Bacterial meningitis early management

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

EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. (DO NOT EDIT)

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Early Management of Acute Bacterial Meningitis (ABM) The Task Force recommends that all patients with suspected ABM should be hospitalized as soon as possible [IIIA]. Care of patients with suspected ABM should be considered as an emergency and fast-tracked for rapid assessment and treatment. The following timeline for management of ABM is proposed: admission to hospital within first 90 minutes (min) of making contact with health service; and assessment and treatment commenced within 60 min of hospital admission, and no longer than 3 hours (h) after contact with health service [IVC]. Pre-hospital antibiotic treatment should only be initiated for patients with strong suspicion of disseminated meningococcal infection (meningococcemia) because of the unpredictable risk of early circulatory collapse from adrenocortical necrosis (Waterhouse–Friderichsen syndrome). For other patients, rapid preadmission antibiotic therapy should be considered only if a delay in excess of 90 min in hospital transfer is anticipated [IIIC]. Lumbar puncture (LP) and cerebrospinal fluid (CSF) analysis is the specific investigation required for diagnosis and management of ABM. Therefore, if diagnosis of bacterial meningitis is suspected and there are no clinical contraindications, LP should be performed as soon as safely possible [IIIC]. In patients with symptoms and signs suggestive of raised intracranial pressure or with high risk of cerebral herniations following LP (imaging evidence of intracranial mass lesion, obstructive hydrocephalus or midline shift), diagnostic LP should be postponed [IA]. In a patient with suspected ABM in whom LP is being delayed or postponed, antibiotic therapy should be commenced immediately after collecting blood sample for culture. Intravenous (IV) or intramuscular (IM) Benzyl Penicillin, or IV Cefotaxime or Ceftriaxone should be administered as empirical therapy for ABM and may be commenced immediately [IIIA]. In patients with known history of severe beta-lactam allergy, vancomycin should be administered as the alternative for pneumococcal meningitis and chloramphenicol for meningococcal meningitis [IVC]. In regions with known or suspected penicillin-resistant strains of pneumococcus, high dose vancomycin should be used in combination with a third-generation cephalosporin [IVC]. Patients with risk factors for Listerial meningitis (old age, immunosuppressed and/or signs of rhombencephalitis) should receive IV amoxicillin in addition to a third-generation cephalosporin as the empirical treatment of ABM initially [IVC]. Dexamethasone in high doses may be appropriate as an adjunctive therapy and should be given shortly before or with the first dose of antibiotics. All ABM patients should be managed as medical emergencies and when available, treated in neurological intensive care units.

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EFNS guideline on the Empirical Antibiotic Therapy in Suspected ABM of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. (DO NOT EDIT)

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Specific Antibiotic Treatment Initial antibiotic treatment of ABM should be parenteral [IA]. Empirical Antibiotic Therapy in Suspected ABM Ceftriaxone 2 g 12 to 24 hourly or Cefotaxime 2 g 6 to 8 hourly [IIIB] Alternative therapy: Meropenem 2 g 8 hourly [IIIC] or Chloramphenicol 1 g 6 hourly. If penicillin or cephalosporin-resistant pneumococcus is suspected, use Ceftriaxone or Cefotaxime plus Vancomycin 60 mg/kg/24 hourly (adjusted for creatinine clearance) after loading dose of 15 mg/kg [IVA]. Ampicillin/Amoxicillin 2 g 4 hourly if Listeria is suspected [IVA]

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EFNS guideline on the Pathogen Specific Antibiotic Therapy in Suspected ABM: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. (DO NOT EDIT)

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Pathogen Specific Antibiotic Therapy in Suspected ABM Pneumococcal meningitis Penicillin-sensitive Pneumococcal meningitis (and including other sensitive Streptococcal species): Benzyl Penicillin 250,000 Units/kg/day (equivalent to 2.4 g 4 hourly) [IVA] or Ampicillin/Amoxicillin 2 g 4 hourly or Ceftriaxone 2 g 12 hourly or Cefotaxime 2 g 6 to 8 hourly. Alternative therapy: Meropenem 2 g 8 hourly [IVC] or Vancomycin 60 mg/kg 24 hourly as continuous infusion (adjusted for creatinine clearance) after 15 mg/kg loading dose aiming for serum levels of 15 to 25 mg/l) plus Rifampicin 600 mg 12 hourly [IVC] or, Moxifloxacin 400 mg daily [IVC] Pneumococcus with reduced susceptibility to penicillin or cephalosporins: Ceftriaxone or Cefotaxime plus Vancomycin ± Rifampicin [IV]. Alternative therapy: Moxifloxacin, Meropenem or Linezolid 600 mg combined with Rifampicin [IV] Meningococcal meningitis Meningococcal meningitis: Benzyl Penicillin or Ceftriaxone or Cefotaxime [IV]. Alternative therapy: Meropenem or Chloramphenicol or Moxifloxacin [IVC] Haemophilus influenzae type B (Hib) Haemophilus influenzae type B (Hib): Ceftriaxone or Cefotaxime [IVC]. Alternative therapy: IV Chloramphenicol–Ampicillin/ Amoxicillin [IVC] Listerial meningitis Listerial meningitis: Ampicillin or Amoxicillin 2 g 4 hourly ± Gentamicin 1 to 2 mg 8 hourly for the first 7 to 10 days [IVC]. Alternative therapy: Trimethoprim–Sulfamethoxazole 10 to 20 mg/kg 6 to 12 hourly or Meropenem [IV] Staphylococcal species Staphylococcal species: Flucloxacillin 2 g 4 hourly [IV] or Vancomycin if penicillin allergy is suspected [IV]. Rifampicin should also be considered in addition to either agent, and Linezolid for methicillin-resistant staphylococcal meningitis [IVC]. Gram-negative Enterobacteriaceae Gram-negative Enterobacteriaceae: Ceftriaxone or Cefotaxime or Meropenem Pseudomonal meningitis Pseudomonal meningitis: Meropenem ± Gentamicin

