Sandbox ID Central Nervous System

Meningitis, bacteria

• Streptococcus pneumoniae (adult)

• Penicillin MIC

• <0.1 μg/mL

• Preferred regimen: Penicillin G 24 mU 6 times per day OR ampicillin 12g 6 times per day
• Alternative regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day OR chloramphenicol 4-6g qid

• 0.1–1.0 μg/mL

• Preferred regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day
• Alternative regimen: Cefepime 6g tid OR meropenem 6g tid

• ≥2.0 μg/mL

• Preferred regimen: Vancomycin 30–45 mg/kg tid/bid AND Ceftriaxone 4g bid/OD OR Vancomycin 30–45 mg/kg tid/bid AND cefotaxime 8-12g 4-6 times per day
• Alternative regimen: Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD

• Cefotaxime or ceftriaxone MIC ≥1.0 μg/mL

• Preferred regimen: Vancomycin 30–45 mg/kg tid/bid AND Ceftriaxone 4g bid/OD OR Vancomycin 30–45 mg/kg tid/bid AND cefotaxime 8-12g 4-6 times per day
• Alternative regimen: Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD

• Streptococcus pneumoniae (pediatric)

• Penicillin MIC

• <0.1 μg/mL

• Preferred regimen: Penicillin G 0.15 mU/kg tid/bid for 0-7 days neonates; 0.2 mU/kg tid/qid for 8-28 days neonates; 0.3 mU/kg 4-6 times per day for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
• Alternative regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children OR chloramphenicol 25 mg/kg OD for 0-7 days neonates; 50 mg/kg bid/OD for 8-28 days neonates; 75–100 mg/kg qid for children

• 0.1–1.0 μg/mL

• Preferred regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
• Alternative regimen: Cefepime 150 mg/kg tid for children OR meropenem 120 mg/kg tid for children

• ≥2.0 μg/mL

• Preferred regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND Ceftriaxone 80–100 mg/kg bid/OD for children OR Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
• Alternative regimen: Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD

• Cefotaxime or ceftriaxone MIC ≥1.0 μg/mL

• Preferred regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND Ceftriaxone 80–100 mg/kg bid/OD for children OR Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
• Alternative regimen: Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD

• Neisseria meningitidis (adult)

• Penicillin MIC

• <0.1 μg/mL

• Preferred regimen: Penicillin G 24 mU 6 times per day OR ampicillin 12g 6 times per day
• Alternative regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day OR chloramphenicol 4-6g qid

• 0.1–1.0 μg/mL

• Preferred regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day
• Alternative regimen: chloramphenicol 4-6g qid OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD OR meropenem 6g tid

• Neisseria meningitidis (pediatric)

• Penicillin MIC

• <0.1 μg/mL

• Preferred regimen: Penicillin G 0.15 mU/kg tid/bid for 0-7 days neonates; 0.2 mU/kg tid/qid for 8-28 days neonates; 0.3 mU/kg 4-6 times per day for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
• Alternative regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children

• 0.1–1.0 μg/mL

• Preferred regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
• Alternative regimen: chloramphenicol 25 mg/kg OD for 0-7 days neonates; 50 mg/kg bid/OD for 8-28 days neonates; 75–100 mg/kg qid for children OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD OR meropenem 120 mg/kg tid for children

• Listeria monocytogenes (adult)

• Preferred regimen: Penicillin G 24 mU 6 times per day OR ampicillin 12g 6 times per day
• Alternative regimen: Trimethoprim-sulfamethoxazole 10–20 mg/kg bid-qid {{or]} meropenem 6g tid

• Listeria monocytogenes (pediatric)

• Preferred regimen: Penicillin G 0.15 mU/kg tid/bid for 0-7 days neonates; 0.2 mU/kg tid/qid for 8-28 days neonates; 0.3 mU/kg 4-6 times per day for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
• Alternative regimen: Trimethoprim-sulfamethoxazole10–20 mg/kg bid-qid for children {{or]} meropenem 120 mg/kg tid for children

• Streptococcus agalactiae (adult)

• Preferred regimen: Penicillin G 24 mU 6 times per day OR ampicillin 12g 6 times per day
• Alternative regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day

• Streptococcus agalactiae (pediatric)

