Sandbox ID Central Nervous System

Central Nervous System

Brain abscess ⇧ Return to Top ⇧

• 1. Empiric antimicrobial therapy

Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.

• 1.1 Brain abscess in otherwise healthy patients

• Preferred regimen (1): (Cefotaxime 8–12 g/day IV q4–6h OR Ceftriaxone 4 g/day IV q12h) AND Metronidazole 30 mg/kg/day IV q6h
• Alternative regimen (1): Meropenem 6 g/day IV q8h

• 1.2 Brain abscess with comorbidities

• 1.2.1 Otitis media, mastoiditis, or sinusitis

• Preferred regimen (1): (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Metronidazole 30 mg/kg/day q6h

• 1.2.2 Dental infection

• Preferred regimen: Penicillin G 4 MU IV q4h AND Metronidazole 30 mg/kg/day q6h

• 1.2.3 Penetrating trauma or post-neurosurgy

• Preferred regimen (1): (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h OR Cefepime 2 g IV q12h) AND Vancomycin 30–45 mg/kg/day q8–12h

• 1.2.4 Lung abscess, empyema, or bronchiectasis

• Preferred regimen: Penicillin G 4 MU IV q4h AND Metronidazole 30 mg/kg/day q6h AND TMP-SMZ 10–20 mg/kg/day q6–12h

• 1.2.5 Bacterial endocarditis

• Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h AND Gentamicin 5 mg/kg/day IV q8h

• 1.2.6 Congenital heart disease

• Preferred regimen (1): Cefotaxime 8–12 g/day q4–6h
• Preferred regimen (2): Ceftriaxone 4 g/day q12h

• 1.2.7 Transplant recipients

• Preferred regimen (1): (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Metronidazole 30 mg/kg/day q6h AND Voriconazole 8 mg/kg/day q12h AND (TMP-SMZ 10–20 mg/kg/day q6–12h OR Sulfadiazine 4–6 g/day q6h)

• 1.2.8 Patients with HIV/AIDS

• Preferred regimen (1): (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Sulfadiazine 4–6 g/day q6h AND Pyrimethamine 25–100 mg/day qd

• 1.2.9 Staphylococcus aureus coverage

• Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h

• 1.2.10 Mycobacterium tuberculosis coverage

• Preferred regimen: Isoniazid 300 mg qd AND Rifampin 600 mg qd AND Pyrazinamide 15–30 mg qd AND Ethambutol 15 mg/kg/day qd

• 2. Pathogen-directed antimicrobial therapy

Note: The optimal duration of antimicrobial therapy remains unclear. A 4- to 6-week course of treatment is usually required.

• 2.1 Bacteria

• 2.1.1 Actinomyces

• Preferred regimen: Penicillin G 4 MU IV q4h
• Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h

• 2.1.2 Bacteroides fragilis

• Preferred regimen: Metronidazole 30 mg/kg/day IV q6h
• Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h

• 2.1.3 Enterobacteriaceae

• Preferred regimen (1): Cefotaxime 2 g IV q4-6h
• Preferred regimen (2): Ceftriaxone 2 g IV q12h
• Preferred regimen (3): Cefepime 2 g IV q12h
• Alternative regimen (1): Aztreonam 6–8 g/day IV q6–8h
• Alternative regimen (2): TMP-SMZ 10–20 mg/kg/day q6–12h
• Alternative regimen (3): Ciprofloxacin 800–1200 mg/day IV q8–12h
• Alternative regimen (4): Meropenem 2 g IV q8h

• 2.1.4 Fusobacterium

• Preferred regimen: Metronidazole 30 mg/kg/day q6h
• Alternative regimen (1): Clindamycin 2400–4800 mg/day IV q6h
• Alternative regimen (2): Meropenem 2 g IV q8h

• 2.1.5 Haemophilus

• Preferred regimen (1): Cefotaxime 2 g IV q4-6h
• Preferred regimen (2): Ceftriaxone 2 g IV q12h
• Preferred regimen (3): Cefepime 2 g IV q12h
• Alternative regimen (1): Aztreonam 6–8 g/day IV q6–8h
• Alternative regimen (2): TMP-SMZ 10–20 mg/kg/day q6–12h

• 2.1.6 Listeria monocytogenes

• Preferred regimen (1): Ampicillin 12 g/day q4h
• Preferred regimen (2): Penicillin G 4 MU IV q4h
• Alternative regimen (1): TMP-SMZ 10–20 mg/kg/day q6–12h

• 2.1.7 Nocardia

• Preferred regimen (1): TMP-SMZ 10–20 mg/kg/day q6–12h
• Preferred regimen (2): Sulfadiazine 4–6 g/day q6h
• Alternative regimen (1): Meropenem 2 g IV q8h
• Alternative regimen (2): Cefotaxime 2 g IV q4-6h
• Alternative regimen (3): Ceftriaxone 2 g IV q12h
• Alternative regimen (4): Amikacin 15 mg/kg/day IV q8h

• 2.1.8 Prevotella melaninogenica

• Preferred regimen (1): Metronidazole 30 mg/kg/day q6h
• Alternative regimen (1): Clindamycin 2400–4800 mg/day IV q6h
• Alternative regimen (2): Meropenem 2 g IV q8h

• 2.1.9 Pseudomonas aeruginosa

• Preferred regimen (1): Ceftazidime 6 g/day q8h
• Preferred regimen (2): Cefepime 6 g/day q8h
• Alternative regimen (1): Aztreonam 6–8 g/day IV q6–8h
• Alternative regimen (2): Ciprofloxacin 800–1200 mg/day IV q8–12h
• Alternative regimen (3): Meropenem 2 g IV q8h

• 2.1.10 Staphylococcus aureus, methicillin-resistant (MRSA)

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 4–6 weeks
• Alternative regimen (1): Linezolid 600 mg PO/IV q12h for 4–6 weeks
• Alternative regimen (2):TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
• Pediatric dose (1): Vancomycin 15 mg/kg/dose IV q6h
• Pediatric dose (2): Linezolid 10 mg/kg/dose PO/IV q8h
• Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin.

• 2.1.11 Staphylococcus aureus, methicillin-susceptible (MSSA)

• Preferred regimen (1): Nafcillin 2 g IV q4h
• Preferred regimen (2): Oxacillin 2 g IV q4h
• Alternative regimen: Vancomycin 30–45 mg/kg/day IV q8–12h

• 2.1.12 Streptococcus

• Preferred regimen (1): Penicillin G 4 MU IV q4h
• Preferred regimen (2): Ampicillin 2 g IV q4h
• Alternative regimen (1): Cefotaxime 2 g IV q4-6h
• Alternative regimen (2): Ceftriaxone 2 g IV q12h
• Alternative regimen (3): Vancomycin 30–45 mg/kg/day IV q8–12h

• 2.2 Fungi

• 2.2.1 Aspergillus

• Preferred regimen: Voriconazole 8 mg/kg/day q12h
• Alternative regimen (1): Amphotericin B deoxycholate 0.6–1.0 mg/kg/day IV q24h
• Alternative regimen (2): Amphotericin B lipid complex 5 mg/kg/day IV q24h
• Alternative regimen (3): Itraconazole 400–600 mg/day IV q12h
• Alternative regimen (4): Posaconazole 800 mg/kg/day IV q6–12h

• 2.2.2 Candida

• Preferred regimen (1): Amphotericin B lipid complex 5 mg/kd/day q24h
• Preferred regimen (2): Amphotericin B deoxycholate 15 mg/kg/day q8h
• Alternative regimen: Fluconazole 400–800 mg/day IV q24h

• 2.2.3 Cryptococcus neoformans

• Preferred regimen (1): Amphotericin B lipid complex 5 mg/kd/day q24h
• Preferred regimen (2): Amphotericin B deoxycholate 15 mg/kg/day q8h
• Alternative regimen: Fluconazole 400–800 mg/day IV q24h

• 2.2.4 Mucorales

• Preferred regimen (1): Amphotericin B lipid complex 5 mg/kd/day q24h
• Preferred regimen (2): Amphotericin B deoxycholate 15 mg/kg/day q8h
• Alternative regimen: Posaconazole 800 mg/kg/day IV q6–12h

• 2.2.5 Pseudallescheria boydii (Scedosporium apiospermum)

• Preferred regimen: Voriconazole 8 mg/kg/day q12h
• Alternative regimen (1): Itraconazole 400–600 mg/day IV q12h
• Alternative regimen (2):Posaconazole 800 mg/kg/day IV q6–12h

• 2.3 Protozoa

• 2.3.1 Toxoplasma gondii

• Preferred regimen: Sulfadiazine 4–6 g/day q6h AND Pyrimethamine 25–100 mg/day qd
• Alternative regimen (1): Pyrimethamine 25–100 mg/day qd AND Clindamycin 2400–4800 mg/day IV q6h
• Alternative regimen (2): Pyrimethamine 25–100 mg/day qd AND (Azithromycin 1200–1500 mg/day IV q24h
• Alternative regimen (3): Atovaquone 750 mg IV q6h
• Alternative regimen (4): Dapsone 100 mg PO q24h
• Alternative regimen (4): TMP-SMZ 10–20 mg/kg/day q6–12h

Cerebrospinal fluid shunt infection ⇧ Return to Top ⇧

• 1. Empiric antimicrobial therapy

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Cefepime 2 g IV q8h OR Ceftazidime 2 g IV q8h OR Meropenem 2 g IV q8h)

• 2. Pathogen-directed antimicrobial therapy

• 2.1 Enterococcus

• Preferred regimen: (Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h) AND Gentamicin 1–1.7 mg/kg IV q8h

• 2.2 Gram-negative bacilli

• Preferred regimen: Ceftriaxone 2 g IV q12h OR Cefepime 2 g IV q12h OR Meropenem 2 g IV q8h OR Aztreonam 2 g IV q6h

• 2.3 Propionibacterium acnes

• Preferred regimen: (Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h) ± Gentamicin 1–1.7 mg/kg IV q8h

• 2.4 Staphylococcus, coagulase-negative

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h ± Rifampin 600 mg IV/PO q24h

• 2.5 Staphylococcus aureus, methicillin-resistant (MRSA)

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h ± Rifampin 600 mg IV/PO q24h

Note: Shunt removal is recommended, and it should not be replaced until cerebrospinal fluid cultures are repeatedly negative.

