Meningitis

 

GEL GBS, E. coli, Listeria

Central Nervous System

Meningitis

Authors: Kimberly Lee, Pharm.D., Michael Stevens, M.D., M.P.H.

Last Updated: January 2019

Evaluation

Typical CSF findings with bacterial meningitis:

Opening Pressure: ≥ 20 cm H2O

WBC: 1,000-5,000 cells/mm3 (Range < 100 to > 10,000 cells/mm3) (Neutrophils > 80%)

Glucose <40 mg/dl (Ratio of CSF:Serum ≤ 0.4)

Protein >200 mg/dl (range 100-500)

Empiric Treatment: 

  

Host	Common Pathogen	Empiric Therapy	Beta-Lactam Allergy3
Age < 50   Community Acquired, Non-Traumatic, Immunocompetent	N. meningitidis,  S. pneumoniae	Vancomycin IV1 AND Ceftriaxone2000 mg IV every 12 hours	Vancomycin IV1 AND Aztreonam 2000 mg IV every 6 hours
Age > or = 50    Community Acquired, Non-Traumatic, Immunocompetent	N. meningitidis,  S. pneumoniae, L. monocytogenes, Aerobic gram-negative bacilli	Vancomycin IV1 AND Ceftriaxone2000 mg IV every 12 hours AND Ampicillin2000 mg IV every 4 hours	Vancomycin IV1 AND Aztreonam2 2000 mg IV every 6 hours AND Trimethoprim/Sulfamethoxazole (TMP/SMX)  5 mg/kg IV every 8 hours
Post-neurosurgery	Coagulase-negative staphylococci, S. aureus, Gram negative bacilli (including Pseudomonas)	Vancomycin IV1 AND Cefepime2000 mg IV every 8 hours	Vancomycin IV1 AND Ciprofloxacin IV 400 mg every 8 hours AND Aztreonam2 2000 mg IV every 6 hours
CSF shunt	S. aureus, Coagulase- negativestaphylococci,  Gram negative bacilli (including Pseudomonas),  P. acnes	Vancomycin IV1 AND Cefepime2000 mg IV every 8 hours	Vancomycin IV1 AND Ciprofloxacin IV 400mg every 8 hours AND Aztreonam2 2000 mg IV every 6 hours

1. Vancomycin administered to maintain serum trough concentration of 15-20 mcg/ml.
2. Aztreonam, Colistin, Daptomycin, and Linezolidmust be approved by ASP or ID.
3. Optimal coverage is with a beta-lactam antibiotic. Attempts should be made to clarify the patient’s allergy. For patients with a history of maculopapular rash only to a penicillin, consideration should be given to using a cephalosporin. For patients with a true immediate hypersensitivity reaction to penicillin (hives, anaphylaxis, angioedema) beta-lactam antibiotics should be avoided. The overall risk for a true hypersensitivity reaction to penicillin is relatively low at 0.5 to 2%. Cross-reactivity between penicillins and cephalosoporins is approximately 2% and 1% for carbapenems. 

 

Use of steroids:

Dexamethasone has shown to be of benefit in suspected pneumococcal meningitis at a dose of 0.15 mg/kg IV every 6 hours for 2-4 days. This must be given 10-20 minutes before, or concomitant with, the first dose of antimicrobial therapy. If the patient has already received antimicrobial therapy, adjunctive dexamethasone is unlikely to improve outcome and should not be given.  If dexamethasone is given, consideration should be made to add Rifampin. If Streptococcus pneumoniae is not identified dexamethasone should be discontinued.

