the FDA Drug Label

1. 3 Bacterial Meningitis (Pediatric Patients 3 Months of Age and Older Only) Meropenem for injection is indicated for the treatment of bacterial meningitis caused by Haemophilus influenzae,Neisseria meningitidis and penicillin-susceptible isolates of Streptococcus pneumoniae. For pediatric patients 3 months of age and older, the meropenem for injection dose is 10 mg/kg, 20 mg/kg or 40 mg/kg every 8 hours (maximum dose is 2 grams every 8 hours), depending on the type of infection (cSSSI, cIAI, intra-abdominal infection or meningitis). For pediatric patients weighing over 50 kg administer meropenem for injection at a dose of 500 mg every 8 hours for cSSSI, 1 gram every 8 hours for cIAI and 2 grams every 8 hours for meningitis.

The management of Bacterial Meningitis in pediatric patients 3 months of age and older involves the use of meropenem for injection at a dose of:

• 10 mg/kg, 20 mg/kg or 40 mg/kg every 8 hours (maximum dose is 2 grams every 8 hours) for patients weighing 50 kg or less
• 2 grams every 8 hours for patients weighing over 50 kg 2

From the Research

Management of Bacterial Meningitis

The management of bacterial meningitis involves several key steps, including:

• Rapid hospitalization and assessment for lumbar puncture (LP) if clinically safe 3
• Initiation of antibiotic therapy within 3 hours of first contact with the health service, with parenteral therapy with a third-generation cephalosporin as the initial antibiotic of choice in the absence of penicillin allergy and bacterial resistance 3
• Sending a blood sample for culture before initiating antibiotic therapy 3
• Laboratory examination of cerebrospinal fluid to guide the choice of antibiotics and duration of therapy 3

Antibiotic Therapy

The choice of antibiotic therapy depends on the suspected cause of the meningitis, with options including:

• Third-generation cephalosporins, such as ceftriaxone, as the initial antibiotic of choice 3, 4, 5
• Vancomycin as the preferred antibiotic for penicillin-resistant pneumococcal meningitis 3, 6, 7
• Amoxicillin in addition to a third-generation cephalosporin if meningitis due to Listeria monocytogenes is suspected 3
• Benzyl penicillin in the absence of a known history of penicillin allergy for suspected Neisseria meningitidis infection 3

Supportive Therapy

Supportive therapy, such as dexamethasone, may be administered in certain cases, including:

• Adults and children with suspected Streptococcus pneumoniae or H. influenzae meningitis 3
• Patients with rapidly evolving petechial skin rash, in which case antibiotic therapy must be initiated immediately 3