Management of Acute Bacterial Meningitis in HIV-Positive Patients
Continue antiretroviral therapy (ARV) without interruption while treating acute bacterial meningitis with standard empiric antibiotics, as there is no evidence to support stopping ARVs and doing so would risk HIV disease progression.
Empiric Antibiotic Treatment
The immediate priority is rapid initiation of appropriate antibiotics, as delayed treatment worsens mortality in bacterial meningitis 1, 2.
For HIV-Positive Adults <60 Years Old:
- Ceftriaxone 2g IV every 12 hours OR Cefotaxime 2g IV every 6 hours 3
- Alternative if cephalosporin allergy: Chloramphenicol 25 mg/kg IV every 6 hours 3
For HIV-Positive Adults ≥60 Years Old:
- Ceftriaxone 2g IV every 12 hours OR Cefotaxime 2g IV every 6 hours 3
- PLUS Amoxicillin 2g IV every 4 hours (to cover Listeria monocytogenes, which has increased incidence in immunocompromised patients) 3, 4
Additional Considerations for Resistant Organisms:
- Add Vancomycin 15-20 mg/kg IV twice daily OR Rifampicin 600mg twice daily if penicillin-resistant pneumococci are suspected, particularly if recent travel to high-resistance areas 3
Antiretroviral Therapy Management
Do not stop ARVs during acute bacterial meningitis treatment. The provided guidelines address immunocompetent adults, but the fundamental principle is that HIV-positive patients should maintain viral suppression to optimize immune function during serious infections 3.
Key Principles:
- Continue current ARV regimen without interruption
- Monitor for potential drug-drug interactions between antibiotics and ARVs (particularly rifampicin if added, which has significant interactions with protease inhibitors and some integrase inhibitors)
- Consult infectious disease specialists if rifampicin is required, as ARV regimen adjustment may be necessary
Treatment Duration by Pathogen
Once the causative organism is identified:
- Meningococcal meningitis: 5 days if clinically recovered 3, 4
- Pneumococcal meningitis: 10-14 days (10 days if recovered by day 10; 14 days if delayed response or resistant organism) 3, 4
- Listeria monocytogenes: 21 days 4
- Gram-negative bacilli: 21 days 5
Critical Pitfalls to Avoid
- Never delay antibiotics for imaging or lumbar puncture - treatment should be initiated within 3 hours of first medical contact 6
- Do not stop ARVs - interrupting HIV treatment during acute illness risks immune deterioration and viral rebound
- Do not forget Listeria coverage in HIV-positive patients ≥60 years - add amoxicillin empirically 3, 4
- Consider adjunctive dexamethasone - should be given before or with the first antibiotic dose for suspected pneumococcal or H. influenzae meningitis 2, 6
Monitoring and Adjustment
- Obtain blood cultures before initiating antibiotics 6
- Perform lumbar puncture when clinically safe (after imaging if indicated) 6
- Adjust antibiotics based on culture results and sensitivities 3, 6
- Seek infectious disease consultation for complex cases, particularly regarding ARV-antibiotic interactions 3