 

Specific Antimicrobial Therapy by Pathogen

Pathogen	Therapy	Alternative Therapy	Duration
Streptococcus pneumoniae   PCN MIC<0.06 mcg/ml	Penicillin G 4 million units IV every 4 hours	Ceftriaxone 2000 mg IV every 12 hours	10-14 days
PCN MIC>0.12 mcg/ml   Ceftriaxone MIC <1.0   mcg/ml	Ceftriaxone 2000 mg IV every 12 hours	Cefepime 2000 mg IV every 8 hours
PCN MIC>0.12 mcg/ml   Ceftriaxone MIC >1.0     mcg/ml	Vancomycin IV1 Plus Ceftriaxone 2000 mg IV every 12 hours	**ID CONSULT HIGHLY RECOMMENDED**; Moxifloxacin2 +/- vancomycin or Ceftriaxone
Neisseria meningitidis PCN MIC   <0.1 ug/ml	Penicillin G 4 million units IV every 4 hours	Ceftriaxone 2000 mg IV every 12 hours	7 days
0.1-1.0 ug/ml	Ceftriaxone 2000 mg IV every 12 hours	Meropenem 2000 mg IV every 8 hours
Propionibacterium acnes	Penicillin G 4 million units IV every 4 hours	Ceftriaxone 2000 mg IV every 12 hours	10-14 days
Listeria monocytogenes	Ampicillin 2000 mg IV every 4 hours	TMP/SMX 5 mg/kg IV every 8 hours	21 days
Streptococcus agalactiae	Ampicillin 2000 mg IV every 4 hours	Ceftriaxone 2000 mg IV every 12 hours	14-21 days
Escherichia coli and other Enterobacteriaceae	Ceftriaxone 2000 mg IV every 12 hours	Ciprofloxacin  400 mg IV every 8 hours	10-21 days
Extended spectrum B-lactamase-producing gram-negative bacilli	Meropenem2000mg IV every 8 hours	Cefepime 2000mg IV every 8 hours or Ciprofloxacin IV400mg every 8 hours	14 days
Acinetobacter baumannii	Meropenem2000mg IV every 8 hours	Colistin (see dosing in antibiotic guide)	14 days
Pseudomonas aeruginosa	Cefepime 2000 mg IV every 8 hours	Ciprofloxacin IV400 mg every 8 hours (encourage obtaining an ID consult)	14-21 days
Haemophilus influenzae   beta-lactamase negative	Ampicillin 2000 mg IV every 4 hours	Ceftriaxone 2000 mg IV every 12 hours	7 days
beta-lactamase positive	Ceftriaxone 2000 mg IV every 12 hours	Ciprofloxacin IV400 mg  every 8 hours
Staphylococcus aureus MSSA	Nafcillin 2000 mg IV every 4 hours	Vancomycin IV1	14-21 days
MRSA	Vancomycin IV1	**ID CONSULT HIGHLY RECOMMENDED**; Potential options could include: TMP/SMX  5 mg/kg IV every  8 hours, Linezolid2 600mg IV every 12 hours, Daptomycin2 8 mg/kg IV daily
Coagulase negativestaphylococci	Vancomycin IV1	Linezolid2 600mg IV every 12 hours	10-14 days
Enterococcus species Ampicillin-susceptible	Ampicillin 2000 mg IV every  4 hours Plus Gentamicin 1.5 mg/kg IV every 8 hours(if synergy)	**ID CONSULT HIGHLY RECOMMENDED**	Consult ID
Ampicillin-resistant	Vancomycin IV1 Plus Gentamicin 1.5 mg/kg IV every 8 hours (if synergy)	**ID CONSULT HIGHLY RECOMMENDED**
Vancomycin-resistant	**ID CONSULT HIGHLY RECOMMENDED**	**ID CONSULT HIGHLY RECOMMENDED**

 

1. Administer vancomycin to maintain serum trough concentration of 15-20 mcg/ml.

2. Aztreonam, Colistin, Daptomycin, Linezolid, and Moxifloxacin must be approved by ASP or ID.

 

References:

1. Practice Guidelines for the Management of Bacterial Meningitis. Clin Infect Dis 2004;39:1267-1284.

2. 2017 IDSA Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis 2017.