Sandbox endocarditis2

Medical Therapy

Pharmacotherapy

Community-Acquired Meningitis

Relatively Penicillin-Resistant Streptococci, MIC 0.2–0.5 µg/ml Preferred Regimen ▸ Adult:Aqueous crystalline penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses X 4 Wks ▸ Pediatrics:Aqueous crystalline penicillin G sodium 300 000 U/24 h IV in 4–6 equally divided doses X 4 Wks OR ▸Adult:Ceftriaxone 2 g/24 h IV/IM in 1 dose ▸Pediatrics:Ceftriaxone 100 mg/kg per 24 h IV/IM in 1 dose AND ▸ Adult:Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks ▸ Pediatrics: Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose or 3 equally divided doses X 2 Wks Relatively Penicillin-Resistant Streptococci, MIC > 0.5 µg/ml, consider Enterococcal regimen Preferred Regimen ▸ Adult:Aqueous crystalline penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses X 4 Wks AND ▸ Adult:Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks Unable to tolerate Aqueous crystalline penicillin G sodium or Ceftriaxone Preferred Regimen ▸ Adult: Vancomycin 30 mg/kg per 24 h IV in 2 equally divided doses not to exceed 2 g/24 h, unless serum concentrations are inappropriately low ▸ Pediatrics: Vancomycin 40 mg/kg 24 h in 2 or 3 equally divided doses X 4 Wks

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 ▸ Meropenem2 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 monocytogenesis also suspected.

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

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.
• 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.

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 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

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

Age 1—23 Months 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

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 References