• 2.6 Staphylococcus aureus, methicillin-susceptible (MSSA)

• Preferred regimen: (Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h) ± Rifampin 600 mg IV/PO q24h

• 2.7 Streptococcus agalactiae

• Preferred regimen: (Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h) AND Gentamicin 1–1.7 mg/kg IV q8h

• 2.8 Fungi

• Preferred regimen: Amphotericin B 0.6–1.0 mg/kg IV q24h OR Amphotericin B liposomal 5 mg/kg/day IV q24h

Encephalitis ⇧ Return to Top ⇧

• 1. Empiric antimicrobial therapy

• Preferred regimen: Acyclovir 10 mg/kg IV q8h for 14–21 days
• Note (1): Acyclovir should be initiated in all patients with suspected encephalitis, pending results of diagnostic studies.
• Note (2): Other empiric antimicrobial agents should be administered on the basis of specific epidemiologic or clinical clues.

• 2. Specific epidemiologic considerations

• 2.1 Agammaglobulinemia — Enteroviruses, Mycoplasma pneumoniae
• 2.2 Age

• 2.2.1 Neonates — Herpes simplex virus type 2, cytomegalovirus, rubella virus, Listeria monocytogenes, Treponema pallidum, Toxoplasma gondii
• 2.2.2 Infants and children — Eastern equine encephalitis virus, Japanese encephalitis virus, Murray Valley encephalitis virus, influenza virus, La Crosse virus
• 2.2.3 Elderly persons — Eastern equine encephalitis virus, St. Louis encephalitis virus, West Nile virus, sporadic CJD, L. monocytogenes

• 2.3 Animal contact

• 2.3.1 Bats — Rabies virus, Nipah virus
• 2.3.2 Birds — West Nile virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, Murray Valley encephalitis virus, Japanese encephalitis virus, Cryptococcus neoformans (bird droppings)
• 2.3.3 Cats — Rabies virus, Coxiella burnetii, Bartonella henselae, T. gondii
• 2.3.4 Dogs — Rabies virus
• 2.3.5 Horses — Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, Hendra virus
• 2.3.6 Old World primates — B virus
• 2.3.7 Raccoons — Rabies virus, Baylisascaris procyonis
• 2.3.8 Rodents — Eastern equine encephalitis virus (South America), Venezuelan equine encephalitis virus, tickborne encephalitis virus, Powassan virus (woodchucks), La Crosse virus (chipmunks and squirrels), Bartonella quintana
• 2.3.9 Sheep and goats — C. burnetii
• 2.3.10 Skunks — Rabies virus
• 2.3.11 Swine — Japanese encephalitis virus, Nipah virus
• 2.3.12 White-tailed deer — Borrelia burgdorferi

• 2.4 Immunocompromised persons — Varicella zoster virus, cytomegalovirus, human herpesvirus 6, West Nile virus, HIV, JC virus, L. monocytogenes, Mycobacterium tuberculosis, C. neoformans, Coccidioides species, Histoplasma capsulatum, T. gondii

• 2.5 Ingestion

• 2.5.1 Raw or partially cooked meat — T. gondii
• 2.5.2 Raw meat, fish, or reptiles — Gnanthostoma species
• 2.5.3 Unpasteurized milk — Tickborne encephalitis virus, L. monocytogenes, C. burnetii

• 2.6 Insect contact

• 2.6.1 Mosquitoes — Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, Murray Valley encephalitis virus, Japanese encephalitis virus, West Nile virus, La Crosse virus, Plasmodium falciparum
• 2.6.2 Sandflies — Bartonella bacilliformis
• 2.6.3 Ticks — Tickborne encephalitis virus, Powassan virus, Rickettsia rickettsii, Ehrlichia chaffeensis, Anaplasma phagocytophilum, C. burnetii (rare), B. burgdorferi
• 2.6.4 Tsetse flies — Trypanosoma brucei gambiense, Trypanosoma brucei rhodesiense

• 2.7 Occupation

• 2.7.1 Exposure to animals — Rabies virus, C. burnetii, Bartonella species
• 2.7.2 Exposure to horses — Hendra virus
• 2.7.3 Exposure to Old World primates — B virus
• 2.7.4 Laboratory workers — West Nile virus, HIV, C. burnetii, Coccidioides species
• 2.7.5 Physicians and health care workers — Varicella zoster virus, HIV, influenza virus, measles virus, M. tuberculosis
• 2.7.6 Veterinarians — Rabies virus, Bartonella species, C. burnetii

• 2.8 Person-to-person transmission — Herpes simplex virus (neonatal), varicella zoster virus, Venezuelan equine encephalitis virus (rare), poliovirus, nonpolio enteroviruses, measles virus, Nipah virus, mumps virus, rubella virus, Epstein-Barr virus, human herpesvirus 6, B virus, West Nile virus (transfusion, transplantation, breast feeding), HIV, rabies virus (transplantation), influenza virus, M. pneumoniae, M. tuberculosis, T. pallidum

• 2.9 Recent vaccination — Acute disseminated encephalomyelitis

• 2.10 Recreational activities

• 2.10.1 Camping/hunting — Agents transmitted by mosquitoes and ticks
• 2.10.2 Sexual contact — HIV, T. pallidum
• 2.10.3 Spelunking — Rabies virus, H. capsulatum
• 2.10.4 Swimming — Enteroviruses, Naegleria fowleri

• 2.11 Season

• 2.11.1 Late summer/early fall — Agents transmitted by mosquitoes and ticks, enteroviruses
• 2.11.2 Winter — Influenza virus

• 2.12 Transfusion and transplantation — Cytomegalovirus, Epstein-Barr virus, West Nile virus, HIV, tickborne encephalitis virus, rabies virus, iatrogenic CJD, T. pallidum, A. phagocytophilum, R. rickettsii, C. neoformans, Coccidioides species, H. capsulatum, T. gondii

• 2.13 Travel

• 2.13.1 Africa — Rabies virus, West Nile virus, P. falciparum, T. brucei gambiense, T. brucei rhodesiense
• 2.13.2 Australia — Murray Valley encephalitis virus, Japanese encephalitis virus, Hendra virus
• 2.13.3 Central America — Rabies virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, R. rickettsii, P. falciparum, Taenia solium
• 2.13.4 Europe — West Nile virus, tickborne encephalitis virus, A. phagocytophilum, B. burgdorferi
• 2.13.5 India, Nepal — Rabies virus, Japanese encephalitis virus, P. falciparum
• 2.13.6 Middle East — West Nile virus, P. falciparum
• 2.13.7 Russia — Tickborne encephalitis virus
• 2.13.8 South America — Rabies virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, R. rickettsii, B. bacilliformis (Andes mountains), P. falciparum, T. solium
• 2.13.9 Southeast Asia, China, Pacific Rim — Japanese encephalitis virus, tickborne encephalitis virus, Nipah virus, P. falciparum, Gnanthostoma species, T. solium
• 2.13.10 Unvaccinated status — Varicella zoster virus, Japanese encephalitis virus, poliovirus, measles virus, mumps virus, rubella virus

• 3. Specific clinical considerations

• 3.1 General findings

• 3.1.1 Hepatitis — Coxiella burnetii
• 3.1.2 Lymphadenopathy — HIV, Epstein-Barr virus, cytomegalovirus, measles virus, rubella virus, West Nile virus, Treponema pallidum, Bartonella henselae and other Bartonella species, Mycobacterium tuberculosis, Toxoplasma gondii, Trypanosoma brucei gambiense
• 3.1.3 Parotitis — Mumps virus
• 3.1.4 Rash — Varicella zoster virus, B virus, human herpesvirus 6, West Nile virus, rubella virus, some enteroviruses, HIV, Rickettsia rickettsii, Mycoplasma pneumoniae, Borrelia burgdorferi, T. pallidum, Ehrlichia chaffeensis, Anaplasma phagocytophilum
• 3.1.5 Respiratory tract findings — Venezuelan equine encephalitis virus, Nipah virus, Hendra virus, influenza virus, adenovirus, M. pneumoniae, C. burnetii, M. tuberculosis, Histoplasma capsulatum
• 3.1.6 Retinitis — Cytomegalovirus, West Nile virus, B. henselae, T. pallidum
• 3.1.7 Urinary symptoms — St. Louis encephalitis virus

