Standard regimens for the empirical treatment of meningitis in adults and children 2 months or older
The following empirical regimens are intended for the treatment of meningitis in adults and children 2 months or older in whom the pathogen has not been identified, or susceptibility results are not available. In patients with risk factors for Listeria monocytogenes or Streptococcus pneumoniae, add on therapy is required – regimens are included below.
For the empirical treatment of meningitis in adults and children 2 months or older, use:
1ceftriaxone 2 g (child: 50 mg/kg up to 2 g) intravenously, 12-hourly1 ceftriaxone ceftriaxone ceftriaxone
OR
1cefotaxime 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly. 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 4 days23. dexamethasone dexamethasone dexamethasone
Listeria monocytogenes is intrinsically resistant to cephalosporins. Benzylpenicillin is added to the above regimens for patients at risk of L. monocytogenes infection, including patients who:
- are older than 50 years
- have immune compromise
- are pregnant
- have a history of hazardous alcohol consumption.
Add:
benzylpenicillin 2.4 g (child: 60 mg/kg up to 2.4 g) intravenously, 4-hourly. For dosage adjustment in adults with kidney impairment, see benzylpenicillin dosage adjustment. benzylpenicillin benzylpenicillin benzylpenicillin
Vancomycin is added to the above regimens to ensure that empirical therapy is adequate for S. pneumoniae isolates that have reduced susceptibility or resistance to penicillin or cephalosporins. Add vancomycin if:
- gram-positive diplococci are seen on Gram stain
- pneumococcal antigen assay of cerebrospinal fluid (CSF) is positive
- the patient has known or suspected otitis media or sinusitis
- the patient has been recently treated with a beta-lactam antibiotic.
Also consider adding vancomycin if:
- gram-positive cocci resembling staphylococci are seen on Gram stain
- CSF tests are not possible because lumbar puncture is contraindicated.
Add:
vancomycin intravenously 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.
If vancomycin is used, administer it after ceftriaxone or cefotaxime due to the long infusion time required.