Healthcare-associated meningitis (including CSF shunt-related ventriculitis)
Meningitis or ventriculitis can follow cranial trauma, neurosurgery, spinal surgery, or insertion of an intracranial device, or can occur spontaneously in patients with ventricular shunts. The presence of white cells in cerebrospinal fluid (CSF), especially following surgery and in the absence of other clinical features of bacterial infection, does not always indicate healthcare-associated meningitis – consider alternative diagnoses (eg postsurgical sterile inflammation, haemorrhage).
For empirical therapy for healthcare-associated meningitis in adults and children, as a 2-drug regimen, use initially:
vancomycin intravenously; see advice on modification and duration of therapy vancomycin vancomycin vancomycin
adult: 25 mg/kg (actual body weight) rounded up to nearest 125 mg, up to 3 g, as a loading dose. See Calculated vancomycin loading dosage in critically ill adults for calculated weight-based loading doses. Subsequent doses are dependent on weight and kidney function; see Intermittent vancomycin dosing for critically ill adults
child: for initial dosing, see Intermittent vancomycin dosing for young infants and children
PLUS EITHER
1ceftazidime 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see ceftazidime dosage adjustment. See advice on modification and duration of therapy ceftazidime ceftazidime ceftazidime
OR
2cefepime 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see cefepime dosage adjustment. See advice on modification and duration of therapy. cefepime cefepime cefepime
For patients who have had a nonsevere (immediate or delayed) or severe immediate1 hypersensitivity reaction to a penicillin, use the ceftazidime- or cefepime-based regimen above.
For patients who have had a severe delayed2 hypersensitivity reaction to a penicillin, as a 2-drug regimen, use initially:
1ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment. See advice on modification and duration of therapy ciprofloxacin ciprofloxacin ciprofloxacin
OR
1ciprofloxacin 750 mg (child: 20 mg/kg up to 750 mg) orally, 12-hourly. For dosage adjustment in adults with kidney impairment, see ciprofloxacin oral dosage adjustment. See advice on modification and duration of therapy
PLUS
vancomycin intravenously; see advice on modification and duration of therapy vancomycin vancomycin vancomycin
adult: 25 mg/kg (actual body weight) rounded up to nearest 125 mg, up to 3 g, as a loading dose. See Calculated vancomycin loading dosage in critically ill adults for calculated weight-based loading doses. Subsequent doses are dependent on weight and kidney function; see Intermittent vancomycin dosing for critically ill adults
child: for initial dosing, see Intermittent vancomycin dosing for young infants and children.
For patients who have a temporary external ventricular catheter (used for drainage and management of intracranial pressure) that become infected, remove the catheter.
Whenever possible, remove permanent shunts that are infected. Shunt removal and replacement follows a two-stage approach. After the shunt has been removed, if required, place a temporary external shunt, for 7 to 10 days. The patient should remain on antibiotics during this period. After 7 to 10 days, if the CSF is sterile, place a new shunt.