• 3.2 Neurologic findings

• 3.2.1 Cerebellar ataxia — Varicella zoster virus (children), Epstein-Barr virus, mumps virus, St. Louis encephalitis virus, Tropheryma whipplei, T. brucei gambiense
• 3.2.2 Cranial nerve abnormalities — Herpes simplex virus, Epstein-Barr virus, Listeria monocytogenes, M. tuberculosis, T. pallidum, B. burgdorferi, T. whipplei, Cryptococcus neoformans, Coccidioides species, H. capsulatum
• 3.2.3 Dementia — HIV, human transmissible spongiform encephalopathies (sCJD and vCJD), measles virus (SSPE), T. pallidum, T. whipplei
• 3.2.4 Myorhythmia — T. whipplei (oculomasticatory)
• 3.2.5 Parkinsonism — Japanese encephalitis virus, St. Louis encephalitis virus, West Nile virus, Nipah virus, T. gondii, T. brucei gambiense
• 3.2.6 Poliomyelitis-like flaccid paralysis — Japanese encephalitis virus, West Nile virus, tickborne encephalitis virus; enteroviruses (enterovirus-71, coxsackieviruses), poliovirus
• 3.2.7 Rhombencephalitis — Herpes simplex virus, West Nile virus, enterovirus 71, L. monocytogenes

• 4. Pathogen-directed antimicrobial therapy

• 4.1 Viruses

• 4.1.1 Adenovirus

• Preferred regimen: supportive

• 4.1.2 B virus (herpes B virus)

• 4.1.2.1 Established disease

• Preferred regimen: Valacyclovir 1,000 mg PO tid OR Ganciclovir 5 mg/kg IV q12h for ≥ 14 days until resolution of neurologic symptoms, then Acyclovir 800 mg PO 5 times daily indefinitely OR Valacyclovir 1 g PO tid indefinitely
• Alternative regimen: Acyclovir 15 mg/kg IV q8h for ≥ 14 days until resolution of neurologic symptoms, then Acyclovir 800 mg PO 5 times daily OR Valacyclovir 1 g PO tid indefinitely

• 4.1.2.2 Prophylaxis after bite or scratch

• Preferred regimen: Valacyclovir 1,000 mg PO tid

• 4.1.3 Cytomegalovirus (CMV)

• Preferred regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days, followed by 5 mg/kg IV qd for maintenance AND Foscarnet 90 mg/kg IV q12h for 14–21 days, followed by 90-120 mg/kg IV qd for maintenance

• 4.1.4 Chikungunya virus

• Preferred regimen: supportive

• 4.1.5 Eastern equine encephalitis virus

• Preferred regimen: supportive

• 4.1.6 Epstein-Barr virus (EBV)

• Preferred regimen: supportive ± Corticosteroids
• Note: Acyclovir is not recommended.

• 4.1.7 Hendra virus

• Preferred regimen: supportive

• 4.1.8 HSV-1 and HSV-2

• Preferred regimen: Acyclovir 10 mg/kg IV q8h for 14–21 days
• Preferred regimen (neonates): Acyclovir 20 mg/kg IV q8h for 21 days

• 4.1.9 Human herpesvirus 6 (HHV-6)

• Preferred regimen (1): Ganciclovir 5 mg/kg IV q12h for 14–21 days, followed by 5 mg/kg IV qd for maintenance

• Preferred regimen (2): Foscarnet 90 mg/kg IV q12h for 14–21 days, followed by 90-120 mg/kg IV qd for maintenance

• 4.1.10 Human immunodeficiency virus (HIV)

• Preferred regimen: HAART

• 4.1.11 Influenza virus

• Preferred regimen: Oseltamivir 75 mg PO bid

• 4.1.12 Japanese encephalitis virus

• Preferred regimen: supportive
• Note: Interferon alpha is not recommended.

• 4.1.13 JC virus

• Preferred regimen: Reversal or control of immunosuppression OR HAART in patients with AIDS

• 4.1.14 La Crosse virus

• Preferred regimen: supportive

• 4.1.15 Louping ill virus

• Preferred regimen: supportive

• 4.1.16 Lymphocytic choriomeningitis virus (LCMV)

• Preferred regimen: supportive

• 4.1.17 Me Tri virus

• Preferred regimen: supportive

• 4.1.18 Measles virus

• Preferred regimen: supportive
• Note: Ribavirin is not approved by the US Food and Drug Administration (FDA) for this indication, and such use should be considered experimental.

• 4.1.19 Monkeypox virus

• Preferred regimen: supportive
• Alternative regimen: Cidofovir OR vaccinia immune globulin

• 4.1.20 Mumps virus

• Preferred regimen: supportive

• 4.1.21 Murray Valley encephalitis virus

• Preferred regimen: supportive

• 4.1.22 Nipah virus

• Preferred regimen: supportive
• Alternative regimen: Ribavirin

• 4.1.23 Nonpolio enteroviruses

• Preferred regimen: supportive
• Note: Consider intraventricular γ-globulin for chronic and/or severe disease.

• 4.1.24 Poliovirus

• Preferred regimen: supportive

• 4.1.25 Powassan virus

• Preferred regimen: supportive

• 4.1.26 Rabies virus

• 4.1.26.1 Not previously vaccinated

• Preferred regimen (1): Wound cleansing with soap and water followed by povidine-iodine solution irrigation if available.
• Preferred regimen (2): Human rabies immune globulin (HRIG) 20 IU/kg
• Preferred regimen (3): Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area), 1 each on days 0, 3, 7, and 14

• 4.1.26.2 Previously vaccinated

• Preferred regimen (1): Wound cleansing with soap and water followed by povidine-iodine solution irrigation if available.
• Preferred regimen (2): Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area), 1 each on days 0 and 3
• Note: If anatomically feasible, the full dose of HRIG should be infiltrated around and into the wounds, and any remaining volume should be administered at an anatomical site intramuscularly distant from vaccine administration. In addition, HRIG should not be administered in the same syringe as vaccine. Because RIG might partially suppress active production of rabies virus antibody, no more than the recommended dose should be administered.

• 4.1.27 Rocio virus

• Preferred regimen: supportive

• 4.1.28 Rubella virus

• Preferred regimen: supportive

• 4.1.29 Snowshoe hare virus

• Preferred regimen: supportive

• 4.1.30 St. Louis encephalitis virus

• Preferred regimen: supportive
• Alternative regimen: IFN-α-2b

• 4.1.31 Tickborne encephalitis virus

• Preferred regimen: supportive

• 4.1.32 Toscana virus

• Preferred regimen: supportive

• 4.1.33 Vaccinia

• Preferred regimen: supportive ± Corticosteroids (if suggestive of post-immunization)

• 4.1.34 Venezuelan equine encephalitis virus

• Preferred regimen: supportive

• 4.1.35 Varicella zoster virus (VZV)

• Preferred regimen: Acyclovir 10–15 mg/kg IV q8h for 10–14 days ± Corticosteroids
• Alternative regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days THEN 5 mg/kg IV qd for maintenance ± Corticosteroids

• 4.1.36 West Nile virus

• Preferred regimen: supportive

• 4.1.37 Western equine encephalitis virus

• Preferred regimen: supportive

• 4.2 Bacteria

• 4.2.1 Anaplasma phagocytophilum (human granulocytotrophic ehrlichiosis)

• Preferred regimen: Doxycycline 100 mg PO/IV bid for 8 weeks

• 4.2.2 Bartonella bacilliformis (Oroya fever, Carrion's disease)

• Preferred regimen: Chloramphenicol 25 mg/kg q6h for 14 days OR Doxycycline 100 mg PO/IV bid for 8 weeks OR Ampicillin 2 mg IV q4h for 3-6 weeks OR Trimethoprim-Sulfamethoxazole 4 mg/kg IV q6h for 3-6 weeks

• 4.2.3 Bartonella henselae (cat scratch disease)

• Preferred regimen: Doxycycline 100 mg PO/IV bid for 8 weeks OR Azithromycin 250 mg PO qd for 8 weeks ± Rifampin 300 mg PO bid for 8 weeks

• 4.2.4 Borrelia burgdorferi (Lyme disease)

• Preferred regimen: Ceftriaxone 2g IV q24h for 2-4 weeks OR Cefotaxime 2g IV q8h for 2-4 weeks OR Penicillin G 20MU IV q4hr in divided doses for 2-4 weeks

• 4.2.5 Coxiella burnetii (Q fever)

• Preferred regimen: Doxycycline 100 mg IV/PO bid for 8 weeks AND Ciprofloxacin 500-750 mg PO bid for 8 weeks AND Rifampin 300 mg PO bid for 8 weeks

• 4.2.6 Ehrlichia chaffeensis (human monocytotrophic ehrlichiosis)

• Preferred regimen: Doxycycline 100 mg IV/PO bid for 8 weeks

• 4.2.7 Listeria monocytogenes

• Preferred regimen: Ampicillin 2 mg IV q4h for 3-6 weeks AND Gentamicin 5 mg/kg/day IV divided q8h for 3-6 weeks
• Alternative regimen: Trimethoprim-Sulfamethoxazole 4 mg/kg IV q6h for 3-6 weeks

• 4.2.8 Mycobacterium tuberculosis

• Preferred regimen: (Isoniazid 300 mg PO qd for 10-12 months AND Rifampicin 450-600 mg PO qd for 10-12 months AND Pyrazinamide 1.5-2g mg PO qd for 2 months AND Ethambutol 15 mg/kg PO qd for 2 month) ± Dexamethasone (if suggestive of meningitis)

• 4.2.9 Mycoplasma pneumoniae

• Preferred regimen: Azithromycin 250 mg PO qd for 8 weeks OR Doxycycline 100 mg PO/IV bid for 8 weeks

• 4.2.10 Rickettsia rickettsii (Rocky Mountain spotted fever)

• Preferred regimen: Doxycycline 100 mg PO/IV bid for 8 weeks
• Alternative regimen, pregnant patient: Chloramphenicol 25 mg/kg q6h for 14 days

• 4.2.11 Treponema pallidum (syphilis)

• Preferred regimen: Penicillin G 20MU IV q4hr in divided doses for 2-4 weeks
• Alternative regimen: Ceftriaxone 2g IV q24h for 2-4 weeks

• 4.2.12 Tropheryma whipplei (Whipple's disease)

• Preferred regimen: Ceftriaxone 2g IV q24h for 2-4 weeks, followed by Trimethoprim-Sulfamethoxazole for 1–2 years OR Cefixime for 1–2 years

• 4.3 Fungi

• 4.3.1 Coccidioides

• Preferred regimen: Fluconazole 400-800 mg IV qd for 3-4 weeks
• Alternative regimen: Itraconazole 200 mg IV bid for 2 days THEN 200 mg IV qd for 12 days OR Voriconazole OR Amphotericin B (intravenous and intrathecal)

• 4.3.2 Cryptococcus neoformans

• Preferred regimen (1): Amphotericin B deoxycholate AND Flucytosine for 2 weeks, followed by Fluconazole for 8 weeks
• Preferred regimen (2): Amphotericin B lipid complex AND Flucytosine for 2 weeks, followed by Fluconazole for 8 weeks
• Preferred regimen (3): Amphotericin B deoxycholate AND Flucytosine for 6–10 weeks, followed by Fluconazole for 8 weeks
• Note: Consider placement of lumbar drain or VP shunt.

