What I Have Learned About Infectious Diseases With My Sleeves Rolled Up

Karen L. Roos, MD


Semin Neurol. 2002;22(1) 

In This Article

Empiric Therapy

"Time is brain" not only in the management of patients with cerebrovascular disease and multiple sclerosis, but very much so in the management of patients with bacterial meningitis and encephalitis. For the patient in the Emergency Room with fever, headache, and an altered level of consciousness and/or new onset seizure activity, the initial discussion should not be whether the patient needs a computed tomography scan or a lumbar puncture first, but rather "Should doxycycline be added to the empiric regimen of a third or fourth generation cephalosporin plus vancomycin plus acyclovir?" Empiric therapy should include a third-generation cephalosporin, either ceftriaxone (Rocephin; pediatric dose, 100 mg/kg/d in a 12-hour dosing interval; adult dose, 2 g every 12 hours) or cefotaxime (Claforan; pediatric dose, 200 mg/kg/d in a 4- to 6-hour dosing interval; adult dose, 2 g every 4 hours), or a fourth-generation cephalosporin, cefepime (Maxipime; adult dose 2 g every 12 hours), plus vancomycin (Vancocin; pediatric dose, 40 to 60 mg/kg/d in a 6- or 12-hour dosing interval; adult dose, 500 mg every 6 hours or 1 g every 12 hours) plus acyclovir (pediatric and adult dose 10 mg/kg every 8 hours). A combination of ampicillin (12 g/d in a 4-hour dosing interval) and gentamicin (6 mg/kg/d in an 8-hour dosing interval) should be added to the empiric regimen in individuals with impaired cell-mediated immunity because of chronic illness, organ transplantation, pregnancy, AIDS, malignancies, or immunosuppressive therapy who are at risk for meningitis due to Listeria monocytogenes. Doxycycline 100 mg every 12 hours is added to the empiric regimen in patients who may have tick-borne bacterial diseases, including Rocky Mountain spotted fever, ehrlichioses, and Lyme disease. Dexamethasone is recommended for children with proven or suspected H. influenzae meningitis and for children and adults with proven or suspected pneumococcal meningitis. The dose of dexamethasone for children is 0.15 mg/kg body weight intravenously every 6 hours for 2 to 4 days. The dose of dexamethasone for adults is 8 to 10 mg intravenously every 8 hours for 2 to 4 days. The first dose of dexamethasone should be administered before the first dose of antibiotics.


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