• Preferred regimen: Penicillin G 0.15 mU/kg tid/bid for 0-7 days neonates; 0.2 mU/kg tid/qid for 8-28 days neonates; 0.3 mU/kg 4-6 times per day for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
• Alternative regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children

• Escherichia coli and other Enterobacteriaceae (adult)

• Preferred regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day
• Alternative regimen: Aztreonam 6–8 g tid/qid OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD OR meropenem 6g tid OR Trimethoprim-sulfamethoxazole 10–20 mg/kg bid-qid {{or]} ampicillin 12g 6 times per day

• Escherichia coli and other Enterobacteriaceae (pediatric)

• Preferred regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
• Alternative regimen: Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD OR meropenem 120 mg/kg tid for children OR Trimethoprim-sulfamethoxazole10–20 mg/kg bid-qid for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children

• Pseudomonas aeruginosa (adult)

• Preferred regimen: Cefepime 6g tid OR ceftazidime 6g tid
• Alternative regimen: Aztreonam 6–8 g tid/qid OR ciprofloxacin 800–1200 mg bid/tid {or}} meropenem 6g tid

• Pseudomonas aeruginosa (pediatric)

• Preferred regimen: Cefepime 150 mg/kg tid for children OR ceftazidime 100–150 mg/kg tid/bid for 0-7 days neonates; 150 mg/kg tid for 8-28 days neonates; 150 mg/kg tid for children
• Alternative regimen: meropenem 120 mg/kg tid for children

• Haemophilus influenzae (adult)

• β-Lactamase negative

• Preferred regimen: ampicillin 12g 6 times per day
• Alternative regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day OR Cefepime 6g tid OR chloramphenicol 4-6g qid OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD

• β-Lactamase positive

• Preferred regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day
• Alternative regimen: Cefepime 6g tid OR chloramphenicol 4-6g qid OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD

• Haemophilus influenzae (pediatric)

• β-Lactamase negative

• Preferred regimen:ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
• Alternative regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children OR Cefepime 150 mg/kg tid for children OR chloramphenicol 25 mg/kg OD for 0-7 days neonates; 50 mg/kg bid/OD for 8-28 days neonates; 75–100 mg/kg qid for children OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD

• β-Lactamase positive

• Preferred regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
• Alternative regimen: Cefepime 150 mg/kg tid for children OR chloramphenicol 25 mg/kg OD for 0-7 days neonates; 50 mg/kg bid/OD for 8-28 days neonates; 75–100 mg/kg qid for children OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD

• Staphylococcus aureus (adult)

• Methicillin susceptible

• Preferred regimen: Nafcillin 9–12 g 6 times per day OR oxacillin 9–12 g 6 times per day
• Alternative regimen: Vancomycin 30–45 mg/kg tid/bid OR meropenem 6g tid

• Methicillin resistant

• Preferred regimen: Vancomycin 30–45 mg/kg tid/bid
• Alternative regimen: Trimethoprim-sulfamethoxazole 10–20 mg/kg bid-qid OR linezolid

• Staphylococcus aureus (pediatric)

• Methicillin susceptible

• Preferred regimen: Nafcillin 75 mg/kg bid/tid for 0-7 days neonates; 100–150 mg/kg tid/qid for 8-28 days neonates; 200 mg/kg qid for children OR oxacillin 75 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 200 mg/kg qid for children
• Alternative regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children OR meropenem 120 mg/kg tid for children

• Methicillin resistant

• Preferred regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children
• Alternative regimen: Trimethoprim-sulfamethoxazole 10–20 mg/kg bid-qid for children OR linezolid

• Staphylococcus epidermidis (adult)

• Preferred regimen: Vancomycin 30–45 mg/kg tid/bid
• Alternative regimen: Linezolid

• Staphylococcus epidermidis (pediatric)

• Preferred regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children
• Alternative regimen: Linezolid

• Enterococcus species (adult)

• Ampicillin susceptible

• Preferred regimen: ampicillin 12g 6 times per day AND gentamicin 5 mg/kg tid

• Ampicillin resistant

• Preferred regimen: Vancomycin 30–45 mg/kg tid/bid AND gentamicin 5 mg/kg tid

• Ampicillin and vancomycin resistant

• Preferred regimen: Linezolid

• Enterococcus species (pediatric)

