What is the recommended treatment for meningitis?

Treatment of Meningitis

The recommended treatment for bacterial meningitis in adults is empiric therapy with ceftriaxone 2g IV every 12 hours or cefotaxime 2g IV every 6 hours, with additional agents based on patient age and risk factors. 1

Empirical Treatment Algorithm

Initial Antibiotic Selection

• For adults <60 years of age:

  • Ceftriaxone 2g IV every 12 hours OR Cefotaxime 2g IV every 6 hours 1
  • Alternative: Chloramphenicol 25 mg/kg IV every 6 hours (if cephalosporin allergic) 1

• For adults ≥60 years of age:

  • Ceftriaxone 2g IV every 12 hours OR Cefotaxime 2g IV every 6 hours 1
  • PLUS Amoxicillin 2g IV every 4 hours (for Listeria coverage) 1
  • Alternative: Chloramphenicol 25 mg/kg IV every 6 hours AND Co-trimoxazole 10-20 mg/kg (of trimethoprim component) in four divided doses 1

• If penicillin-resistant pneumococci is suspected (e.g., recent travel to areas with high resistance rates):

  • Add Vancomycin 15-20 mg/kg IV every 12 hours OR Rifampicin 600 mg orally/IV every 12 hours 1

Pathogen-Specific Treatment

Streptococcus pneumoniae meningitis

• If penicillin sensitive (MIC ≤0.06 mg/L):

  • Benzylpenicillin 2.4g IV every 4 hours OR continue ceftriaxone/cefotaxime 1
  • Duration: 10 days if recovered; up to 14 days if slower response 1

• If penicillin resistant but cephalosporin sensitive:

  • Continue ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 1
  • Duration: 10 days if recovered; up to 14 days if slower response 1

• If both penicillin and cephalosporin resistant:

  • Continue ceftriaxone/cefotaxime PLUS vancomycin 15-20 mg/kg IV every 12 hours PLUS rifampicin 600 mg orally/IV every 12 hours 1
  • Duration: 14 days 1
  • Target vancomycin trough levels of 15-20 mg/L 1

Neisseria meningitidis meningitis

• Preferred treatment:
  • Continue ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 1
  • Alternative: Benzylpenicillin 2.4g IV every 4 hours 1
  • Duration: 5 days if recovered 1
• If not treated with ceftriaxone:
  • Add single dose of ciprofloxacin 500 mg orally (for eradication of throat carriage) 1

Listeria monocytogenes meningitis

• Amoxicillin 2g IV every 4 hours 1
• Alternative: Co-trimoxazole 10-20 mg/kg (of trimethoprim component) in four divided doses 1
• Duration: 21 days 1

Haemophilus influenzae meningitis

• Continue ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 1
• Alternative: Moxifloxacin 400 mg once daily 1
• Duration: 10 days 1

Special Considerations

• Patients with no identified pathogen: If recovered by day 10, treatment can be discontinued 1

• Suspected meningococcal sepsis without lumbar puncture:

  • If recovered by day 5 with typical petechial/purpuric rash, treatment can be stopped 1

• Outpatient IV therapy: Consider for clinically well patients 1

• Gram-negative bacilli meningitis:

  • Continue ceftriaxone/cefotaxime and seek specialist advice regarding local resistance patterns 1
  • If ESBL-producing organism suspected, use meropenem 2g IV every 8 hours 1
  • Duration: 21 days 1

Important Caveats

• Antimicrobial resistance: Check recent travel history and consult local infectious disease expertise if patient has visited areas with high resistance rates 1

• Dexamethasone: Consider adjunctive therapy with dexamethasone for suspected bacterial meningitis, especially for pneumococcal meningitis 1

• Ceftriaxone administration: Should be administered intravenously by infusion over 30 minutes; concentrations between 10-40 mg/mL are recommended 2

• Ceftriaxone precautions: Do not use diluents containing calcium, such as Ringer's solution or Hartmann's solution, to reconstitute ceftriaxone due to risk of precipitation 2

• Recent research: A 2023 study suggests that for penicillin-susceptible S. pneumoniae meningitis, a ceftriaxone dose of 2g daily may be as effective as 2g twice daily, though this is not yet reflected in guidelines 3