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	Meningitis Main Page
Patient Information
Overview
Causes
Classification Viral Meningitis Bacterial Meningitis Fungal Meningitis
Differential Diagnosis
Diagnosis
Treatment

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Latest revision as of 19:33, 14 January 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Medical Therapy

Empiric Treatment

Adjunctive Dexamethasone (0.15 mg/kg IV q6h for 2—4 days) is recommended for both children and adult patients with acute bacterial meningitis.

Community-Acquired Meningitis

Newborn, Age <1 Week
Preferred Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Cefotaxime 100—150 mg/kg/day IV q8—12h
Alternative Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Gentamicin 2.5 mg/kg IV q12h
Newborn, Age 1—4 Weeks
Preferred Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Cefotaxime 150—200 mg/kg/day IV q6—8h
Alternative Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Gentamicin 2.5 mg/kg IV q8h OR ▸ Tobramycin 2.5 mg/kg IV q8h OR ▸ Amikacin 10 mg/kg IV q8h
Infant and Children^†
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q6h to achieve serum trough concentrations of 15–20 μg/mL
AND
▸ Cefotaxime 225—300 mg/kg/day IV q6–8h OR ▸ Ceftriaxone 80—100 mg/kg/day IV q12–24h

Adult, Age <50 Years^†
Preferred Regimen
▸ Vancomycin 30–60 mg/kg/day IV q8–12h to achieve serum trough concentrations of 15–20 μg/mL
AND
▸ Cefotaxime 8–12 g/day IV q4–6h OR ▸ Ceftriaxone 2 g IV q12h
Adult, Age >50 Years
Preferred Regimen
▸ Vancomycin 30–60 mg/kg/day IV q8–12h
AND
▸ Ampicillin 2 g IV q4h
AND
▸ Cefotaxime 8–12 g/day IV q4–6h OR ▸ Ceftriaxone 2 g IV q12h
Immunocompromised
Preferred Regimen
▸ Vancomycin 30–60 mg/kg/day IV q8–12h
AND
▸ Ampicillin 2 g IV q4h
AND
▸ Cefepime 2 g IV q8h OR ▸ Meropenem 2 g IV q8h
Recurrent
Preferred Regimen
▸ Vancomycin 30—60 mg/kg/day IV q8–12h
AND
▸ Cefotaxime 8–12 g/day IV q4–6h OR ▸ Ceftriaxone 2 g IV q12h

^†Add Ampicillin 2 g IV q4h (50 mg/kg IV q6h for children) if meningitis caused by Listeria monocytogenes is also suspected.

Adapted from Advances in treatment of bacterial meningitis. Lancet. 2012;380(9854):1693-702.^[1]

Healthcare-Associated Meningitis

References

↑ van de Beek, D.; Brouwer, MC.; Thwaites, GE.; Tunkel, AR. (2012). "Advances in treatment of bacterial meningitis". Lancet. 380 (9854): 1693–702. doi:10.1016/S0140-6736(12)61186-6. PMID 23141618. Unknown parameter |month= ignored (help)

[van_de_Beek-2012-1] van de Beek, D.; Brouwer, MC.; Thwaites, GE.; Tunkel, AR. (2012). "Advances in treatment of bacterial meningitis". Lancet. 380 (9854): 1693–702. doi:10.1016/S0140-6736(12)61186-6. PMID 23141618. Unknown parameter |month= ignored (help)

[1]