• 4.3.3 Histoplasma capsulatum

• Preferred regimen: Amphotericin B liposomal for 4–6 weeks, followed by Itraconazole for at least 1 year and until resolution of CSF abnormalities

• 4.4 Protozoa

• 4.4.1 Acanthamoeba

• Preferred regimen (1): Trimethoprim-Sulfamethoxazole AND Rifampin AND Ketoconazole
• Preferred regimen (2): Fluconazole AND Sulfadiazine AND Pyrimethamine 100-200 mg PO once THEN 50-100 mg PO qd for 6 weeks

• 4.4.2 Balamuthia mandrillaris

• Preferred regimen: (Azithromycin OR Clarithromycin) AND Pentamidine AND Flucytosine AND Fluconazole AND Sulfadiazine AND (Thioridazine OR Trifluoperazine)

• 4.4.3 Naegleria fowleri

• Preferred regimen: Amphotericin B (intravenous and intrathecal) AND Rifampin AND (Azithromycin OR Sulfisoxazole OR Miconazole)

• 4.4.4 Plasmodium falciparum

• Preferred regimen: Quinine OR Quinidine OR Artesunate OR Artemether
• Alternative regimen (1): Atovaquone-Proguanil
• Alternative regimen (2): Exchange transfusion (for > 10% parasitemia or cerebral malaria)

• 4.4.5 Toxoplasma gondii

• Preferred regimen: Pyrimethamine AND Sulfadiazine OR Clindamycin 900 mg IV q 6hr qd for 6 weeks
• Alternative regimen (1): Trimethoprim-sulfamethoxazole
• Alternative regimen (2): Pyrimethamine AND (Atovaquone OR Clarithromycin OR Azithromycin OR Dapsone)

• 4.4.6 Trypanosoma brucei gambiense (West African trypanosomiasis)

• Preferred regimen: Eflornithine OR Melarsoprol 2-3.6 mg/kg IV q24h for 3 days THEN repeat the same regimen after 7 days THEN repeat the same regimen again (total of 3 regimens after 7 days of the 2nd regimen

• 4.4.7 Trypanosoma brucei rhodesiense (East African trypanosomiasis)

• Preferred regimen: Melarsoprol

• 4.5 Helminths

• 4.5.1 Baylisascaris procyonis

• Preferred regimen: Albendazole AND Diethylcarbamazine AND Corticosteroids

• 4.5.2 Gnathostoma

• Preferred regimen: Albendazole OR Ivermectin

• 4.5.3 Taenia solium (cysticercosis)

• Preferred regimen: Albendazole AND Corticosteroids
• Alternative regimen: Praziquantel AND Corticosteroids

• 4.6 Prion

• 4.6.1 Human transmissible spongiform encephalopathy

• Preferred regimen: supportive

References

Epidural abscess ⇧ Return to Top ⇧

• 1. Spinal epidural abscess

• 1.1 Empiric antimicrobial therapy

• Preferred regimen: Vancomycin loading dose 25–30 mg/kg IV followed by 15–20 mg/kg IV q8–12h for 2–4 weeks, then PO to complete 6–8 weeks AND Ceftriaxone 2 g IV q24h for 2–4 weeks, then PO to complete 6–8 weeks
• Note (1): Decompressive laminectomy in conjunction with long-term antibiotic therapy tailored to culture results is required.
• Note (2): For critically ill patients, a loading dose of Vancomycin 20–25 mg/kg may be considered.

• 1.2 Pathogen-directed antimicrobial therapy

• 1.2.1 Penicillin-susceptible Staphylococcus aureus or Streptococcus

• Preferred regimen: Penicillin G 4 MU IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks

• 1.2.2 Methicillin-susceptible Staphylococcus aureus or Streptococcus

• Preferred regimen (1): Cefazolin 2 g IV q8h for 2–4 weeks THEN PO to complete 6–8 weeks

• Preferred regimen (2): Nafcillin 2 g IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks

• Preferred regimen (3): Oxacillin 2 g IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks
• Alternative regimen: Clindamycin 600 mg IV q6h for 2–4 weeks, then PO to complete 6–8 weeks

• 1.2.3 Methicillin-resistant Staphylococcus aureus (MRSA)

• Preferred regimen: Vancomycin loading dose 25–30 mg/kg IV followed by 15–20 mg/kg IV q8–12h for 2–4 weeks, then PO to complete 6–8 weeks
• Alternative regimen: Linezolid 600 mg PO/IV q12h for 4–6 weeks OR TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
• Pediatric dose: Vancomycin 15 mg/kg/dose IV q6h OR Linezolid 10 mg/kg/dose PO/IV q8h
• Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin in adult patients.

• 1.2.4 Streptococcus

• Preferred regimen (1): Penicillin G 3–4 MU IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks

• Preferred regimen (2): Ampicillin 2 g IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks

• 1.2.5 Enterococcus

• Preferred regimen (1): Penicillin G 3–4 MU IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks

• Preferred regimen (2): Ampicillin 2 g IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks

• 1.2.6 Enterobacteriaceae

• Preferred regimen (1): Ceftriaxone 1–2 g IV q12h for 2–4 weeks THEN PO to complete 6–8 weeks

• Preferred regimen (2): Cefotaxime 2 g IV q6–8h for 2–4 weeks THEN PO to complete 6–8 weeks

• 1.2.7 Gram-negative bacteria

• Preferred regimen (1): Ceftazidime 2 g IV q8h for 2–4 weeks THEN PO to complete 6–8 weeks

• Preferred regimen (2): Cefepime 2 g IV q12h for 2–4 weeks THEN PO to complete 6–8 weeks
• Alternative regimen (1): Ciprofloxacin 400 mg IV q12h for 2–4 weeks THEN PO to complete 6–8 weeks

• Alternative regimen (2): Levofloxacin 750 mg IV q24h for 2–4 weeks THEN PO to complete 6–8 weeks

• Alternative regimen (3): Moxifloxacin 400 mg IV q24h for 2–4 weeks THEN PO to complete 6–8 weeks

• 1.2.8 Anaerobes

• Preferred regimen: Metronidazole 500 mg IV q6h for 2–4 weeks THEN PO to complete 6–8 weeks

• 1.2.9 Staphylococcus, Gram-negative bacteria, and anaerobes (mixed infection)

• Preferred regimen (1): Ampicillin-Sulbactam 3 g IV q6h for 2–4 weeks THEN PO to complete 6–8 weeks

• Preferred regimen (2): Ticarcillin-Clavulanate 3.1 g IV q4h for 2–4 weeks THEN PO to complete 6–8 weeks

• Preferred regimen (3): Piperacillin-Tazobactam 3.375 g IV q4–6h for 2–4 weeks THEN PO to complete 6–8 weeks
• Alternative regimen (1): Imipenem 500–1000 mg IV q6h for 2–4 weeks THEN PO to complete 6–8 weeks

• Alternative regimen (2): Meropenem 1–2 g IV q8h for 2–4 weeks THEN PO to complete 6–8 weeks

Lyme neuroborreliosis ⇧ Return to Top ⇧

• 1. Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines

• 1.1 Early neurologic disease

• 1.1.1 Cranial nerve palsy (adult)

• Preferred regimen (1): Amoxicillin 500 mg PO tid for 14 (14–21) days

• Preferred regimen (2): Doxycycline 100 mg PO bid for 14 (14–21) days

• Preferred regimen (3): Cefuroxime 500 mg PO bid for 14 (14–21) days
• Alternative regimen (1): Azithromycin 500 mg PO qd for 7–10 days

• Alternative regimen (2): Clarithromycin 500 mg PO bid for 14–21 days (not for pregnant)

• Alternative regimen (3): Erythromycin 500 mg PO qid for 14–21 days

• 1.1.2 Cranial nerve palsy (pediatric)

• Preferred regimen (1): Amoxicillin 50 mg/kg/day PO tid (Maxmum, 500 mg/dose) for 14 (14–21) days

• Preferred regimen (2): Doxycycline (for children aged ≥ 8 years) 4 mg/kg/day PO q12h (Maxmum, 100 mg/dose) for 14 (14–21) days

• Preferred regimen (3): Cefuroxime 30 mg/kg/day PO q12h (Maxmum, 500 mg/dose) for 14 (14–21) days
• Alternative regimen (1): Azithromycin 10 mg/kg/day PO (Maxmum, 500 mg/dose) for 7–10 days

• Alternative regimen (2): Clarithromycin 7.5 mg/kg PO bid (Maxmum, 500 mg/dose) for 14–21 days

• Alternative regimen (3): Erythromycin 12.5 mg/kg PO bid (Maxmum, 500 mg/dose) for 14–21 days

• 1.1.3 Meningitis or radiculopathy (adult)

• Preferred regimen: Ceftriaxone 2 g IV q24h for 14 (10–28) days
• Alternative regimen (1): Cefotaxime 2 g IV q8h for 14 (10–28) days

• Alternative regimen (2): Penicillin G 18–24 MU/day IV q4h for 14 (10–28) days
• Note: for nonpregnant adult patients intolerant of β-lactam agents, Doxycycline 200–400 mg/day PO/IV q12h may be considered.

