Overview of empirical therapy for adults and children 2 months or older with meningitis
The following recommendations apply to adults and children 2 months or older with meningitis who are being treated in hospital. For patients presenting with meningitis in the community, see Prehospital management of suspected meningitis.
Ideally obtain microbiological samples (eg cerebrospinal fluid [CSF], blood) before starting empirical antimicrobial therapy. However, if there is a significant delay in performing investigations, do not withhold empirical treatment.
If the pathogen or susceptibility is unknown, start empirical antimicrobials and dexamethasone1 as soon as possible, ideally within 1 hour of presentation to hospital, regardless of whether a prehospital dose of ceftriaxone or benzylpenicillin was given.
When the source of infection has not been identified, or the susceptibility is not known, the empirical regimens for meningitis included in these guidelines are:
- Standard regimens for the empirical treatment of meningitis in adults and children 2 months or older
- Penicillin hypersensitivity regimens for the empirical treatment of meningitis in adults and children 2 months or older.
Dexamethasone should ideally be administered before, or within 20 minutes of, starting antibiotic therapy. However, it can be administered up to 4 hours after starting antibiotic therapy (including when antibiotic therapy is started before hospital admission)van de Beek 2016. Do not delay antibiotic therapy if dexamethasone is not available. If the pathogen is known to be Neisseria meningitidis or Streptococcus agalactiae (group B streptococcus), dexamethasone should not be given because steroid therapy is of no benefit. If corticosteroids are indicated (eg meningitis caused by Streptococcus pneumoniae, Streptococcus suis or Haemophilus influenzae type b [Hib]; tuberculous meningitis; eosinophilic meningitis), continue dexamethasone for 4 days. The benefit of dexamethasone in Listeria monocytogenes meningoencephalitis is unclearCharlier 2017 but several observational studies suggest benefitAmaya-Villar 2010Brouwer 2023Moscatt 2022Pelegrin 2014.
When the pathogen has been microbiologically confirmed and the results of susceptibility testing are available, choose the appropriate directed regimen; see Directed therapy for meningitis.
If a pathogen is not isolated, but CSF results are suggestive of bacterial meningitis, continue the empirical antibiotic regimen for a minimum of 10 days, depending on response.
If the CSF examination is consistent with viral meningitis, consider stopping antimicrobials and dexamethasone; however, do not stop antimicrobials if the patient is clinically unwell. In unwell patients, continue empirical therapy until an organism is identified or until 48 hours of negative culture results have been reported. Seek expert advice.
For CSF examination findings that suggest viral meningitis, see here for adults and here for children.