@@ Line 6: / Line 6: @@
 ==Medical Therapy==
-===Pharmacotherapy===
+===Empiric Treatment===
-====Empiric Treatment====
-* Do not wait for the results of the [[CT scan]] and the [[lumbar puncture]]; empiric treatment should be started as soon as possible.
-* Blood cultures should be drawn before starting the [[antibiotic]] therapy, and then the antibiotic treatment should be changed once the blood culture results are out.
-* Empiric antibiotic treatment should be started within 30 minutes after the patient presentation.
+* Adjunctive '''''[[Dexamethasone]] (0.15 mg/kg IV q6h for 2—4 days)''''' is recommended for both children and adult patients with acute bacterial meningitis.
-* In case of high suspicion of pneumococcal meningitis in adult patients, 0.15 mg/kg IV Q6H dexomethasone should be administered for 2 to 4 days.
-** The first dose of dexomethasone is given along with or 20 minutes prior to starting the antibiotics treatment.
+====Community-Acquired Meningitis====
 {|
 |-
 | valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:20em" cellpadding="0" cellspacing="0";
+{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:32em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Age <1 Week}}''
+! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Newborn, Age <1 Week}}''
 |-
 ! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
 |-
@@ Line 31: / Line 26: @@
 | style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 100—150 mg/kg/day IV q8—12h'''''
 |-
 ! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
 |-
@@ Line 41: / Line 34: @@
 | style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q12h'''''
 |-
+! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Newborn, Age 1—4 Weeks}}''
-|}
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:20em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Age 1—4 Weeks}}''
 |-
 ! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
 |-
@@ Line 58: / Line 44: @@
 | style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 150—200 mg/kg/day IV q6—8h'''''
 |-
 ! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
 |-
@@ Line 68: / Line 52: @@
 | style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Tobramycin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Amikacin]] 10 mg/kg IV q8h'''''
 |-
+! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Infant and Children}}''<sup>†</sup>
-|}
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:20em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Age 1—23 Months}}''
 |-
 ! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
 |-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
+| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q6h''''' <BR> to achieve serum trough concentrations of 15–20 μg/mL
 |-
 | style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
 |-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 150—200 mg/kg/day IV q6—8h'''''
+| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 225—300 mg/kg/day IV q6–8h''''' <BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 80—100 mg/kg/day IV q12–24h''''' <BR> <BR> <BR> <BR>
+|-
+|}
+| valign=top |
+{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:32em" cellpadding="0" cellspacing="0";
+! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult, Age <50 Years}}<sup>†</sup>''
 |-
+! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
 |-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
+| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30–60 mg/kg/day IV q8–12h''''' <BR> to achieve serum trough concentrations of 15–20 μg/mL
 |-
 | style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
 |-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Tobramycin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Amikacin]] 10 mg/kg IV q8h'''''
+| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 8–12 g/day IV q4–6h'''''<BR> ''OR'' <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
-|-
-|}
-<!--
-;Shown below is a table summarizing the preferred and alternative empiric treatment for meningitis.<ref name="pmid15494903">{{cite journal |author=Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ |title=Practice guidelines for the management of bacterial meningitis |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=39 |issue=9 |pages=1267–84 |year=2004 |month=November |pmid=15494903 |doi=10.1086/425368 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=15494903 |accessdate=2012-11-28}}</ref>
-{| class="wikitable" border="1" style="background:FloralWhite"
-|- align="center"
-|'''Characteristics of the Patient'''
-|'''Possible Pathogens'''
-|'''Preferred Treatment'''
-|'''Duration of Treatment'''
-|'''Alternative Treatment'''
-|- align="center"
-|'''Immunocompentent patient'''
-'''Age<50'''
-|Streptococcus pneumonia,
-Nisseria meningitis,
-Hemophilus influenzae
-|'''Vancomycin'''
-Loading dose:25-35 mg/kg, then 15-20 mg/kg Q8-12H
-Trough concentration: 20mcg/mL
-'''+'''
-'''Ceftriaxone'''
-g IV Q12H
-|Stop or adjust treatment choice and duration when the results of the lumbar puncture are out
-|In case of penicillin allergy:
-Chloramphenicol
-'''+'''
-Vancomycin
-|- align="center"
-|'''Immunocompentent patient'''
-'''Age>50'''
-|Streptococcus pneumonia,
-Listeria,
-Nisseria meningitis,
-Group B streptococci,
-Hemophilus influenzae
-|'''Vancomycin'''
-Loading dose:25-35 mg/kg, then 15-20 mg/kg Q8-12H
-Trough concentration: 20mcg/mL
-'''+'''
-'''Ceftriaxone'''
-g IV Q12H
-'''+'''
-'''Ampicillin'''
-g IV Q4H
-|Stop or adjust treatment choice and duration when the results of the lumbar puncture are out