• 1.1.4 Meningitis or radiculopathy (pediatric)

• Preferred regimen: Ceftriaxone 50–75 mg/kg IV q24h (Maxmum, 2 g/day) for 14 (10–28) days
• Alternative regimen (1): Cefotaxime 150–200 mg/kg/day IV q6-8h (Maxmum, 6 g/day) for 14 (10–28) days

• Alternative regimen (2): Penicillin G 200,000–400,000 U/kg/day IV q4h (Maxmum, 18–24 MU/day) for 14 (10–28) days
• Note: for children ≥ 8 years of age intolerant of β-lactam agents, Doxycycline 4–8 mg/kg/day PO/IV q12h, max 200–400 mg/day may be considered

• 1.2 Late neurologic disease

• 1.2.1 Central or peripheral nervous system disease (adult)

• Preferred regimen: Ceftriaxone 2 g IV q24h for 14 (10–28) days
• Alternative regimen (1): Cefotaxime 2 g IV q8h for 14 (10–28) days

• Alternative regimen (2): Penicillin G 18–24 MU/day IV q4h for 14 (10–28) days

• 1.2.2 Central or peripheral nervous system disease (pediatric)

• Preferred regimen: Ceftriaxone 50–75 mg/kg IV q24h (Maxmum, 2 g/day) for 14 (10–28) days.
• Alternative regimen (1): Cefotaxime 150–200 mg/kg/day IV q6–8h (Maxmum, 6 g/day) for 14 (10–28) days

• Alternative regimen (2): Penicillin G 200,000–400,000 U/kg/day IV q4h (Maxmum, 18–24 MU/day) for 14 (10–28) days

• 2. American Academy of Neurology (AAN) Practice Parameter

• 2.1 Meningitis

• Preferred regimen: Ceftriaxone 2 g IV q24h for 14 days OR Cefotaxime 2 g IV q8h for 14 days OR Penicillin G 18–24 MU/day q4h for 14 days
• Alternative regimen: Doxycycline 100–200 mg BID for 14 days
• Pediatric regimen: Ceftriaxone 50–75 mg/kg/day IV q24h, max 2 g/day; Cefotaxime 150–200 mg/kg/day IV q6–8h, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day; Doxycycline (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day

• 2.2 Any neurologic syndrome with CSF pleocytosis

• Preferred regimen: Ceftriaxone 2 g IV q24h for 14 days OR Cefotaxime 2 g IV q8h for 14 days OR Penicillin G 18–24 MU/day IV q4h for 14 days
• Alternative regimen: Doxycycline 100–200 mg BID for 14 days
• Pediatric regimen: Ceftriaxone 50–75 mg/kg/day IV q24h, max 2 g; Cefotaxime 150–200 mg/kg/day IV q6–8h, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day q4h, max 18–24 MU/day; Doxycycline (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day

• 2.3 Peripheral nervous system disease (radiculopathy, diffuse neuropathy, mononeuropathy multiplex, cranial neuropathy; normal CSF)

• Preferred regimen: Doxycycline 100–200 mg BID for 14 days
• Alternative regimen: Ceftriaxone 2 g IV q24h for 14 days OR Cefotaxime 2 g IV q8h for 14 days OR Penicillin G 18–24 MU/day IV q4h for 14 days
• Pediatric regimen: Doxycycline (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day; Ceftriaxone 50–75 mg/kg/day IV q24h, max 2 g/day; Cefotaxime 150–200 mg/kg/day IV q6–8h, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day; Doxycycline (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day

• 2.4 Encephalomyelitis

• Preferred regimen: Ceftriaxone 2 g IV q24h for 14 days OR Cefotaxime 2 g IV q8h for 14 days OR Penicillin G 18–24 MU/day q4h for 14 days
• Pediatric regimen: Ceftriaxone 50–75 mg/kg/day IV q24h, max 2 g/day; Cefotaxime 150–200 mg/kg/day IV q6–8h, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day

• 2.5 Encephalopathy

• Preferred regimen: Ceftriaxone 2 g IV q24h for 14 days OR Cefotaxime 2 g IV q8h for 14 days OR Penicillin G 18–24 MU/day q4h for 14 days
• Pediatric regimen: Ceftriaxone 50–75 mg/kg/day IV q24h, max 2 g/day; Cefotaxime 150–200 mg/kg/day IV q6–8h, max 6 g/day; Penicillin G 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day

• 2.6 Post-treatment Lyme syndrome

• Preferred regimen: symptomatic management
• Note: Antibiotic therapy is not indicated.

References

Meningitis ⇧ Return to Top ⇧

• Bacterial meningitis

• 1. Empiric antimicrobial therapy based on specific predisposing factors

• 1.1 Age

• 1.1.1 Age < 1 month

• Common causative pathogens: Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes, Klebsiella species
• Preferred regimen: Ampicillin 12 g/day IV q4h AND (Cefotaxime 8–12 g/day q4–6h OR Amikacin 15 mg/kg/day IV q8h OR Gentamicin 5 mg/kg/day IV q8h OR Tobramycin 5 mg/kg/day IV q8h)

• 1.1.2 Age 1–23 months

• Common causative pathogens: Streptococcus pneumoniae, Neisseria meningitidis, S. agalactiae, Haemophilus influenzae, E. coli
• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)

• 1.1.3 Age 2–50 years

• Common causative pathogens: N . meningitidis, S. pneumoniae
• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)

• 1.1.4 Age > 50 years

• Common causative pathogens: S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic Gram-negative bacilli
• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND Ampicillin 12 g/day IV q4h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)

• 1.2 Head trauma

• 1.2.1 Basilar skull fracture

• Common causative pathogens: S. pneumoniae, H. influenzae, group A β-hemolytic streptococci
• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)

• 1.2.2 Penetrating trauma

• Common causative pathogens: Staphylococcus aureus, coagulase-negative staphylococci (especially Staphylococcus epidermidis), aerobic Gram-negative bacilli (including Pseudomonas aeruginosa)
• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Cefepime 6 g/day IV q8h OR Ceftazidime 6 g/day IV q8h OR Meropenem 6 g/day IV q8h)

• 1.3 Postneurosurgery

• Common causative pathogens: Aerobic Gram-negative bacilli (including P. aeruginosa), S. aureus, coagulase-negative staphylococci (especially S. epidermidis)
• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Cefepime 6 g/day IV q8h OR Ceftazidime 6 g/day IV q8h OR Meropenem 6 g/day IV q8h)

• 1.4 CSF shunt

• Common causative pathogens: Coagulase-negative staphylococci (especially S. epidermidis), S. aureus, aerobic Gram-negative bacilli (including P. aeruginosa), Propionibacterium acnes
• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Cefepime 6 g/day IV q8h OR Ceftazidime 6 g/day IV q8h OR Meropenem 6 g/day IV q8h)

• 2. CSF Gram stain-directed antimicrobial therapy

• 2.1 Gram positive, lancet-shaped diplococci suggestive of Streptococcus pneumoniae

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)
• Alternative regimen: Meropenem 6 g/day IV q8h OR Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h

• 2.2 Gram negative diplococci suggestive of Neisseria meningitidis

• Preferred regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h
• Alternative regimen: Penicillin G 24 MU/day IV q4h OR Ampicillin 12 g/day IV q4h OR Chloramphenicol 4–6 g/day IV q6h OR Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h OR Aztreonam 6–8 g/day IV q6–8h

• 2.3 Gram positive, short bacilli suggestive of Listeria monocytogenes

• Preferred regimen: (Ampicillin 12 g/day IV q4h OR Penicillin G 24 MU/day IV q4h) ± (Amikacin 15 mg/kg/day IV q8h OR Gentamicin 5 mg/kg/day IV q8h OR Tobramycin 5 mg/kg/day IV q8h)
• Alternative regimen: Trimethoprim-Sulfamethoxazole 10–20 mg/kg/day q6–12h OR Meropenem 6 g/day IV q8h

• 2.4 Gram positive cocci in short chains suggestive of Streptococcus agalactiae

• Preferred regimen: (Ampicillin 12 g/day IV q4h OR Penicillin G 24 MU/day IV q4h) ± (Amikacin 15 mg/kg/day IV q8h OR Gentamicin 5 mg/kg/day IV q8h OR Tobramycin 5 mg/kg/day IV q8h)
• Alternative regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h

• 2.5 Gram negative coccobacilli suggestive of Haemophilus influenzae

• Preferred regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h
• Alternative regimen: Chloramphenicol 4–6 g/day IV q6h OR Cefepime 6 g/day IV q8h OR Meropenem 6 g/day IV q8h OR Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h

• 2.6 Gram negative bacilli suggestive of Escherichia coli

• Preferred regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h
• Alternative regimen: Cefepime 6 g/day IV q8h OR Meropenem 6 g/day IV q8h OR Aztreonam 6–8 g/day IV q6–8h OR Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h OR Trimethoprim-Sulfamethoxazole 10–20 mg/kg/day q6–12h

