What is the recommended treatment for meningitis?

Treatment of Bacterial Meningitis

The recommended empirical treatment for bacterial meningitis in adults is 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

For Adults <60 Years:

• Ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 2, 1
• If penicillin-resistant pneumococci is suspected (e.g., recent travel to areas with high resistance rates), add vancomycin 15-20mg/kg IV twice daily OR rifampicin 600mg twice daily 2

For Adults ≥60 Years:

• Ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 2, 1
• PLUS amoxicillin 2g IV every 4 hours (for Listeria coverage) 2, 1
• Consider adding co-trimoxazole 10-20mg/kg (of trimethoprim component) in four divided doses as an alternative to amoxicillin 2

Pathogen-Specific Treatment

Streptococcus pneumoniae:

• If penicillin-sensitive (MIC ≤0.06 mg/L): Benzylpenicillin 2.4g IV every 4 hours OR continue ceftriaxone/cefotaxime 2, 1
• If penicillin-resistant but cephalosporin-sensitive: Continue ceftriaxone/cefotaxime 2
• If both penicillin and cephalosporin-resistant: Continue ceftriaxone/cefotaxime PLUS vancomycin 15-20mg/kg IV twice daily PLUS rifampicin 600mg twice daily 2
• Duration: 10 days if recovered, 14 days if not recovered by day 10 or for resistant strains 2, 1

Neisseria meningitidis:

• Ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours OR benzylpenicillin 2.4g IV every 4 hours 2, 1
• Duration: 5 days 1

Listeria monocytogenes:

• Amoxicillin 2g IV every 4 hours 1
• Duration: 21 days 1

Haemophilus influenzae:

• Ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 1
• Duration: 10 days 1

Special Considerations

Antimicrobial Resistance:

• Check recent travel history to countries with high pneumococcal resistance rates 2, 1
• Consult local infectious disease expertise for up-to-date resistance patterns 2
• Resources for resistance data: European Centre for Disease Prevention and Control website or World Health Organisation (http://bit.ly/1Kosckx and http://bit.ly/1rOb3cx) 2

Administration Considerations:

• Ceftriaxone should be administered intravenously by infusion over a period of 30 minutes 3
• Do not use diluents containing calcium with ceftriaxone due to risk of precipitation 3
• Concentrations between 10 mg/mL and 40 mg/mL are recommended for IV administration 3

Clinical Evidence:

• Third-generation cephalosporins have demonstrated excellent bactericidal activity against common meningitis pathogens and good penetration of inflamed meninges 2, 4
• Ceftriaxone maintains cerebrospinal fluid concentrations 10-100 times higher than the MIC of pathogenic bacteria for 24 hours after dosing 5
• High-dose cefotaxime (300 mg/kg/day) has been effective in treating pneumococcal meningitis with decreased susceptibility to cephalosporins 6

Important Caveats

• Empirical therapy should be started immediately after obtaining blood cultures and before lumbar puncture results are available 1
• For viral meningitis caused by varicella-zoster virus, the treatment differs significantly - intravenous aciclovir (10-15 mg/kg three times daily) is recommended instead of antibiotics 7
• Meningococcal resistance to penicillin is extremely rare, but pneumococcal resistance varies geographically 2
• Consider adjunctive dexamethasone therapy, especially for pneumococcal meningitis 1
• In cases with no identified pathogen, treatment can be discontinued if clinical recovery occurs by day 10 1