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.

1 Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return
2 In children, a single daily dose of ceftriaxone (100 mg/kg up to 4 g intravenously, daily) is used in some centres. A single daily dose of ceftriaxone may also be used when patients complete their course of treatment at home in an ambulatory antimicrobial therapy program.Return
3 Moxifloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, clinical trial data suggest that adverse musculoskeletal events are usually mild and short term, similar to those observed in adults. Moxifloxacin can be used in children when it is the drug of choice.Return
4 Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return
5 Contact details for Australian state and territory government health departments and public health units are available here.Return