• 3. Pathogen-directed antimicrobial therapy

• 3.1 Acinetobacter baumannii

• Preferred regimen: Meropenem 2 g IV q8h
• Alternative regimen: Colistin 1.25 mg/kg IV q6—12h OR Polymyxin B 0.75—1.25 mg/kg IV q12h

• 3.2 Borrelia burgdorferi

• Preferred regimen: Ceftriaxone 2 g IV q24h for 10—28 days
• Alternative regimen: Cefotaxime 2 g IV q8h for 10—28 days OR Penicillin G 3—4 MU IV q4h for 10—28 days OR Doxycycline 100—200 mg PO q12h for 10—28 days

• 3.3 Enterococcus species

• 3.3.1 Ampicillin susceptible

• Preferred regimen: Ampicillin 12 g/day IV q4h AND Gentamicin 5 mg/kg/day IV q8h

• 3.3.2 Ampicillin resistant

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND Gentamicin 5 mg/kg/day IV q8h

• 3.3.3 Ampicillin and vancomycin resistant

• Preferred regimen: Linezolid 600 mg IV q12h

• 3.4 Escherichia coli and other Enterobacteriaceae

• Preferred regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h
• Alternative regimen: Aztreonam 6–8 g/day IV q6–8h OR Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h OR Meropenem 6 g/day IV q8h OR Trimethoprim-Sulfamethoxazole 10–20 mg/kg/day q6–12h OR Ampicillin 12 g/day IV q4h

• 3.5 Haemophilus influenzae

• 3.5.1 β-Lactamase negative

• Preferred regimen: Ampicillin 12 g/day IV q4h
• Alternative regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h OR Cefepime 6 g/day IV q8h OR Chloramphenicol 4–6 g/day IV q6h OR Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h

• 3.5.2 β-Lactamase positive

• Preferred regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h
• Alternative regimen: Cefepime 6 g/day IV q8h OR Chloramphenicol 4–6 g/day IV q6h OR Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h

• 3.6 Listeria monocytogenes

• Preferred regimen: Ampicillin 12 g/day IV q4h OR Penicillin G 24 MU/day IV q4h
• Alternative regimen: Trimethoprim-Sulfamethoxazole 10–20 mg/kg/day q6–12h OR Meropenem 6 g/day IV q8h

• 3.7 Mycobacterium tuberculosis

• 3.7.1 First-line therapy (dosing information: [1][2][3])

• Isoniazid
• Rifampin
• Rifabutin
• Pyrazinamide
• Ethambutol

• 3.7.2 Second-line therapy (dosing information: [4][5][6])

• Cycloserine
• Ethionamide
• Streptomycin
• Amikacin
• Kanamycin
• Capreomycin
• p-Aminosalicylic acid
• Levofloxacin
• Moxifloxacin
• Gatifloxacin

• 3.7.3 Tuberculous meningitis caused by susceptible Mycobacterium tuberculosis

• 3.7.3.1 Intensive phase (adult)

• Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) for 2 months AND Rifampin 10 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months

• 3.7.3.2 Continuation phase (adult)

• Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) for 7–10 months AND Rifampin 10 mg/kg (max: 600 mg) for 7–10 months

• 3.7.3.3 Intensive phase (pediatric)

• Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 2 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months

• 3.7.3.3 Continuation phase (pediatric)

• Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 7–10 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 7–10 months
• Note (1): World Health Organization guidelines recommend that Ethambutol should be replaced by Streptomycin in tuberculous meningitis. Streptomycin is contraindicated in pregnancy.
• Note (2): A 9– to 12–month course of treatment is recommended for tuberculous meningitis.

Note (3): Adjuvant Dexamethasone 0.3–0.4 mg/kg/day (max: 24 mg) is recommended unless drug resistance is suspected.

Note (4): Liaise with microbiology laboratory about genotype testing for drug resistance if there is high risk for MDR-TB.

• 3.7.4 Tuberculous meningitis caused by Mycobacterium tuberculosis resistant to isoniazid or rifampin

• 3.7.4.1 Isoniazid monoresistance

• Substitute Fluoroquinolones for Isoniazid in intensive phase regimen.
• Continue treatment with Rifampin, Pyrazinamide, and Fluoroquinolone for 12 months.

• 3.7.4.2 Rifampin monoresistance

• Substitute Fluoroquinolones for Rifampin in intensive phase regimen.
• Continue treatment with Isoniazid, Pyrazinamide, and Fluoroquinolone for 18 months.

• 3.7.4.3 MDR-TB (resistant to Isoniazid and Rifampin)

• MDR tuberculosis therapy should be considered if there is a history of prior tuberculosis treatment, contact with a patient with MDR tuberculosis, or a poor clinical response to first-line TB therapy within 2 weeks despite a firm diagnosis and an adequate adherence to treatment.
• Second-line agents such as Aminoglycosides penetrate the BBB only in the presence of inflamed meninges, and Fluoroquinolones, while able to penetrate into the CNS, have lower CSF levels than in the serum or brain parenchyma.
• Consult infectious disease specialist.

• 3.7.4.4 XDR-TB (resistant to Isoniazid, Rifampin, Fluoroquinolones, and either Capreomycin, Kanamycin, or Amikacin)

• Consider Ethionamide or Cycloserine to build the treatment regimen.
• Consult infectious disease specialist.

• 3.8 Neisseria gonorrheoae

• Preferred regimen: Ceftriaxone 1–2 g IV q12h for 10–14 days

• 3.9 Neisseria meningitidis

• 3.9.1 Penicillin MIC < 0.1 μg/mL

• Preferred regimen: Penicillin G 24 MU/day IV q4h OR Ampicillin 12 g/day IV q4h
• Alternative regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h OR Chloramphenicol 4–6 g/day IV q6h

• 3.9.2 Penicillin MIC 0.1–1.0 μg/mL

• Preferred regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h
• Alternative regimen: Chloramphenicol 4–6 g/day IV q6h OR Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h OR Meropenem 6 g/day IV q8h

• 3.10 Pseudomonas aeruginosa

• Preferred regimen: Cefepime 6 g/day IV q8h OR Ceftazidime 6 g/day IV q8h
• Alternative regimen: Aztreonam 6–8 g/day IV q6–8h OR Ciprofloxacin 800–1200 mg IV q8–12h OR Meropenem 6 g/day IV q8h

• 3.11 Staphylococcus aureus

• 3.11.1 Methicillin susceptible (MSSA)

• Preferred regimen: Nafcillin 9–12 g/day IV q4h OR Oxacillin 9–12 g/day IV q4h
• Alternative regimen: Vancomycin 30–45 mg/kg/day IV q8–12h OR Meropenem 6 g/day IV q8h

• 3.11.2 Methicillin resistant (MRSA)

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h
• Alternative regimen: Trimethoprim-Sulfamethoxazole 10–20 mg/kg/day q6–12h OR Linezolid 600 mg IV q12h
• Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin in adult patients.

• 3.12 Staphylococcus epidermidis

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h
• Alternative regimen: Linezolid 600 mg IV q12h

• 3.13 Streptococcus agalactiae

• Preferred regimen: Ampicillin 12 g/day IV q4h OR Penicillin G 24 MU/day IV q4h
• Alternative regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h

• 3.14 Streptococcus pneumoniae

• 3.14.1 Penicillin MIC < 0.1 μg/mL

• Preferred regimen: Penicillin G 24 MU/day IV q4h OR Ampicillin 12 g/day IV q4h
• Alternative regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h OR Chloramphenicol 4–6 g/day IV q6h

• 3.14.2 Penicillin MIC 0.1–1.0 μg/mL

• Preferred regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h
• Alternative regimen: Cefepime 6 g/day IV q8h OR Meropenem 6 g/day IV q8h

• 3.14.3 Penicillin MIC ≥ 2.0 μg/mL

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)
• Alternative regimen: Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h

• 3.14.4 Cefotaxime or ceftriaxone MIC ≥ 1.0 μg/mL

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)
• Alternative regimen: Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h

• 3.15 Treponema pallidum (neurosyphilis)

• Preferred regimen: Aqueous crystalline penicillin G 3–4 MU IV q4h or continuously for 10–14 days
• Alternative regimen: Procaine penicillin G 2.4 MU IM q24h for 10–14 days AND Probenecid 500 mg PO qid for 10–14 days
• Note: Benzathine penicillin G 2.4 MU IM once per week for up to 3 weeks may be considered after completion of above mentioned regimens to provide a comparable total duration of therapy.

