Treatment of tuberculous meningitis (TB meningitis)
The treatment of tuberculous meningitis (TB meningitis) is complicated—seek expert advice.
Emerging pharmacokinetic evidence suggests that many first-line tuberculosis drugs do not sufficiently penetrate the cerebrospinal fluid (CSF), with inadequate concentrations reached in brain tissue compared with the lung. Consequently, there is uncertainty about the appropriateness of standard drug dosage regimens for TB meningitis. In particular, many specialists replace ethambutol with an alternative drug that has better CSF penetration, such as ethionamide or moxifloxacin. Pharmacokinetic studies have also shown relatively poor CSF penetration of rifampicin, so higher doses (eg 20 mg/kg) should be considered when used to treat TB meningitis. The use of intravenous rifampicin in the first weeks of treatment increased survival in a small pilot study1.
Treatment with corticosteroids is recommended in the first 6 to 8 weeks of treatment of TB meningitis—see Corticosteroid use in tuberculosis.
Treatment for TB meningitis is continued for 12 months.