What is the role of empiric antibiotic therapy in the treatment of Haemophilus influenzae type b (Hib) meningitis?

Updated: Jul 09, 2018
  • Author: Prateek Lohia, MD, MHA; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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Currently, the agent of choice for the treatment of Hib meningitis in children who are older than 6 weeks and younger than 6 years is a third-generation cephalosporin (eg, cefotaxime or ceftriaxone), given intravenously (IV). These agents are at least as effective as the older regimen of combination therapy with ampicillin and chloramphenicol and are more effective in children who are infected with microbes that are resistant to ampicillin or chloramphenicol. They are well tolerated, with few adverse effects.

In addition, third-generation cephalosporins can be effectively administered in fewer total daily doses. Thus, although the total daily dose of cefotaxime has usually been divided into 3 doses given at 8-hour intervals, evidence supports administration twice or even once daily. Likewise, the long half-life of ceftriaxone affords the opportunity, in selected cases, for a once-daily antibiotic regimen, enabling patients who have responded well to initial treatment to be discharged home for outpatient IV therapy to complete the course of treatment for Hib meningitis.

Once started, these cephalosporins are generally administered for a total 10-day course, although emerging evidence suggests that 7 days may be adequate for uncomplicated Hib meningitis. The course may be prolonged to a total duration of 14-21 days in complicated cases or in those manifesting prolonged or recurrent fever.

Although older studies suggested that the second-generation cephalosporin cefuroxime might be reliably effective for Hib meningitis, subsequent studies have not confirmed that reliance, and it is no longer recommended. The rejection of this drug as standard therapy is based on evidence that it is slower than third-generation cephalosporins in sterilization of cerebrospinal fluid (CSF) and that treatment may prove ineffective, with more prolonged illness, greater chance for hearing loss and other complications, and risk of recurrence of infection with discontinuation.

Meropenem may be considered a good alternative to the third-generation cephalosporins for the treatment of HiB meningitis.

Ampicillin and gentamicin remain the agents of empiric choice for those younger than 6 weeks because of the importance of gram-negative organisms in that age group and the rarity of Hib meningitis in such very young infants.

With the considerable decline in Hib meningitis among vaccinated children younger than 6 years, the percentage of cases of Streptococcus pneumoniae in that age group has increased. Furthermore, because resistance of S pneumoniae to both penicillin and cephalosporins is increasing in some parts of the world, vancomycin should be included in empiric therapy of children presenting with meningitis.

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