• 3.16 Borrelia burgdorferi (Lyme meningitis)

• Preferred regimen (1): Ceftriaxone 2 g IV q24h for 14 days
• Preferred regimen (2):Cefotaxime 2 g IV q8h for 14 days
• Preferred regimen (3):Penicillin G 18–24 MU/day q4h for 14 days
• Alternative regimen: Doxycycline 100–200 mg BID for 14 days
• Pediatric regimen: Ceftriaxone 50–75 mg/kg/day IV q24h, max 2 g/day OR Cefotaxime 150–200 mg/kg/day IV q6–8h, max 6 g/day OR Penicillin G 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day OR Doxycycline (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day

• 4. Pediatric dose:

• Amikacin

• Neonates age 0–7 days: 15–20 mg/kg/day q12h
• Neonates age 8–28 days: 30 mg/kg/day q8h
• Infants and children: 20–30 mg/kg/day q8h

• Ampicillin

• Neonates age 0–7 days: 150 mg/kg/day q8h
• Neonates age 8–28 days: 200 mg/kg/day q6–8h
• Infants and children: 300 mg/kg/day q6h

• Cefepime

• Infants and children: 150 mg/kg/day q8h

• Cefotaxime

• Neonates age 0–7 days: 100–150 mg/kg/day q8–12h
• Neonates age 8–28 days: 150–200 mg/kg/day q6–8h
• Infants and children: 225–300 mg/kg/day q6–8h

• Ceftazidime

• Neonates age 0–7 days: 100–150 mg/kg/day q8–12h
• Neonates age 8–28 days: 150 mg/kg q8h
• Infants and children: 150 mg/kg

• Ceftriaxone

• Infants and children: 80–100 mg/kg/day q12–24h

• Chloramphenicol

• Neonates age 0–7 days: 25 mg/kg/day q24h
• Neonates age 8–28 days: 50 mg/kg/day q12–24h
• Infants and children: 75–100 mg/kg/day q6h

• Gentamicin

• Neonates age 0–7 days: 5 mg/kg/day q12h
• Neonates age 8–28 days: 7.5 mg/kg/day q8h
• Infants and children: 7.5 mg/kg/day q8h

• Meropenem

• Infants and children: 120 mg/kg/day q8h

• Nafcillin

• Neonates age 0–7 days: 75 mg/kg/day q8–12h
• Neonates age 8–28 days: 100–150 mg/kg/day q6–8h
• Infants and children: 200 mg/kg/day q6h

• Oxacillin

• Neonates age 0–7 days: 75 mg/kg/day q8–12h
• Neonates age 8–28 days: 150–200 mg/kg/day q6–8h
• Infants and children: 200 mg/kg/day q6h

• Penicillin G

• Neonates age 0–7 days: 0.15 MU/kg/day q8–12h
• Neonates age 8–28 days: 0.2 MU/kg/day q6–8h
• Infants and children: 0.3 MU/kg/day q4–6h

• Rifampin

• Neonates age 8–28 days: 10–20 mg/kg/day q12h
• Infants and children: 10–20 mg/kg/day q12–24h

• Tobramycin

• Neonates age 0–7 days: 5 mg/kg/day q12h
• Neonates age 8–28 days: 7.5 mg/kg/day q8h
• Infants and children: 7.5 mg/kg/day q8h

• Trimethoprim-Sulfamethoxazole

• Infants and children: 10–20 mg/kg q6–12h

• Vancomycin

• Neonates age 0–7 days: 20–30 mg/kg/day q8–12h
• Neonates age 8–28 days: 30–45 mg/kg/day q6–8h
• Infants and children: 60 mg/kg/day q6h

References

Meningitis, tuberculous ⇧ Return to Top ⇧

• Tuberculous meningitis (TB meningitis)

• First-line therapy (dosing information: [7][8][9])

• Isoniazid
• Rifampin
• Rifabutin
• Pyrazinamide
• Ethambutol

• Second-line therapy (dosing information: [10][11][12])

• Cycloserine
• Ethionamide
• Streptomycin
• Amikacin
• Kanamycin
• Capreomycin
• p-Aminosalicylic acid
• Levofloxacin
• Moxifloxacin
• Gatifloxacin

• Tuberculous meningitis caused by susceptible Mycobacterium tuberculosis

• Intensive phase (adult)

• Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) for 2 months AND Rifampin 10 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months

• Continuation phase (adult)

• Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) for 7–10 months AND Rifampin 10 mg/kg (max: 600 mg) for 7–10 months

• Intensive phase (pediatric)

• Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 2 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months

• Continuation phase (pediatric)

• Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 7–10 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 7–10 months

Note (1): World Health Organization guidelines recommend that Ethambutol should be replaced by Streptomycin (contraindicated in pregnancy) in tuberculous meningitis.

Note (2): A 9– to 12–month course of treatment is recommended for tuberculous meningitis.

Note (3): Adjuvant Dexamethasone 0.3–0.4 mg/kg/day (max: 24 mg) is recommended unless drug resistance is suspected.

Note (4): Liaise with microbiology laboratory about genotype testing for drug resistance if there is high risk for MDR-TB.

• Tuberculous meningitis caused by Mycobacterium tuberculosis resistant to isoniazid or rifampin

• Isoniazid monoresistance

• Substitute fluoroquinolone for isoniazid in intensive phase regimen.
• Continue treatment with rifampin, pyrazinamide, and fluoroquinolone for 12 months.

• Rifampin monoresistance

• Substitute Fluoroquinolones for Rifampin in intensive phase regimen.
• Continue treatment with isoniazid, pyrazinamide, and fluoroquinolone for 18 months.

• MDR-TB (resistant to Isoniazid and Rifampin)

• MDR tuberculosis therapy should be considered if there is a history of prior tuberculosis treatment, contact with a patient with MDR tuberculosis, or a poor clinical response to first-line TB therapy within 2 weeks despite a firm diagnosis and an adequate adherence to treatment.
• Second-line agents such as Aminoglycosides penetrate the BBB only in the presence of inflamed meninges, and Fluoroquinolones, while able to penetrate into the CNS, have lower CSF levels than in the serum or brain parenchyma.
• Consult infectious disease specialist.

• XDR-TB (resistant to Isoniazid, Rifampin, Fluoroquinolones, and either Capreomycin, Kanamycin, or Amikacin)

• Consider Ethionamide or Cycloserine to build the treatment regimen.
• Consult infectious disease specialist.

References

Meningitis, parasitic ⇧ Return to Top ⇧

• Meningitis, parasitic

• 1. Protozoal meningitis

• 1.1 Naegleria fowleri (primary amebic meningoencephalitis)

• Preferred regimen: (Amphotericin B 1.5 mg/kg/day IV q12h for 3 days, followed by Amphotericin B 1 mg/kg/day IV q24h for 11 days) AND (Amphotericin B 1.5 mg/kg/day intrathecal q24h for 2 days, followed by Amphotericin B 1 mg/kg/day intrathecal qod for 8 days) AND Azithromycin 10 mg/kg/day IV/PO q24h for 28 days AND Fluconazole 10 mg/kg/day IV/PO q24h for 28 days AND Rifampin 10 mg/kg/day IV/PO q24h for 28 days AND Miltefosine 50 mg PO bid–tid for 28 days AND Dexamethasone 0.15 mg/kg IV q6h for 4 days

• 1.2 Toxoplasma gondii

• Preferred regimen: Sulfadiazine 4–6 g/day q6h AND Pyrimethamine 25–100 mg/day qd
• Alternative regimen (1): Pyrimethamine 25–100 mg/day qd AND Clindamycin 2400–4800 mg/day IV q6h
• Alternative regimen (2): Pyrimethamine 25–100 mg/day qd AND (Azithromycin 1200–1500 mg/day IV q24h OR Atovaquone 750 mg IV q6h OR Dapsone 100 mg PO q24h)
• Alternative regimen (3): TMP-SMZ 10–20 mg/kg/day q6–12h

• 2. Helminthic meningitis

• 2.1 Angiostrongylus cantonensis

• Preferred regimen: Albendazole 15–20 mg/kg/day PO qd–bid for 10–20 days AND Dexamethasone 10–20 mg PO qd for 10–20 days
• Alternative regimen: Mebendazole 100 mg PO bid for 10–20 days AND Dexamethasone 10–20 mg PO qd for 10–20 days

• 2.2 Baylisascaris procyonis

• Preferred regimen: Albendazole 25–50 mg/kg PO qd or 400 mg PO bid for 10 days AND Dexamethasone 10–20 mg PO qd for 10 days
• Alternative regimen: Thiabendazole 50 mg/kg/day PO bid for 10 days AND Dexamethasone 10–20 mg PO qd for 10 days

• 2.3 Gnathostoma spinigerum

• Preferred regimen: Albendazole 400 mg PO bid for 3 weeks AND Dexamethasone 10–20 mg PO qd for 3 weeks
• Alternative regimen: Ivermectin 0.2 mg/kg PO qd for 2 days AND Dexamethasone 10–20 mg PO qd for 3 weeks

References

Meningitis, fungal ⇧ Return to Top ⇧

• Fungal meningitis

• 1. Blastomyces dermatitidis

• Preferred regimen: Liposomal Amphotericin B 5 mg/kg/day IV for 4–6 weeks, followed by Fluconazole 800 mg PO qd OR Itraconazole 200 mg PO bid–tid OR Voriconazole 200–400 mg PO bid for ≥12 months until CSF abnl resolves

• 2. Candida spp.

• Preferred regimen: Liposomal Amphotericin B 3–5 mg/kg/day IV ± Flucytosine 25 mg/kg PO qid for several weeks, followed by Fluconazole 400–800 mg (6–12 mg/kg) PO qd until CSF abnl resolves
• Alternative regimen: Fluconazole 400–800 mg PO qd (6–12 mg/kg IV q24h) OR Voriconazole 400 mg PO bid for 2 doses, followed by 200 mg PO bid OR Voriconazole 6 mg/kg IV q12h for 2 doses, followed by 3 mg/kg IV q12h

Note: Removal of intraventricular devices is recommended.

