Bacterial Meningitis

An ID consult is strongly recommended for all cases of bacterial meningitis.

Choice of Antibiotics

Patient Population Usual Organisms Empiric Antimicrobial Regimens*
Age 18-50 years and immunocompetent S. pneumoniae, N. meningitides, H. influenzae

cefTRIAXone 2 g IV q12h†

+
vancomycin 20 mg/kg IV x 1 dose, then 15 mg/kg IV q12h

β-lactam allergy (non-anaphylaxis):

meropenem 2g IV q8h

+

vancomycin 20 mg/kg IV x 1 dose, then 15 mg/kg IV q12h

β-lactam allergy (anaphylaxis):

Consult ID

+

vancomycin 20 mg/kg IV x 1 dose, then 15 mg/kg IV q12h

+

moxifloxacin 400 mg IV q24h

Age > 50 years, or presence of risk factors:

  • Alcoholism

  • Immunocompromised

  • Pregnancy

 S. pneumoniae, L. monocytogenes, N. meningitides, Enterobacterales (e.g. Klebsiella or E. coli)

cefTRIAXone 2 g IV q12h†

+

vancomycin 20 mg/kg IV x 1 dose, then 15 mg/kg IV q12h

+
ampicillin 2 g IV q4h

β-lactam allergy (non-anaphylaxis):

meropenem 2g IV q8h

+

vancomycin 20 mg/kg IV x 1 dose, then 15 mg/kg IV q12h

β-lactam allergy (anaphylaxis):

Consult ID

+

vancomycin 20 mg/kg IV x 1 dose, then 15 mg/kg IV q12h

+

moxifloxacin 400 mg IV q24h

* Once cultures are available, therapy can be tailored.

† Change cefTRIAXone to cefTAZidime 2 g IV q8h for patient with a history of neurosurgery or head trauma in last 30 days, a neurosurgical device, or a CSF leak due to high risk of P. aeruginosa and Acinetobacter infections.

Consider dexamethasone 0.15 mg/kg IV q6h x 4 days. Initiate dose 15-20 min before, or with first antibiotic dose but do NOT give if first dose of antibiotics has already been given. Consider discontinuing dexamethasone if meningitis is not caused by S. pneumoniae.

Duration of Therapy

Causative Organism Duration
N. meningitides 7 days
H. influenzae 7-10 days
S. pneumoniae 10-14 days
Group B Streptococcus 14-21 days
L. monocytogenes 21 days
Enterobacterales (e.g. Klebsiella or E.coli) 21 days

References

  1. Van de Beek D et al. Community-Acquired Bacterial Meningitis in Adults. NEJM. 2006; 352: 44-53.

  2. Tunkel AR et al. IDSA Guidelines Practice Guidelines for the Management of Bacterial Meningitis. Clin Infect Dis. 2004:39:1267-84,