What is the diagnosis and treatment for Cerebrospinal Fluid (CSF) meningitis?

From the Guidelines

For the treatment of community-acquired bacterial meningitis, a combination of cefotaxime or ceftriaxone plus vancomycin is recommended as empiric antibiotic therapy, with the addition of dexamethasone to reduce inflammation and improve outcomes, as suggested by the ESCMID guideline 1. The choice of specific antimicrobial agents depends on the patient's age and the presence of risk factors for certain pathogens, such as Listeria monocytogenes.

• 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 based on age 1.
• For patients between 1 month and 18 years old, cefotaxime or ceftriaxone plus vancomycin is recommended, with dosing adjusted for age and weight 1.
• For adults between 18 and 50 years old, ceftriaxone or cefotaxime plus vancomycin is also recommended, with adjustments for renal function and other factors 1.
• For patients over 50 years old or those with risk factors for Listeria, the addition of amoxicillin/ampicillin/penicillin G to the empiric regimen is advised 1. It is crucial to note that dexamethasone should be administered before or with the first dose of antibiotics, but its use should be reconsidered if the pathogen is identified as not being susceptible to its benefits, such as in the case of Listeria monocytogenes, where its use has been associated with increased mortality 1. The management of bacterial meningitis requires prompt and effective antimicrobial therapy, along with supportive care to manage complications and prevent further damage.
• The use of adjunctive treatments such as intracranial pressure-based therapies and therapeutic hypothermia is not recommended for routine care without further evidence from randomized controlled trials 1.
• The diagnosis of meningitis involves lumbar puncture with CSF analysis, including cell count, glucose, protein, Gram stain, and culture, to guide targeted antimicrobial therapy 1. In summary, the treatment of community-acquired bacterial meningitis should prioritize the use of empiric antibiotic therapy with coverage for common pathogens, along with dexamethasone for its anti-inflammatory effects, and supportive care to manage complications and improve outcomes, as recommended by the most recent guidelines 1.

From the FDA Drug Label

Ceftriaxone penetrated the inflamed meninges of infants and pediatric patients; CSF concentrations after a 50 mg/kg IV dose and after a 75 mg/kg IV dose are also shown in Table 3. In the treatment of meningitis, it is recommended that the initial therapeutic dose be 100 mg/kg (not to exceed 4 grams). Ceftriaxone for Injection is indicated for the treatment of the following infections when caused by susceptible organisms: ... MENINGITIS Caused by Haemophilus influenzae, Neisseria meningitidis or Streptococcus pneumoniae

Ceftriaxone is effective against CSF meningitis caused by susceptible organisms, with CSF concentrations reaching therapeutic levels after IV administration. The recommended dose for meningitis is 100 mg/kg (not to exceed 4 grams) as an initial therapeutic dose. 2 2 2

From the Research

CSF Meningitis

• CSF evaluation is the single most important aspect of the laboratory diagnosis of meningitis, including measurement of pressure, cell count and white cell differential, determination of glucose and protein levels, Gram's stain, and culture 3.
• In bacterial meningitis, the use of empiric vancomycin plus a third-generation cephalosporin has been recommended since 1997, and vancomycin should still be included as empiric therapy for bacterial meningitis 4.
• The penetration of vancomycin into the cerebrospinal fluid (CSF) is not significantly affected by concomitant dexamethasone use in adult patients with acute bacterial meningitis, and appropriate concentrations of vancomycin in CSF may be obtained even when concomitant steroids are used 5, 6.
• Ceftriaxone is effective therapy for presumed bacterial meningitis, but must be combined with ampicillin initially, since L. monocytogenes meningitis cannot be excluded in most cases until CSF culture results are available 7.
• The diagnosis of meningitis should be approached with caution, and institution of antibiotic therapy for suspected meningitis should not be delayed while neuroradiologic studies are obtained to exclude abscess or while measures are instituted to reduce intracranial pressure 3.