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EFNS guideline on the Pathogen Specific Antibiotic Therapy in Suspected ABM Duration of Therapy: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. (DO NOT EDIT)

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Duration of Therapy Unspecified bacterial meningitis: 10 to 14 days [IVC] Pneumococcal meningitis: 10 to 14 days [IVA] Meningococcal meningitis: 5 to 7 days [IVA] Hib meningitis: 7 to 14 days [IVB] Listerial meningitis: 21 days [IVB] Gram-negative bacillary and Pseudomonal meningitis: 21 to 28 days [IVB]

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EFNS guideline on Adjunctive Therapy of ABM: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. (DO NOT EDIT)

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Adjunctive Therapy of ABM Adjuvant dexamethasone is recommended with or shortly before the first parenteral dose of antibiotic in all previously well and non-immunosuppressed adults with pneumococcal meningitis at a dose of 10 mg every 6 hours for 4 days [IA] and children at a dose of 0.15 mg/kg every 6 hours for 4 days for Hib and pneumococcal meningitis [IA]. In all patients with clinically suspected pneumococcal (or Hib) meningitis (early focal neurological signs), the Task Force recommends that dexamethasone is given with the first dose of empirical antibiotic therapy as above [IVC]. In ABM because of other bacterial etiology, routine use of high dose dexamethasone is not presently recommended [IA]. If dexamethasone was initiated on clinical suspicion of ABM, which was subsequently proven to be inaccurate by CSF microbiology, the treatment should be promptly withdrawn. There is insufficient evidence to recommend the use of dexamethasone in pharmacological doses after antibiotic therapy has begun. Dose and duration of therapy with corticosteroids in such cases should be guided by specific clinical indications in individual patients (e.g., physiological doses of steroids in cases of adrenal insufficiency because of meningococcemia, pharmacological doses of steroids for raised intracranial pressure). By reducing subarachnoid space inflammation and blood brain barrier permeability, steroids may lower CSF penetration of antibiotics and patients receiving vancomycin for penicillin-resistant pneumococcal meningitis require close clinical and CSF monitoring.

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EFNS guideline on Adjunctive Therapy of ABM: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. (DO NOT EDIT)

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Other Symptomatic and Adjunctive Therapies Circulatory shock as part of severe sepsis or in meningococcemia should be handled in neurointensive care unit. Treatment should consist of a 30 degree head-up position, head midline, minimal suction, deep sedation, normo- or moderate hypothermia and strict avoidance of hypercapnia (Nadel and Kroll, 2007). Head elevation and hyperosmolar agents are recommended for the management of cerebral oedema but have never been systematically evaluated in the context of bacterial meningitis. As a hyperosmolar agent, 20% mannitol may be given intravenously either as a bolus injection of 1 g/kg over 10 to 15 min, repeated at 4 to 6 hour intervals, or in smaller but frequent doses (0.25 mg/kg every 2 to 3 hours), to maintain a target serum osmolality of 315 to 320 mOsm/l [IVC]. CSF pressure monitoring may be helpful in cases where CSF drainage (ventricular) is under consideration for obstructive hydrocephalus, and the decision to perform the procedure should be based on patient's level of consciousness and the degree of ventricular dilatation visualized in brain imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) [IVC]. Seizures are frequent in ABM and are associated with severe inflammation, structural brain lesion and pneumococcal meningitis may increase mortality (Zoons et al., 2008) and should be treated with a parenteral anticonvulsant, such as phenytoin (fosphenytoin) [IIIB]. Prophylactic anticoagulation to prevent deep vein thrombosis may be considered in patients who do not have coagulopathy and are considered to be at a high risk of deep vein thrombosis (e.g., obesity and recent hip surgery). Heparin was considered beneficial in a retrospective study of patients with septic cavernous sinus thrombosis; however, experience with therapeutic anticoagulation for venous sinus thrombosis in ABM is limited and is best reserved for patients who deteriorate neurologically because of venous sinus thrombosis and require close monitoring of coagulation profile and brain imaging

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References

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