What is the recommended treatment for streptococcal meningitis?

Treatment of Streptococcal Meningitis

For streptococcal meningitis, the recommended treatment is a third-generation cephalosporin (ceftriaxone 2g IV every 12 hours or cefotaxime 2g IV every 6 hours) with the addition of vancomycin or rifampicin if penicillin resistance is suspected. 1

Initial Treatment Approach

• Third-generation cephalosporins are the cornerstone of treatment for streptococcal meningitis due to their excellent CSF penetration and activity against streptococcal species 1
• For Streptococcus pneumoniae (pneumococcal) meningitis:
  • Ceftriaxone 2g IV every 12 hours or cefotaxime 2g IV every 6 hours is the preferred initial treatment 1
  • If the pneumococcus is penicillin-sensitive (MIC ≤0.06 mg/L), benzylpenicillin 2.4g IV every 4 hours can be used as an alternative 1

Management Based on Antimicrobial Susceptibility

• For penicillin-sensitive streptococci (MIC ≤0.06 mg/L):

  • Benzylpenicillin 2.4g IV every 4 hours OR
  • Continue third-generation cephalosporin (ceftriaxone or cefotaxime) 1

• For penicillin-resistant but cephalosporin-sensitive streptococci:

  • Continue third-generation cephalosporin (ceftriaxone or cefotaxime) 1

• For highly resistant strains (penicillin and cephalosporin resistant):

  • Combination therapy with ceftriaxone/cefotaxime PLUS vancomycin (15-20 mg/kg IV every 12 hours) PLUS rifampicin (600 mg IV/orally every 12 hours) 1
  • Serum vancomycin trough concentrations should be maintained at 15-20 mg/mL 1

Special Considerations

• Vancomycin should never be used as monotherapy for streptococcal meningitis, even for highly resistant strains 1
• Rifampicin should only be added if the organism is shown to be susceptible and there is a delay in the expected clinical or bacteriologic response 1
• Meropenem (40 mg/kg every 8 hours, up to 6g/day) can be considered as an alternative to third-generation cephalosporins in adults with streptococcal meningitis 2

Duration of Treatment

• For pneumococcal meningitis:
  • 10 days if the patient has recovered by day 10 1
  • 14 days if the patient has not recovered by day 10 or has penicillin/cephalosporin-resistant infection 1
• For Group B streptococcal meningitis:
  • At least 14 days of therapy is recommended 1

Common Pitfalls and Caveats

• Delaying antimicrobial therapy significantly increases mortality; treatment should be initiated within one hour of suspicion of bacterial meningitis 1
• Vancomycin penetrates poorly into the CSF, especially when inflammation is resolving, which is why it should always be combined with a third-generation cephalosporin 1
• When using vancomycin, monitoring serum trough levels is essential to ensure adequate CSF concentrations 1
• First-generation cephalosporins should not be used for streptococcal meningitis due to poor CSF penetration and high rates of treatment failure 3, 4
• For patients with culture-negative meningitis but clinical presentation suggestive of bacterial meningitis, empiric treatment should be continued for at least 2 weeks 1

The evidence strongly supports using third-generation cephalosporins as the backbone of therapy for streptococcal meningitis, with the addition of vancomycin and/or rifampicin for suspected or confirmed resistant strains. This approach has been shown to optimize outcomes in terms of mortality and neurological sequelae.