What is the recommended treatment for a patient with 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 the addition of amoxicillin 2g IV every 4 hours in patients ≥60 years old. 1

Empirical Antibiotic Therapy

• For adults under 60 years old, empirical treatment should consist of:

  • Ceftriaxone 2g IV every 12 hours OR
  • Cefotaxime 2g IV every 6 hours 1
  • Alternative: Chloramphenicol 25 mg/kg IV every 6 hours (for patients with severe beta-lactam allergies) 1, 2

• For adults 60 years and older, empirical treatment should include:

  • Ceftriaxone 2g IV every 12 hours OR
  • Cefotaxime 2g IV every 6 hours
  • PLUS
  • Amoxicillin 2g IV every 4 hours (to cover Listeria monocytogenes) 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

• Add vancomycin 15-20 mg/kg IV every 12 hours OR rifampicin 600 mg twice daily if penicillin-resistant pneumococci are suspected (e.g., patient recently arrived from a country with high prevalence of resistance) 1

Pathogen-Specific Treatment

Streptococcus pneumoniae

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

  • Continue ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours OR
  • Switch to benzylpenicillin 2.4g IV every 4 hours 1
  • Duration: 10 days if stable; up to 14 days if slower response 1

• For penicillin-resistant but cephalosporin-sensitive pneumococci:

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

• For penicillin and cephalosporin-resistant pneumococci:

  • Continue ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours
  • PLUS vancomycin 15-20 mg/kg IV every 12 hours
  • PLUS rifampicin 600 mg IV/orally twice daily 1
  • Duration: 14 days 1

Neisseria meningitidis

• Continue ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours OR
• Switch to benzylpenicillin 2.4g IV every 4 hours 1, 2
• If not treated with ceftriaxone, add a single dose of ciprofloxacin 500 mg orally 1
• Duration: 5 days if clinical recovery is observed 1, 2

Listeria monocytogenes

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

Haemophilus influenzae

• Cefotaxime 2g IV every 6 hours
• Alternative: Moxifloxacin 400 mg once daily 1
• Duration: 10 days 1

Special Considerations

• For pediatric patients with bacterial meningitis, meropenem is FDA-approved for treatment of meningitis caused by H. influenzae, N. meningitidis, and penicillin-susceptible S. pneumoniae at a dose of 40 mg/kg (maximum 2g) every 8 hours 3

• In children, combination treatment with cefotaxime (300 mg/kg per day) or ceftriaxone (100 mg/kg per day) and vancomycin (60 mg/kg per day) is recommended as first-line therapy when pneumococcal meningitis cannot be ruled out 4

• Ceftriaxone should be administered intravenously over 30 minutes in adults, but over 60 minutes in neonates to reduce the risk of bilirubin encephalopathy 5

Monitoring and Follow-up

• If the patient is not improving clinically, consider:
  • Obtaining susceptibility testing and adjusting antibiotics accordingly 2
  • Extending treatment duration 2
  • Repeating lumbar puncture, especially in pneumococcal meningitis with uncertain susceptibility 1

Common Pitfalls to Avoid

• Do not delay treatment while waiting for culture results if bacterial meningitis is suspected 2
• Do not use rifampin as monotherapy due to the risk of developing resistance 2
• Do not discontinue therapy prematurely, even if clinical improvement occurs rapidly, as this may lead to relapse 2
• Do not use diluents containing calcium (e.g., Ringer's solution) to reconstitute ceftriaxone due to risk of precipitation 5
• Do not administer ceftriaxone simultaneously with calcium-containing IV solutions 5