What is the treatment for Streptococcal pneumonia meningitis?

Treatment of Streptococcal Pneumonia Meningitis

Initiate empiric therapy with ceftriaxone 2g IV every 12 hours (or cefotaxime 2g IV every 4-6 hours) PLUS vancomycin 10-20 mg/kg IV every 8-12 hours (targeting trough levels of 15-20 μg/mL) within 60 minutes of hospital arrival, before lumbar puncture if delayed. 1

Immediate Management Algorithm

Time-Critical Antibiotic Administration

• Start antibiotics within 1 hour of hospital presentation - delays in treatment are strongly associated with death and poor outcomes 1
• Draw blood cultures immediately, but never delay antibiotics while awaiting lumbar puncture or imaging results 1
• If lumbar puncture is delayed due to cranial imaging (required for focal deficits, new seizures, GCS <10, or severe immunocompromise), start empiric treatment immediately on clinical suspicion 1

Age-Stratified Empiric Regimens

Adults 18-50 years:

• Ceftriaxone 2g IV every 12 hours (or cefotaxime 2g IV every 4-6 hours) PLUS vancomycin 10-20 mg/kg IV every 8-12 hours 1
• Alternative: Rifampicin 300mg IV/PO every 12 hours can replace vancomycin 1

Adults >50 years or immunocompromised:

• Same as above PLUS amoxicillin 2g IV every 4 hours to cover Listeria monocytogenes 1

Pediatric patients 1 month to 18 years:

• Ceftriaxone 50mg/kg IV every 12 hours (maximum 2g every 12 hours) OR cefotaxime 75mg/kg IV every 6-8 hours PLUS vancomycin 10-15mg/kg IV every 6 hours (targeting trough 15-20 μg/mL) 1

Penicillin allergy:

• Chloramphenicol 25mg/kg IV every 6 hours 1

Definitive Therapy Based on Susceptibility

Penicillin-Sensitive Pneumococcus (MIC ≤0.06 mg/L)

• Switch to ceftriaxone 2g IV every 12 hours alone (or cefotaxime 2g IV every 6 hours) - vancomycin can be discontinued 1
• Alternative: Benzylpenicillin 2.4g IV every 4 hours 1
• Duration: 10 days if clinically stable by day 10; extend to 14 days if slower response 1, 2, 3

Penicillin-Resistant but Cephalosporin-Sensitive (Penicillin MIC >0.06, Ceftriaxone MIC ≤0.5 mg/L)

• Continue ceftriaxone 2g IV every 12 hours alone - vancomycin can be discontinued 1
• Duration: 10-14 days 1, 2

Penicillin AND Cephalosporin-Resistant (Ceftriaxone/Cefotaxime MIC >0.5 mg/L)

• Continue ceftriaxone 2g IV every 12 hours PLUS vancomycin 15-20 mg/kg IV every 12 hours PLUS rifampicin 600mg IV/PO every 12 hours 1, 4
• This triple therapy is essential for highly resistant strains with ceftriaxone MIC >4 μg/mL 4, 5
• Duration: 14 days mandatory 1, 2

Critical Adjunctive Therapy

Dexamethasone:

• Administer dexamethasone 10mg IV every 6 hours for 4 days, ideally 15-20 minutes before or with the first antibiotic dose 6
• Steroid therapy was used in 88.6% of critically ill pneumococcal meningitis patients in recent cohorts 7

Common Pitfalls and How to Avoid Them

Pitfall #1: Delaying antibiotics for diagnostic procedures

• Never wait for lumbar puncture or CT results - every hour of delay increases mortality 1, 7
• In a 2023 ICU cohort, delay in antibiotic initiation was independently associated with 30-day mortality (OR 18.69) 7

Pitfall #2: Using ceftriaxone monotherapy empirically

• Always add vancomycin empirically due to 25.7% penicillin non-susceptibility rates and 5.2% cephalosporin resistance 7
• Documented microbiological failures have occurred with ceftriaxone alone against resistant strains 8

Pitfall #3: Inadequate vancomycin dosing

• Target trough levels of 15-20 μg/mL - lower levels may fail against resistant strains 1

Pitfall #4: Stopping treatment too early

• Do not shorten duration based on early clinical improvement alone 2
• Only 65.8% of critically ill patients achieve clinical response by 72 hours 7
• Minimum 10 days for susceptible strains, 14 days for resistant strains 1, 2, 3

Pitfall #5: Using meropenem as monotherapy

• While meropenem shows activity against resistant pneumococci, it is not recommended as monotherapy for highly resistant strains 4, 5, 8
• If used, combine with vancomycin or ceftriaxone 4

Special Considerations for Treatment Failure

If clinical response is not achieved by 72 hours (persistent fever, altered mental status, or worsening CSF parameters):

• Verify adequate vancomycin CSF penetration (trough levels 15-20 μg/mL) 1
• Add rifampicin 600mg IV/PO every 12 hours if not already included 1, 4
• Consider moxifloxacin (a fluoroquinolone with pneumococcal activity) combined with ceftriaxone or vancomycin as salvage therapy 4
• Early treatment failure is independently associated with 30-day mortality (OR 21.75) 7