What is the empirical coverage for meningitis?

From the Guidelines

Empirical treatment for bacterial meningitis should include ceftriaxone 2g IV every 12 hours plus vancomycin 15-20 mg/kg IV every 8-12 hours, with the addition of ampicillin 2g IV every 4 hours for patients over 50 years or immunocompromised individuals to cover Listeria monocytogenes. This recommendation is based on the most recent and highest quality study available, which provides guidance on the empiric antibiotic treatment for community-acquired bacterial meningitis 1. The study suggests that ceftriaxone or cefotaxime plus vancomycin or rifampicin is the standard treatment for patients between 1 month and 18 years old, as well as for patients between 18 and 50 years old. However, for patients over 50 years old or those with risk factors for Listeria monocytogenes, the addition of ampicillin is recommended.

Key Considerations

• The choice of empirical antibiotic treatment should be based on the patient's age and underlying health conditions, as well as the local epidemiology of meningitis-causing pathogens.
• Dexamethasone 0.15 mg/kg IV every 6 hours for 2-4 days should be administered before or with the first antibiotic dose to reduce inflammation and improve outcomes, particularly in pneumococcal meningitis 1.
• Treatment should begin immediately after obtaining blood cultures and cerebrospinal fluid (if lumbar puncture can be performed safely), without waiting for results.
• The regimen provides broad coverage against common meningitis pathogens including Streptococcus pneumoniae, Neisseria meningitidis, group B streptococci, Haemophilus influenzae, and Listeria.
• Once culture results and sensitivities are available, therapy should be narrowed accordingly.
• The typical duration of treatment is 7-14 days depending on the identified pathogen, with longer courses sometimes needed for certain organisms.

Special Considerations

• For patients with suspected Listeria monocytogenes, the use of ampicillin is recommended, as well as the consideration of stopping dexamethasone treatment due to increased mortality risk 1.
• For patients with suspected meningococcal disease, a single dose of Ciprofloxacin should be given to eliminate throat carriage, unless contraindicated, in which case rifampicin can be used as an alternative 1.

From the FDA Drug Label

In the treatment of meningitis, it is recommended that the initial therapeutic dose be 100 mg/kg (not to exceed 4 grams). Thereafter, a total daily dose of 100 mg/kg/day (not to exceed 4 grams daily) is recommended. Central nervous system infections, e.g., meningitis and ventriculitis, caused by Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, Klebsiella pneumoniae* and Escherichia coli*.

Empirical Meningitis Coverage:

• Ceftriaxone provides coverage for meningitis caused by Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae.
• Cefotaxime also provides coverage for meningitis caused by Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, Klebsiella pneumoniae, and Escherichia coli.
• The recommended dose for ceftriaxone in the treatment of meningitis is an initial therapeutic dose of 100 mg/kg (not to exceed 4 grams), followed by a total daily dose of 100 mg/kg/day (not to exceed 4 grams daily) 2.
• The specific dose for cefotaxime in the treatment of meningitis is not provided in the given text 3.

From the Research

Empiric Meningitis Coverage

• The use of empiric vancomycin plus a third-generation cephalosporin for suspected bacterial meningitis has been recommended since 1997 4.
• A single daily dose of ceftriaxone may be optimal for the treatment of bacterial meningitis in adults, with a total daily dose of 2 g potentially associated with similar outcomes to a 4 g total daily dose, provided that the causative organism is highly susceptible to ceftriaxone 5, 6.
• The recommended empiric ceftriaxone dosing regimen for acute bacterial meningitis in adults is 2 g every 12 h, but the dose may be reduced to a single dose of 2 g every 24 h after the causative microorganism is identified 5.
• Listeria monocytogenes meningitis is rare and difficult to diagnose, but it is essential to start appropriate antibiotic treatment as soon as possible due to its high mortality rate 7.
• Predictive risk factors for Listeria monocytogenes meningitis compared to pneumococcal meningitis include a prior history of receiving immunosuppressive therapy and chronic liver disease 8.

Ceftriaxone Dosing Regimens

• A study of 52 patients with S. pneumoniae meningitis found no statistical difference in outcome between the 2 g every 24 h and the 2 g every 12 h ceftriaxone dosing regimens 5.
• Another study of 84 adult patients with bacterial meningitis found that a single daily dose of ceftriaxone (50 mg/[kg.d]; maximum, 4 g/d) was effective in treating the infection 6.

Risk Factors for Listeria Monocytogenes Meningitis

• A prior history of receiving immunosuppressive therapy is a significant predictive risk factor for Listeria monocytogenes meningitis, with an odds ratio of 8.12 (95 % CI 2.47-26.69) 8.
• Chronic liver disease is also a predictive risk factor for Listeria monocytogenes meningitis, with an odds ratio of 5.03 (95 % CI 1.56-16.22) 8.