Streptococcus pneumoniae (pneumococcal) meningitis
In adults and children with meningitis caused by Streptococcus pneumoniae (pneumococcal meningitis), treatment depends on the susceptibility of penicillin, ceftriaxone or cefotaxime. Determine the minimum inhibitory concentrations (MICs) of penicillin and ceftriaxone or cefotaxime for all S. pneumoniae isolates.
For strains susceptible to penicillin (MIC less than 0.125 mg/L), use:
benzylpenicillin 2.4 g (child: 60 mg/kg up to 2.4 g) intravenously, 4-hourly for 10 to 14 days. For dosage adjustment in adults with kidney impairment, see benzylpenicillin dosage adjustment benzylpenicillin benzylpenicillin benzylpenicillin
PLUS
dexamethasone 10 mg (child: 0.15 mg/kg up to 10 mg) intravenously, preferably starting before the first dose of antibiotic, then 6-hourly for a total of 4 days (empiric + directed therapy). dexamethasone dexamethasone dexamethasone
For strains resistant to penicillin (MIC 0.125 mg/L or more) but susceptible to ceftriaxone or cefotaxime (MIC less than 1.0 mg/L), including in patients who have had a nonsevere (immediate or delayed) or severe immediate1 hypersensitivity reaction to a penicillin, use:
1ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously, 12-hourly for 10 to 14 days2 ceftriaxone ceftriaxone ceftriaxone
OR
1cefotaxime 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly for 10 to 14 days. For dosage adjustment in adults with kidney impairment, see cefotaxime dosage adjustment cefotaxime cefotaxime cefotaxime
PLUS with either of the above regimens
dexamethasone 10 mg (child: 0.15 mg/kg up to 10 mg) intravenously, preferably starting before the first dose of antibiotic, then 6-hourly for a total of 4 days (empiric + directed therapy). dexamethasone dexamethasone dexamethasone
For strains resistant to penicillin (MIC 0.125 mg/L or more), and with a ceftriaxone or cefotaxime MIC 1.0 to 2.0 mg/L, add moxifloxacin or vancomycin to ceftriaxone or cefotaxime. If using moxifloxacin, start treatment and confirm susceptibility when results are available. Add:
1moxifloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, daily for 10 to 14 days3. For dosage adjustment in adults with kidney impairment, see moxifloxacin dosage adjustment moxifloxacin moxifloxacin moxifloxacin
OR
1vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for noncritically ill adults or Intermittent vancomycin dosing for young infants and children. vancomycin vancomycin vancomycin
If the MIC of ceftriaxone or cefotaxime is more than 2.0 mg/L, seek expert advice.
For patients who have had a severe delayed4 hypersensitivity reaction to a penicillin, use:
moxifloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, daily for 10 to 14 days3. For dosage adjustment in adults with kidney impairment, see moxifloxacin dosage adjustment moxifloxacin moxifloxacin moxifloxacin
PLUS
dexamethasone 10 mg (child: 0.15 mg/kg up to 10 mg) intravenously, preferably starting before the first dose of antibiotic, then 6-hourly for a total of 4 days (empiric + directed therapy). dexamethasone dexamethasone dexamethasone
Report cases of S. pneumoniae meningitis to the local public health authority5. For case definitions and other public health advice, see the public health advice for Pneumococcal disease – invasive.