Bacterial meningitis medical therapy: Difference between revisions
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==Medical therapy== | ==Medical therapy== | ||
==Principles of Therapy for Bacterial Meningitis== | |||
===Factors Determining Antimicrobial Activity=== | |||
* Factors determine the acitivity of antimicrobial agents include [[pharmacodynamics]], [[pharmacokinetics]], penetration into the CSF, and [[bactericidal]] activity within the CSF.<ref name="Andes-1999">{{Cite journal | last1 = Andes | first1 = DR. | last2 = Craig | first2 = WA. | title = Pharmacokinetics and pharmacodynamics of antibiotics in meningitis. | journal = Infect Dis Clin North Am | volume = 13 | issue = 3 | pages = 595-618 | month = Sep | year = 1999 | doi = | PMID = 10470557 }}</ref> | |||
* [[Beta-lactam]]s, [[aminoglycoside]]s, [[glycopeptide]]s, [[linezolid]], and [[daptomycin]] are considered to have poor penetration into the CSF, while [[fluoroquinolone]]s, [[chloramphenicol]], [[aztreonam]], and [[tigecycline]] generally achieve [[MIC|minimum inhibitory concentration (MIC)]] in the CSF at standard dosage.<ref name="Nau-2010">{{Cite journal | last1 = Nau | first1 = R. | last2 = Sörgel | first2 = F. | last3 = Eiffert | first3 = H. | title = Penetration of drugs through the blood-cerebrospinal fluid/blood-brain barrier for treatment of central nervous system infections. | journal = Clin Microbiol Rev | volume = 23 | issue = 4 | pages = 858-83 | month = Oct | year = 2010 | doi = 10.1128/CMR.00007-10 | PMID = 20930076 }}</ref> | |||
* [[Aminoglycoside]]s and [[fluoroquinolone]]s express a concentration-dependent manner of bactericidal activity; [[beta-lactam]]s typically follow a a time-dependent antimicrobial pattern (i.e., the activity is dependent on the time that CSF concentration exceeds [[MIC]] as a proportion of the dosing interval). | |||
* Penetration into the CSF is less prominent for drugs with a high [[molecular weight]], high protein-binding ability, low lipid solubility, and drugs that are subject to [[active transport]] in the [[choroid plexus]] such as [[penicillin]]s and [[cephalosporin]]s. Toxicity due to dose escalation may limit the usage the [[aminoglycoside]]s, [[glycopeptide]]s, and [[polymyxin]]s, thus [[intrathecal]] or [[intraventricular]] administration might be occasionally required (see table below). | |||
{| style="border: 2px solid #696969;" | |||
|+ <SMALL>''Recommended Doses of Antimicrobial Agents via the Intraventricular Route.''<ref name="van de Beek-2010">{{Cite journal | last1 = van de Beek | first1 = D. | last2 = Drake | first2 = JM. | last3 = Tunkel | first3 = AR. | title = Nosocomial bacterial meningitis. | journal = N Engl J Med | volume = 362 | issue = 2 | pages = 146-54 | month = Jan | year = 2010 | doi = 10.1056/NEJMra0804573 | PMID = 20071704 }}</ref><ref name="Rodríguez Guardado-2008">{{Cite journal | last1 = Rodríguez Guardado | first1 = A. | last2 = Blanco | first2 = A. | last3 = Asensi | first3 = V. | last4 = Pérez | first4 = F. | last5 = Rial | first5 = JC. | last6 = Pintado | first6 = V. | last7 = Bustillo | first7 = E. | last8 = Lantero | first8 = M. | last9 = Tenza | first9 = E. | title = Multidrug-resistant Acinetobacter meningitis in neurosurgical patients with intraventricular catheters: assessment of different treatments. | journal = J Antimicrob Chemother | volume = 61 | issue = 4 | pages = 908-13 | month = Apr | year = 2008 | doi = 10.1093/jac/dkn018 | PMID = 18281693 }}</ref><ref name="Cruciani-1992">{{Cite journal | last1 = Cruciani | first1 = M. | last2 = Navarra | first2 = A. | last3 = Di Perri | first3 = G. | last4 = Andreoni | first4 = M. | last5 = Danzi | first5 = MC. | last6 = Concia | first6 = E. | last7 = Bassetti | first7 = D. | title = Evaluation of intraventricular teicoplanin for the treatment of neurosurgical shunt infections. | journal = Clin Infect Dis | volume = 15 | issue = 2 | pages = 285-9 | month = Aug | year = 1992 | doi = | PMID = 1387805 }}</ref></SMALL> | |||
| style="background: #545454; border: 0px solid #696969; padding: 0 5px; width: 300px; color: #F8F8FF;"| '''Antimicrobial Agent''' || style="background: #545454; border: 0px solid #696969; padding: 0 5px; width: 300px; color: #F8F8FF;" | '''Daily Intraventricular Dose''' | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Vancomycin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''5—20 mg''''' | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Gentamicin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''4—8 mg''''' | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Tobramycin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''5—20 mg''''' | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Amikacin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''5—50 mg''''' | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Polymyxin B]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''5 mg''''' | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Colistin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''10 mg''''' | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Quinupristin dalfopristin|Quinupristin/Dalfopristin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''2—5 mg''''' | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Teicoplanin]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''5—40 mg''''' | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | ▸ '''''[[Amphotericin B]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''0.1—0.5 mg/day''''' | |||