-|In case of penicillin allergy:
-Chloramphenicol
-'''+'''
-Vancomycin
-'''+'''
-TMP/SMX
-|- align="center"
-|'''Immunocompromised patient'''
-|Streptococcus pneumonia,
-Nisseria meningitis,
-Hemophilus influenzae,
-Listeria,
-(Gram-negatives)
-|'''Vancomycin'''
-Loading dose:25-35 mg/kg, then 15-20 mg/kg Q8-12H
-Trough concentration: 20mcg/mL
-'''+'''
-'''Cefepime'''
-g IV Q8H
-'''+'''
-'''Ampicillin'''
-g IV Q4H
-|Stop or adjust treatment choice and duration when the results of the lumbar puncture are out
-|In case of penicillin allergy:
-Vancomycin
-'''+'''
-TMP/SMX
-'''+'''
-Ciprofloxacin
-|- align="center"
-|'''Patient with history of penetrating head trauma or neurosurgery'''
-|Streptococcus pneumonia (if CSF leak),
-Hemophilus influenzae,
-Staphylococci,
-(Gram-negatives)
-|'''Vancomycin'''
-Loading dose:25-35 mg/kg, then 15-20 mg/kg Q8-12H
-Trough concentration: 20mcg/mL
-'''+'''
-'''Cefepime'''
-g IV Q8H
-|Stop or adjust treatment choice and duration when the results of the lumbar puncture are out
-|In case of penicillin allergy:
-Vancomycin
-'''+'''
-Ciprofloxacin
-|- align="center"
-|'''Shunt infection'''
-|Streptococcus aureus,
-Coagulase negative staphylococci,
-Gram-negatives (rare)
-|'''Vancomycin'''
-Loading dose:25-35 mg/kg, then 15-20 mg/kg Q8-12H
-Trough concentration: 20mcg/mL
-'''+'''
-'''Cefepime'''
-g IV Q8H
-|Stop or adjust treatment choice and duration when the results of the lumbar puncture are out
-|In case of penicillin allergy:
-Vancomycin
-'''+'''
-Ciprofloxacin
-|}
--->
-==References==
-{{reflist|2}}
-[[Category:Needs overview]]
-[[Category:Primary care]]
-[[Category:Disease]]
-[[Category:Infectious disease]]
-[[Category:Neurology]]
-[[Category:Emergency medicine]]
-[[Category:Diseases involving the fasciae]]
-[[Category:Inflammations]]
-[[Category:Neurological disorders]]
-{{WikiDoc Help Menu}}
-{{WikiDoc Sources}}
-{|
 |-
-| valign=top |
+! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult, Age >50 Years}}''
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:20em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Age <1 Week}}''
 |-
 ! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
 |-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 50 mg/kg IV q8h'''''
+| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30–60 mg/kg/day IV q8–12h'''''
 |-
 | style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
 |-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 100—150 mg/kg/day IV q8—12h'''''
+| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 50 mg/kg IV q8h'''''
 |-
 | style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
 |-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q12h'''''
+| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 8–12 g/day IV q4–6h'''''<BR> ''OR'' <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
 |-
+! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Immunocompromised}}''
-|}
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:20em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Age 1—4 Weeks}}''
 |-
 ! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
 |-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
+| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30–60 mg/kg/day IV q8–12h'''''
 |-
 | style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
 |-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 150—200 mg/kg/day IV q6—8h'''''
+| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
 |-
 | style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
 |-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Tobramycin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Amikacin]] 10 mg/kg IV q8h'''''
+| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 2 g IV q8h''''' <BR> ''OR'' <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''
 |-
+! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Recurrent}}''
-|}
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:20em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Age 1—23 Months}}''
 |-
 ! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
 |-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
+| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30—60 mg/kg/day IV q8–12h'''''
 |-
 | style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
 |-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 150—200 mg/kg/day IV q6—8h'''''
+| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]]  8–12 g/day IV q4–6h'''''<BR> ''OR'' <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''
-|-
+|}
+|}
+<sup>†</sup>Add '''''[[Ampicillin]] 2 g IV q4h''''' ('''''50 mg/kg IV q6h''''' for children) if meningitis caused by ''[[Listeria monocytogenes]]'' is also suspected.
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
+<SMALL>Adapted from ''Advances in treatment of bacterial meningitis. Lancet. 2012;380(9854):1693-702.''</SMALL><ref name="van de Beek-2012">{{Cite journal  | last1 = van de Beek | first1 = D. | last2 = Brouwer | first2 = MC. | last3 = Thwaites | first3 = GE. | last4 = Tunkel | first4 = AR. | title = Advances in treatment of bacterial meningitis. | journal = Lancet | volume = 380 | issue = 9854 | pages = 1693-702 | month = Nov | year = 2012 | doi = 10.1016/S0140-6736(12)61186-6 | PMID = 23141618 }}</ref>
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Tobramycin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Amikacin]] 10 mg/kg IV q8h'''''
-|-
+====Healthcare-Associated Meningitis====
-|}
+==References==
+{{Reflist|2}}