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Antibiotics
Age 0-4 wk
Age 1 mo-50 y
Age >50 y
Recurrent meningitis
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
10-14
Haemophilus influenzae
Beta-lactamasenegative
Recommended: Ampicillin
Beta-lactamasepositive
Recommended: Meropenem
Beta-lactamasenegative, ampicillinresistant
Neisseria meningitidis
Listeria monocytogenes
...
Alternative: TMP-SMX
14-21
Streptococcus agalactiae
...
14-21
Enterobacteriaceae
...
21
Pseudomonas
aeruginosa
...
21
Recommended: Vancomycin
Alternative: Linezolid
Staphylococcus
epidermidis
Consider addition of rifampin
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.
Bacterial resistance, especially penicillin resistance among S pneumoniaestrains, has been increasing
worldwide. In March 2008, the US Food and Drug Administration (FDA) revised the susceptibility
breakpoints for penicillin versus S pneumoniae. For nonmeningeal infections, the breakpoints are as
follows:
pneumoniae and L monocytogenes, for which this patient population is most at risk . (See Meningitis in
HIV.)
Steroid therapy
The use of corticosteroids (typically, dexamethasone, 0.15 mg/kg every 6 hours for 2-4 days) as
adjunctive treatment for bacterial meningitis improves outcome by attenuating the detrimental effects of
host defenses (eg, inflammatory response to the bacterial products and the products of neutrophil
activation). Controversy surrounds this practice, however, in that dexamethasone may interrupt the
cytokine-mediated neurotoxic effects of bacteriolysis, which are at maximum in the first days of antibiotic
use.[29]
Theoretically, the anti-inflammatory effects of steroids decrease blood-brain barrier permeability and
impede penetration of antibiotics into CSF. Decreased CSF levels of vancomycin have been confirmed in
steroid-treated animals but not in comparably treated humans. Many authorities believe that all other
antibiotics achieve minimal inhibitory concentrations (MICs) in CSF regardless of steroid use, and even
vancomycin may not be affected to a clinically significant extent.
Nevertheless, the use of steroids has been shown to improve the overall outcome of patients with certain
types of bacterial meningitis, including H influenzae,tuberculous, and pneumococcal meningitis.
In a meta-analysis by Brouwer et al, corticosteroids significantly reduced hearing loss and neurologic
sequelae but did not reduce overall mortality. However, there was a trend toward lower mortality in adults
receiving corticosteroids, and subgroup analyses showed that corticosteroids reduced severe hearing
loss in H influenzae meningitis and reduced mortality in S pneumoniae meningitis. However, the
investigators found no beneficial effect for patients in low-income countries. [30]
On the other hand, a meta-analysis of individual patient data by van de Beek et al was unable to identify
which patients were most likely to benefit from dexamethasone treatment; indeed, no significant reduction
in death or neurologic disability was found in any subgroups, including those determined by specific
causative organisms, predexamethasone antibiotic treatment, HIV status, or age. The researchers
concluded that the benefits of adjunctive dexamethasone in bacterial meningitis remain unproven. [31]
In developing countries, the use of oral glycerol (rather than dexamethasone) has been studied as
adjunctive therapy in the treatment of bacterial meningitis in children. In limited studies, it appears to
reduce the incidence of neurologic sequelae while causing few side effects. [32]
Intrathecal antibiotics
Intrathecal administration of antibiotics can be considered in patients with nosocomial meningitis (eg,
meningitis developing after neurosurgery or placement of an external ventricular catheter) that does not
respond to IV antibiotics. Although the FDA has not approved any antibiotics for intraventricular use,
vancomycin and gentamicin are often used in this setting. Other agents used intrathecally include
amikacin, polymyxin B, and colistin.[33]
Intrathecal antibiotic dosages have been determined empirically and are adjusted on the basis of the CSF
concentrations of the agent. Typical daily doses are as follows [33] :
Vancomycin: 5-20 mg
Gentamicin: 1-2 mg in infants and children, 48 mg in adults
Amikacin: 30 mg (range, 5-50 mg)
Polymyxin B: 2 mg in infants and children, 5 mg in adults
Colistin (usually formulated as colistimethate sodium): 10 mg once daily or 5 mg every 12 hours