|- | |||
|} | |||
==References== | ==References== | ||
Revision as of 16:29, 6 January 2017
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Bacterial meningitis Microchapters |
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Diagnosis |
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Treatment |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]
Overview
Acute bacterial meningitis is a medical emergency. Empiric antimicrobial therapy must be administered after obtaining blood and/or cerebrospinal fluid (CSF) cultures in cases of suspected meningitis. Once a bacterial etiology has been identified on a CSF Gram stain, treatment regimen should be individualized accordingly. Neither neuroimaging (such as CT scan and MRI) nor lumbar puncture should delay the administration of antimicrobial therapy. For neonates (age < 1 month), empirical antimicrobial therapy generally includes 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). For children older than 1 month and adults < 50 years, the preferred regimen is usually Vancomycin 30–45 mg/kg/day IV q8–12h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h). For adults ≥ 50 years of age, Ampicillin 12g/day IV q4h is added to the usual adult regimen. The duration of therapy is variable depending on the causative pathogen, but generally the duration is between 1-3 weeks. Adjunctive Dexamethasone at a dose of 0.15 mg/kg q6h for 2—4 days may be effective when administered early (0-20 minutes prior to administration of antimicrobial therapy) among pediatric patients with H. influenzae meningitis and among adults with S. pneumoniae meningitis.
Medical therapy
Principles of Therapy for Bacterial Meningitis
Factors Determining Antimicrobial Activity
- Factors determine the acitivity of antimicrobial agents include pharmacodynamics, pharmacokinetics, penetration into the CSF, and bactericidal activity within the CSF.[1]
- Beta-lactams, aminoglycosides, glycopeptides, linezolid, and daptomycin are considered to have poor penetration into the CSF, while fluoroquinolones, chloramphenicol, aztreonam, and tigecycline generally achieve minimum inhibitory concentration (MIC) in the CSF at standard dosage.[2]
- Aminoglycosides and fluoroquinolones express a concentration-dependent manner of bactericidal activity; beta-lactams typically follow a a time-dependent antimicrobial pattern (i.e., the activity is dependent on the time that CSF concentration exceeds MIC as a proportion of the dosing interval).
- Penetration into the CSF is less prominent for drugs with a high molecular weight, high protein-binding ability, low lipid solubility, and drugs that are subject to active transport in the choroid plexus such as penicillins and cephalosporins. Toxicity due to dose escalation may limit the usage the aminoglycosides, glycopeptides, and polymyxins, thus intrathecal or intraventricular administration might be occasionally required (see table below).
| Antimicrobial Agent | Daily Intraventricular Dose |
| ▸ Vancomycin | 5—20 mg |
| ▸ Gentamicin | 4—8 mg |
| ▸ Tobramycin | 5—20 mg |
| ▸ Amikacin | 5—50 mg |
| ▸ Polymyxin B | 5 mg |
| ▸ Colistin | 10 mg |
| ▸ Quinupristin/Dalfopristin | 2—5 mg |
| ▸ Teicoplanin | 5—40 mg |
| ▸ Amphotericin B | 0.1—0.5 mg/day |
References
- ↑ Andes, DR.; Craig, WA. (1999). "Pharmacokinetics and pharmacodynamics of antibiotics in meningitis". Infect Dis Clin North Am. 13 (3): 595–618. PMID 10470557. Unknown parameter
|month=ignored (help) - ↑ Nau, R.; Sörgel, F.; Eiffert, H. (2010). "Penetration of drugs through the blood-cerebrospinal fluid/blood-brain barrier for treatment of central nervous system infections". Clin Microbiol Rev. 23 (4): 858–83. doi:10.1128/CMR.00007-10. PMID 20930076. Unknown parameter
|month=ignored (help) - ↑ van de Beek, D.; Drake, JM.; Tunkel, AR. (2010). "Nosocomial bacterial meningitis". N Engl J Med. 362 (2): 146–54. doi:10.1056/NEJMra0804573. PMID 20071704. Unknown parameter
|month=ignored (help) - ↑ Rodríguez Guardado, A.; Blanco, A.; Asensi, V.; Pérez, F.; Rial, JC.; Pintado, V.; Bustillo, E.; Lantero, M.; Tenza, E. (2008). "Multidrug-resistant Acinetobacter meningitis in neurosurgical patients with intraventricular catheters: assessment of different treatments". J Antimicrob Chemother. 61 (4): 908–13. doi:10.1093/jac/dkn018. PMID 18281693. Unknown parameter
|month=ignored (help) - ↑ Cruciani, M.; Navarra, A.; Di Perri, G.; Andreoni, M.; Danzi, MC.; Concia, E.; Bassetti, D. (1992). "Evaluation of intraventricular teicoplanin for the treatment of neurosurgical shunt infections". Clin Infect Dis. 15 (2): 285–9. PMID 1387805. Unknown parameter
|month=ignored (help)