• 3. Coccidioides immitis

• Preferred regimen: Fluconazole 400 mg PO qd
• Alternative regimen: Itraconazole 200 mg PO bid–tid

• 4. Cryptococcus neoformans

• 4.1 Non–HIV/AIDS hosts, non–transplant recipients

• Induction therapy: (Amphotericin B 0.7–1.0 mg/kg IV q24h for 4–6 weeks OR Liposomal Amphotericin B 3–4 mg/kg IV q24h for 4–6 weeks OR Amphotericin B lipid complex 5 mg/kg IV q24h for 4–6 weeks) AND Flucytosine 25 mg/kg PO q6h for 4–6 weeks
• Consolidation therapy: Fluconazole 400–800 mg PO q24h for 8 weeks
• Maintenance therapy: Fluconazole 200 mg PO q24h for 6–12 months

• 4.2 HIV/AIDS hosts

• Induction therapy (1): (Amphotericin B 0.7–1.0 mg/kg IV q24h for ≥ 2 weeks OR Liposomal Amphotericin B 3–4 mg/kg IV q24h for ≥ 2 weeks OR Amphotericin B lipid complex 5 mg/kg IV q24h for ≥ 2 weeks) AND Flucytosine 25 mg/kg PO q6h for ≥ 2 weeks
• Induction therapy (2): Amphotericin B 0.7–1.0 mg/kg IV q24h for 4–6 weeks OR Liposomal Amphotericin B 3–4 mg/kg IV q24h for 4–6 weeks OR Amphotericin B lipid complex 5 mg/kg IV q24h for 4–6 weeks
• Induction therapy (3): Amphotericin B 0.7–1.0 mg/kg IV q24h for 2 weeks AND Fluconazole 800 mg PO q24h for 2 weeks
• Induction therapy (4): Fluconazole 1200 mg PO q24h for 6 weeks AND Flucytosine 100 mg/kg PO q24h for 6 weeks
• Induction therapy (5): Fluconazole 800–2000 mg PO q24h for 10–12 weeks
• Induction therapy (6): Itraconazole 200 mg PO q12h for 10–12 weeks
• Consolidation therapy: Fluconazole 400 mg PO q24h for 8 weeks
• Maintenance therapy: Fluconazole 200 mg PO q24h for ≥ 1 year OR Itraconazole 400 mg PO q24h for ≥ 1 year OR Amphotericin B 1.0 mg/kg/week IV for ≥ 1 year

• 4.3 Transplant recipients

• Induction therapy (1): (Liposomal Amphotericin B 3–4 mg/kg IV q24h for ≥ 2 weeks OR Amphotericin B lipid complex 5 mg/kg IV q24h for ≥ 2 weeks) AND Flucytosine 25 mg/kg PO q6h for ≥ 2 weeks
• Induction therapy (2): Liposomal Amphotericin B 3–4 mg/kg IV q24h for 4–6 weeks OR Amphotericin B lipid complex 5 mg/kg IV q24h for 4–6 weeks
• Consolidation therapy: Fluconazole 400–800 mg PO q24h for 8 weeks
• Maintenance therapy: Fluconazole 200–400 mg PO q24h for 6–12 months

• 5. Histoplasma capsulatum

• Preferred regimen: Liposomal Amphotericin B 5 mg/kg IV q24h for 4–6 weeks, followed by Itraconazole 200 mg PO bid–tid for ≥ 12 months

Meningitis, viral ⇧ Return to Top ⇧

• Viral meningitis

• 1. Chronic enterovirus meningoencephalitis

• Preferred regimen: supportive care ± Pleconaril (investigational)

• 2. HSV-2 meningitis

• Preferred regimen: supportive care AND Acyclovir 10 mg/kg IV q8h for 10–14 days, followed by Valacyclovir 1 g PO tid

• 3. Mollaret's meningitis

• Preferred regimen: supportive care AND Acyclovir 400 mg bid–tid OR Famciclovir 250 mg PO bid OR Valacyclovir 500 mg PO qd

• 4. VZV meningitis

• Preferred regimen: supportive care AND Acyclovir 10 mg/kg IV q8h for 10–14 days, followed by Valacyclovir 1 g PO tid

References

Septic thrombosis of cavernous or dural venous sinus ⇧ Return to Top ⇧

• Cavernous sinus thrombosis is considered a medical emergency.
• Duration of therapy is usually a total of 3-4 weeks. More prolonged administration of antimicrobial therapy (total of 6-8 weeks) may be indicated among patients who are suspected to have developed complications (e.g. suppurative intracranial disease).
• ENT surgery must be consulted to evaluate the need of surgical drainage (e.g. sphenoidotomy if sphenoid sinus infection is the primary cause).
• Septic thrombosis of cavernous or dural venous sinus

• 1. Empiric antimicrobial therapy

• Preferred regimen: (Vancomycin 30–45 mg/kg IV q8–12h for 3-4 weeks OR Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks) AND (Ceftriaxone 2 g IV q12h for 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h 3-4 weeks

Note (1): If risk of MRSA is high, Vancomycin should be administered instead of either nafcillin or oxacillin

Note (2): The optimal duration of therapy remains unclear

• 2. Specific anatomic considerations

• 2.1 Cavernous sinus

• Preferred regimen: Vancomycin 30–45 mg/kg IV q8–12h for 3-4 weeks AND (Ceftriaxone 2 g IV q12h for 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h for 3-4 weeks

Note: Daptomycin 8–12 mg/kg IV q24h OR Linezolid 600 mg IV q12h could be considered for patients unable to tolerate vancomycin

• 2.2 Lateral sinus

• Preferred regimen: Cefepime 2 g IV q8h for 3-4 weeks AND Metronidazole 500 mg IV q8h for 3-4 weeks AND Vancomycin 15-20 IV mg/kg for 3-4 weeks
• Alternative regimen: Meropenem 1-2 g IV q8h 3-4 weeks AND Linezolid 600 mg IV q12h 3-4 weeks

• 2.3 Superior sagittal sinus

• Preferred regimen: Ceftriaxone 2 g IV q12h for 3-4 weeks AND Vancomycin 15–20 mg/kg for 3-4 weeks AND Dexamethasone 10 mg IV q6h continued until symptomatic improvement and tailed gradually over several weeks
• Alternative regimen: Meropenem 1–2 g IV q8h for 3-4 weeks AND Vancomycin 15–20 mg/kg for 3-4 weeks AND Dexamethasone 10 mg IV q6h continued until symptomatic improvement and tailed gradually over several weeks

• 3. Pathogen-directed antimicrobial therapy

• Staphylococcus aureus, methicillin-resistant (MRSA)

• Preferred regimen: Vancomycin 15–20 mg/kg/dose IV q8–12h for 4–6 weeks
• Alternative regimen: Linezolid 600 mg PO/IV q12h for 4–6 weeks OR TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
• Pediatric dose: Vancomycin 15 mg/kg/dose IV q6h 4–6 weeks OR Linezolid 10 mg/kg/dose PO/IV q8h 4–6 weeks
• Note (1): Surgical evaluation for incision and drainage of contiguous sites of infection or abscess is recommended whenever possible
• Note (2): Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin

Subdural empyema ⇧ Return to Top ⇧

• Subdural empyema

• Empiric antimicrobial therapy

• Metronidazole is recommended if anaerobes are suspected. Metronidazole is not necessary for antianaerobic activity if Meropenem is used.
• For coverage of aerobic Gram-negative bacilli, empiric therapy with Cefepime, Ceftazidime, or Meropenem is appropriate.
• Depending on the clinical response, parenteral antimicrobial therapy should be administered for 3 to 4 weeks after drainage. Parenteral or oral therapy is frequently continued for up to a total of 6 weeks of therapy.
• A longer course of treatment (minimum of 6–8 weeks) may be required if the patient has accompanying osteomyelitis.
• Consider adjunctive medications including prophylactic anticonvulsants, corticosteroids, and mannitol if clinically indicated.

• Intracranial subdural empyema with unclear source of infection

• Preferred regimen: (Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks) AND (Ceftriaxone 2 g IV q12h for 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h for 3-4 weeks
• Note: Vancomycin 30–45 mg/kg/day IV q8–12h should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Intracranial subdural empyema associated with sinusitis or otitis media

• Preferred regimen: (Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks) AND (Ceftriaxone 2 g IV q12h for 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h for 3-4 weeks
• Note: Vancomycin 30–45 mg/kg/day IV q8–12h should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Intracranial subdural empyema after cranial trauma

• Preferred regimen: Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks
• Note: Vancomycin should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Intracranial subdural empyema after neurosurgical procedures

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 3-4 weeks AND Ceftazidime 2 g IV q8h for 3-4 weeks

• Intracranial subdural empyema in neonates (usually associated with meningitis)

• Infants < 1 month

• Preferred regimen: Ampicillin 200 mg/kg/day IV q4h for 3-4 weeks AND Cefotaxime 200 mg/kg/day IV q6h for 3-4 weeks

• Infants 1–3 months

• Preferred regimen: Ampicillin 200 mg/kg/day IV q4h for 3-4 weeks AND (Cefotaxime 200 mg/kg/day IV q6h for 3-4 weeks OR Ceftriaxone 100 mg/kg/day IV q12h for 3-4 weeks)

• Infants > 3 months

• Preferred regimen: Vancomycin 60 mg/kg/day IV q6h for 3-4 weeks AND (Cefotaxime 200 mg/kg/day IV q6h for 3-4 weeksOR Ceftriaxone 100 mg/kg/day IV q12h for 3-4 weeks OR Cefepime 150 mg/kg/day IV q8h for 3-4 weeks)

• Spinal subdural empyema

• Preferred regimen: Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks
• Note: Vancomycin 30–45 mg/kg/day IV q8–12h should be used in place of nafcillin or oxacillin if MRSA is suspected or if penicillin allergy is present.

• Pathogen-directed antimicrobial therapy

• Staphylococcus aureus, methicillin-resistant (MRSA)

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 4–6 weeks
• Alternative regimen: Linezolid 600 mg PO/IV q12h for 4–6 weeks OR TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
• Pediatric dose: Vancomycin 15 mg/kg/dose IV q6h OR Linezolid 10 mg/kg/dose PO/IV q8h
• Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin therapy.