How is bacterial meningitis treated?

Updated: Jul 16, 2019
  • Author: Rodrigo Hasbun, MD, MPH; Chief Editor: Michael Stuart Bronze, MD  more...
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Answer

Bacterial meningitis (including meningococcal meningitis, Haemophilus influenzae meningitis, and staphylococcal meningitis) is a neurologic emergency that is associated with significant morbidity and mortality. Initiation of empiric antibacterial therapy is therefore essential for better outcome. [32, 33] (See tables 7 and 8 below.)

Table 7. Recommended Empiric Antibiotics for Suspected Bacterial Meningitis, According to Age or Predisposing Factors [33] (Open Table in a new window)

Age or Predisposing Feature

Antibiotics

Age 0-4 wk

Ampicillin plus either cefotaxime or an aminoglycoside

Age 1 mo-50 y

Vancomycin plus cefotaxime or ceftriaxone*

Age >50 y

Vancomycin plus ampicillin plus ceftriaxone or cefotaxime plus vancomycin*

Impaired cellular immunity

Vancomycin plus ampicillin plus either cefepime or meropenem

Recurrent meningitis

Vancomycin plus cefotaxime or ceftriaxone

Basilar skull fracture

Vancomycin plus cefotaxime or ceftriaxone

Head trauma, neurosurgery, or CSF shunt

Vancomycin plus ceftazidime, cefepime, or meropenem

CSF = cerebrospinal fluid.

*Add ampicillin if Listeria monocytogenes is a suspected pathogen.

Table 8. Specific Antibiotics and Duration of Therapy for Acute Bacterial Meningitis (Open Table in a new window)

Bacteria

Susceptibility

Antibiotic(s)

Duration (days)

Streptococcus pneumoniae

Penicillin MIC ≤0.06 μg/mL

Recommended: Penicillin G or ampicillin

Alternatives: Cefotaxime, ceftriaxone, chloramphenicol

10-14

Penicillin MIC ≥0.12 μg/mL

Cefotaxime or ceftriaxone MIC ≥0.12 μg/mL

Recommended: Cefotaxime or ceftriaxone

Alternatives: Cefepime, meropenem

Cefotaxime or ceftriaxone MIC ≥1.0 μg/mL

Recommended: Vancomycin plus cefotaxime or ceftriaxone

Alternatives: Vancomycin plus moxifloxacin

Haemophilus influenzae

Beta-lactamase−negative

Recommended: Ampicillin

Alternatives: Cefotaxime, ceftriaxone, cefepime, chloramphenicol, aztreonam, a fluoroquinolone

7

Beta-lactamase−positive

Recommended: Cefotaxime or ceftriaxone

Alternatives: Cefepime, chloramphenicol, aztreonam, a fluoroquinolone

Beta-lactamase−negative, ampicillin-resistant

Recommended: Meropenem

Alternatives: Cefepime, chloramphenicol, aztreonam, a fluoroquinolone

Neisseria meningitidis

Penicillin MIC < 0.1 μg/mL

Recommended: Penicillin G or ampicillin

Alternatives: Cefotaxime, ceftriaxone, chloramphenicol

7

Penicillin MIC ≥0.1 μg/mL

Recommended: Cefotaxime or ceftriaxone

Alternatives: Cefepime, chloramphenicol, a fluoroquinolone, meropenem

Listeria monocytogenes

...

Recommended: Ampicillin or penicillin G

Alternative: TMP-SMX

14-21

Streptococcus agalactiae

...

Recommended: Ampicillin or penicillin G

Alternatives: Cefotaxime, ceftriaxone, vancomycin

14-21

Enterobacteriaceae

...

Recommended: Cefotaxime or ceftriaxone

Alternatives: Aztreonam, a fluoroquinolone, TMP-SMX, meropenem, ampicillin

21

Pseudomonas aeruginosa

...

Recommended: Ceftazidime or cefepime

Alternatives: Aztreonam, meropenem, ciprofloxacin

21

Staphylococcus epidermidis

 

Recommended: Vancomycin

Alternative: Linezolid

Consider addition of rifampin

 

MIC= minimal inhibitory concentration; TMP-SMX = trimethoprim-sulfamethoxazole.

It is vital to institute empiric antimicrobial therapy (ie, antibacterial treatment or, in selected cases, antiviral or antifungal therapy) as soon as possible. The choice of agents is usually based on the known predisposing factors, initial CSF Gram stain results, or both. Once the pathogen has been identified and antimicrobial susceptibilities determined, the antibiotics may be modified for optimal targeted treatment.


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