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Classification Viral Meningitis Bacterial Meningitis Fungal Meningitis
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Streptococcus pneumoniae

Penicillin MIC ≤0.06 μg/mL Preferred Regimen ▸ Penicillin G Low: 600,000–1.2 million units/day IM; High:≥ 20 million units IV q24h(=12 g) OR ▸ Ampicillin 150–200 mg/kg IV q3-4h Alternative Regimen ▸ Cefotaxime 1 g q8–12h to 2 g IV q4h OR ▸ Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine) OR ▸ Chloramphenicol 0.25–1 g po IV q6h to max. of 4 g/day

Penicillin MIC ≥0.12 μg/mL Cefotaxime or Ceftriaxone MIC† <1.0 μg/mL Preferred Regimen ▸ Cefotaxime 1 g q8–12h to 2 g IV q4h OR ▸ Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine) Alternative Regimen ▸ Cefepime 1–2 g IV q12h OR ▸ Meropenem 2 g IV q8h Cefotaxime or Ceftriaxone MIC† >1.0 μg/mL Preferred Regimen ▸ Vancomycin give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. ) AND ▸ Cefotaxime 1 g q8–12h to 2 g IV q4h OR ▸ Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine)‡ Alternative Regimen ▸ Vancomycin give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. ) AND ▸ Moxifloxacin 400 mg po IV q24h ɸ

Neisseria meningitidis

Neisseria meningitidis Penicillin MIC <0.1 μg/mL Preferred Regimen ▸ Penicillin G Low: 600,000–1.2 million units/day IM ;High:≥ 20 million units IV q24h(=12 g) OR ▸ Ampicillin 0.25–0.5 g po q6h.150–200 mg/kg/day IV Alternative Regimen ▸ Cefotaxime 1 g q8–12h to 2 g IV q4h OR ▸ Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine) OR ▸ Chloramphenicol 0.25–1 g po IV q6h to max. of 4 g/day

Neisseria meningitidis Penicillin MIC ≥0.1 μg/mL Preferred Regimen ▸ Cefotaxime 1 g q8–12h to 2 g IV q4h OR ▸ Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine) Alternative Regimen ▸ Cefepime 1–2 g IV q12h OR ▸ Chloramphenicol 0.25–1 g po IV q6h to max. of 4 g/day OR ▸ Fluoroquinolone OR ▸ Meropenem 2 g IV q8h

Listeria Monocytogenes and Streptococcus agalactiae

Listeria Monocytogenes Preferred Regimen ▸ Ampicillin 0.25–0.5 g po q6h.150–200 mg/kg/day IV OR ▸ Penicillin G Low: 600,000–1.2 million units/day IM ;High:≥ 20 million units IV q24h(=12 g)£ Alternative Regimen ▸ Trimethoprim-sulfamethoxazole 5–20 mg/kg/day q6-12h

Streptococcus agalactiae Preferred Regimen ▸ Ampicillin 0.25–0.5 g po q6h.150–200 mg/kg/day IV OR ▸ Penicillin G Low: 600,000–1.2 million units/day IM ;High:≥ 20 million units IV q24h(=12 g)£ Alternative Regimen ▸ Cefotaxime 1 g q8–12h to 2 g IV q4h OR ▸ Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine) OR ▸ Vancomycin give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. )

Haemophilus influenzae

Haemophilus influenzae β-lactamase negative Preferred Regimen (Adult) ▸ Ampicillin 0.25–0.5 g po q6h.150–200 mg/kg/day IV Alternative Regimen (Adult) ▸ Cefotaxime 1 g q8–12h to 2 g IV q4h OR ▸ Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine) OR ▸ Cefepime 1–2 g IV q12h OR ▸ Chloramphenicol 0.25–1 g po IV q6h to max. of 4 g/day OR ▸ Aztreonam 1 g q8h–2 g IV q6h OR ▸ Fluoroquinolone β-lactamase negative, ampicillin resistant Preferred Regimen ▸ Meropenem 2 g IV q8h Alternative Regimen ▸ Fluoroquinolone

