Empiric Treatment of Bacterial Meningitis

(Lancet 2012;380:1693)

• Adults <50 y: Ceftriaxone + vancomycin (trough 15–20), consider acyclovir IV Adults >50 y: Ceftriaxone + vancomycin + ampicillin, consider acyclovir IV Immunosuppressed: [Cefepime or meropenem] + vanc ± amp (not nec. if on meropenem), consider acyclovir IV & fungal coverage Healthcare assoc. infection (eg, surgery, CSF shunt): [Cefepime or meropenem or ceftazidime] + vancomycin

When possible, organism-directed Rx, guided by sensitivities or local patterns of drug resistance should be used Confirm appropriate dosing as higher doses are often needed in meningitis (though may need to be adjusted for renal function) Corticosteroids: If causative organism is unknown, dexamethasone 10 mg IV q6h × 4 d recommended prior to or with initiation of abx. Greatest benefit in S. pneumoniae and GCS 8-11 (↓ neuro disability & mortality by ~50%). Avoid in crypto (NEJM 2016;374:542). Prophylaxis: for close contacts of Pt w/ N. meningitidis; rifampin (600 mg PO bid × 2 d) or ciprofloxacin (500 mg PO × 1) or ceftriaxone (250 mg IM × 1). See Microbiology in Bacterial Meningitis Table for available vaccinations. Precautions: droplet precautions until N. meningitidis is ruled out