• Ampicillin susceptible

• Preferred regimen: ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children AND gentamicin 5 mg/kg bid for 0-7 days neonates; 7.5 mg/kg tid for 8-28 days neonates; 7.5 mg/kg tid for children

• Ampicillin resistant

• Preferred regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND gentamicin 5 mg/kg bid for 0-7 days neonates; 7.5 mg/kg tid for 8-28 days neonates; 7.5 mg/kg tid for children

• Ampicillin and vancomycin resistant

• Preferred regimen: Linezolid

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Meningitis, MRSA

• Preferred regimen: Vancomycin 15–20 mg/kg/dose IV every 8–12 h for 2 weeks
• Alternative regimen: linezolid 600 mg PO/IV bid OR TMP-SMX 5 mg/kg/dose IV every 8–12 h
• Pediatric regimen: Vancomycin 15 mg/kg/dose IV every 6 h OR linezolid 10 mg/kg/dose PO/IV every 8 h

NOTE: Some experts recommend the addition of rifampin 600 mg QD or 300–450 mg BID to vancomycin for adult patients. For children >12 years of age, linezolid 600 mg BID

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Meningitis, tuberculous

• Preferred regimen: 2 months of Isoniazid 5 (4–6)mg/kg OD AND Rifampicin 10 (8–12)mg/kg OD AND Pyrazinamide 25 (20–30)mg/kg OD AND Streptomycin 15 (12–18)mg/kg OD followed by 7-10 months of Isoniazid 5 (4–6)mg/kg OD AND Rifampicin 10 (8–12)mg/kg OD
• Alternative regimen (1): 2 months of Isoniazid 5 (4–6)mg/kg OD AND Rifampicin 10 (8–12)mg/kg OD AND Pyrazinamide 25 (20–30)mg/kg OD AND Streptomycin 15 (12–18)mg/kg OD followed by 7-10 months of Isoniazid 10 (8–12)mg/kg 3 times per week AND Rifampicin 10 (8–12)mg/kg 3 times per week
• Alternative regimen (2): 2 months of Isoniazid 10 (8–12)mg/kg 3 times per week AND Rifampicin 10 (8–12)mg/kg 3 times per week AND Pyrazinamide 35 (30–40)mg/kg 3 times per week AND Streptomycina 15 (12–18)mg/kg 3 times per week followed by 7-10 months of Isoniazid 10 (8–12)mg/kg 3 times per week AND Rifampicin 10 (8–12)mg/kg 3 times per week

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Septic thrombosis of cavernous or dural venous sinus

Cavernous Sinus

• Preferred regimen: (Vancomycin 13-20mcg/ml AND ceftriaxone 2mg IV q12h) AND metronidazole 500mg IV q8h (if dental/sinus source)

• Alternative regimen: (Daptomycin 8-12mg/kg IV q24h OR Linezolid 600mg IV q12h) AND metronidazole 500mg IV q8h (if dental/sinus source)

Lateral Sinus

• Preferred regimen: cefepime 2mg IV q8h AND metronidazole 500mg IV q8h AND vancomycin 15-20 mcg/ml

• Alternative regimen: meropenem 1-2mg IV q8h AND Linezolid 600 mg IV q12h

Superior Sagittal Sinus

• Preferred regimen: ceftriaxone 2 mg IV q12h AND vancomycin 15-20 mcg/ml AND dexamethasone
• Alternative regimen: meropenem 1-2mg IV q8h AND vancomycin 15-20 mcg/ml AND dexamethasone

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Septic thrombosis of cavernous or dural venous sinus, MRSA

• Preferred regimen: Vancomycin 15–20 mg/kg/dose IV every 8–12 h OR Linezolid 600 mg PO/IV BID
• Alternative regimen: TMP-SMX 5 mg/kg/dose PO/IV every 8-12 h
• Pediatric regimen: Vancomycin 15 mg/kg/dose IV every 6 h OR Linezolid 10 mg/kg/dose PO/IV every 8 h

NOTE: Some experts recommend the addition of rifampin 600 mg QD or 300–450 mg BID to vancomycin for adult patients. For children >12 years of age, linezolid 600 mg BID

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Subdural empyema

• In adult 60–90% are extension of sinusitis or otitis media

• Rx same as primary brain abscess