Haemophilus influenzae β-lactamase positive Preferred Regimen ▸ Cefotaxime 1 g q8–12h to 2 g IV q4h OR ▸ Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine) Alternative Regimen ▸ Cefepime 1–2 g IV q12h OR ▸ Chloramphenicol 0.25–1 g po IV q6h to max. of 4 g/day OR ▸ Aztreonam 1 g q8h–2 g IV q6h OR ▸ Fluoroquinolone

Staphylococcus aureus

Staphylococcus aureus Meticillin sensitive Preferred Regimen ▸ Nafcillin 1–2 g IV/IM q4h OR ▸ Oxacillin 1–2 g IV/IM q4h Alternative Regimen ▸ Vancomycin give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. ) OR ▸ linezolid 600 mg IV/PO q12h OR ▸ Daptomycin 6 mg/kg IV q24h

Staphylococcus aureus Meticillin resistant₦ Preferred Regimen ▸ Vancomycin give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. ) Alternative Regimen ▸ Trimethoprim-sulfamethoxazole 5–20 mg/kg/day q6-12h OR ▸ linezolid 600 mg IV/PO q12h OR ▸ Daptomycin 6 mg/kg IV q24h

Staphylococcus epidermidis and Acinetobacter baumannii^Ω

Staphylococcus epidermidis₦ Preferred Regimen ▸ Vancomycin give loading dose of 25-30 mg/kg IV then 15-20 mg/kg IV q8-12h(Target trough level is 15-20 µg/mL. For individual doses over 1 gm, infuse over 1.5-2 hrs. ) Alternative Regimen ▸ Linezolid 600 mg IV/PO q12h Acinetobacter baumannii Preferred Regimen ▸ Meropenem 2 g IV q8h Alternative Regimen ▸ Colistin in US:2.5-5 mg/kg/day q6-12h( 6.7-13.3 mg/kg/day of colistimethate sodium (CMS),max 800 mg/day); Elsewhere: ≤60 kg, 50,000-75,000 IU/kg/day IV q8h (=4-6 mg/kg per day of CMS). >60 kg, 1-2 mill IU IV q8h (= 80-160 mg IV tid). OR ▸ Polymyxin B 15,000–25,000 units/kg/day q12hǂ Enterobacteriaceae and Pseudomonas aeruginosa EnterobacteriaceaeΩ Preferred Regimen ▸ Cefotaxime 1 g q8–12h to 2 g IV q4h OR ▸ Ceftriaxone 1 g IV qd (2 g IV q12h for Purulent meningitis also IM in 1% lidocaine) Alternative Regimen ▸ Aztreonam 1 g q8h–2 g IV q6h OR ▸ Fluoroquinolone OR ▸ Trimethoprim-sulfamethoxazole 5–20 mg/kg/day q6-12h OR ▸ Meropenem 2 g IV q8h OR ▸ Ampicillin 0.25–0.5 g po q6h.150–200 mg/kg/day IV Pseudomonas aeruginosa Preferred Regimen ▸ Ceftazidime 1–2 g IV/IM q8–12h OR ▸ Cefepime 1–2 g IV q12h£ Alternative Regimen ▸ Aztreonam 1 g q8h–2 g IV q6h OR ▸ Meropenem 2 g IV q8h OR ▸ Ciprofloxacin 500-750 mg po bid£ †MIC=minimum inhibitory concentration.‡Addition of rifampicin can be considered if the organism is susceptible, the expected clinical or bacteriological response is delayed, or the cefotaxime/ceftriaxone MIC of the pneumococcal isolate is >4·0 μg/mLorganism is susceptible, the expected clinical or bacteriological response is delayed, or the cefotaxime/ceftriaxone MIC.ΦNo clinical data exist for use of this agent in patients with pneumococcal meningitis; recommendation is based on cerebrospinal fl uid penetration and in-vitro activity against S pneumoniae.£Addition of an aminoglycoside should be considered; might need intraventricular or intrathecal administration in Gram-negative meningitis. ||Addition of rifampicin should be considered.Ω Choice of a specifi c agent should be based on in-vitro susceptibility testing. ††Might also need to be administered by the intraventricular or intrathecal routes. ǂ Might also need to be administered by the intraventricular or intrathecal routes. ₦ Addition of rifampicin should be considered.