eMedicine Specialties > Neurology > Neurological Infections
Staphylococcal Meningitis: Treatment & Medication
Updated: Mar 27, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Bacterial meningitis is a medical emergency. Once purulent meningitis is confirmed by CSF analysis, initial measures include administration of antibiotics with effective CNS penetration and maintenance of adequate blood pressure. Initial antibiotic selection should be based on Gram stain or rapid bacterial antigen tests. If the spinal tap is delayed or the organism cannot be identified rapidly, empiric selection of an antibiotic with effective CNS penetration should be based on age and underlying disease status, since delay in treatment is associated with adverse clinical outcome.
- Standard empirical therapy varies according to age, as follows:
- In infants younger than 4 weeks, it consists in ampicillin plus cefotaxime or an aminoglycoside.
- Infants aged 4-12 weeks should be treated with ampicillin plus a third-generation cephalosporin.
- In children aged 12 weeks to 18 years, a third-generation cephalosporin or ampicillin plus chloramphenicol is an appropriate combination.
- Adults aged 18-50 years and individuals with basilar skull fracture should be treated with a third-generation cephalosporin, while individuals older than 50 should be treated with ampicillin plus a third-generation cephalosporin.
- Immunocompromised patients should receive the combination of vancomycin, ampicillin, and ceftazidime.
- Patients who have experienced head trauma, have a CSF shunt, or have undergone a neurosurgical procedure should be treated with vancomycin and ceftazidime.
- Vancomycin should be added to empirical regimens when highly penicillin- or cephalosporin-resistant strains of Streptococcus pneumoniae are suspected.
- Ampicillin should be added to empirical treatment at any age if Listeria monocytogenes is a consideration.
- If allergy to penicillins and cephalosporins preclude their use, chloramphenicol is a reasonable alternative.
- Dose calculations are based on a patient's age and renal and hepatic functions.
- Once S aureus meningitis is confirmed and sensitivity determined, therapy may be altered or simplified by using vancomycin, oxacillin, or nafcillin alone. For methicillin-sensitive S aureus, nafcillin or oxacillin is standard therapy. If the infective organism is methicillin-resistant S aureus (MRSA) or S epidermidis, vancomycin is the drug of choice.
- Most experts recommend addition of rifampin if the patient shows no clinical improvement 72 hours after initial treatment of S aureus meningitis.
- Most cases of bacterial meningitis are treated for a period of 10-14 days, except when a parameningeal focus of infection persists (as in most cases of staphylococcal meningitis). In such cases, treatment should be continued for a longer period. Effects of therapy should be tagged to clinical improvement.
- Use of steroids in S aureus meningitis is controversial. While adjunctive dexamethasone is beneficial for H influenzae type B and pneumococcal meningitis, and some authors favor its use in all types of bacterial meningitis, at present the routine use of dexamethasone is not recommended.
- Shunt removal is often necessary to optimize therapy. If infection is suspected, CSF should be removed from the shunt and sent for studies. Treatment should be started if initial results point to meningeal inflammation and should be modified according to culture results. If infections are difficult to eradicate or if the shunt cannot be removed, direct instillation of the antimicrobial agent is warranted. Daily intraventricular vancomycin doses range from 4-10 mg. Gentamicin doses are 1-2 mg/day for children and 4-8 mg/day for adults. Combination with an IV agent is always required. Intraventricular teicoplanin also has been employed successfully. Since the entire shunt has a propensity to be contaminated once one section is infected, partial shunt revision is not recommended.
Surgical Care
In cases of S aureus meningitis due to septicemia, once the source of infection is identified, surgical debridement or excision may be indicated.
Consultations
Obstructive or normal pressure hydrocephalus may complicate the clinical picture, leading to further obtundation. When either of these is present, neurosurgical consultation for shunting should be considered.
Activity
Bed rest and general supportive measures are needed until the acute illness phase has passed; thereafter, physical activity may be increased gradually as tolerated.
Medication
The goals of pharmacotherapy are to eradicate the infection, reduce morbidity, and prevent complications.
Antibiotics
The agents named are effective in treatment of susceptible bacterial infections such as meningitis due to penicillinase-producing strains of S aureus.
Nafcillin (Nafcil, Unipen, Nallpen)
Interferes with bacterial cell wall synthesis during active multiplication, causing cell death and resultant bactericidal activity against susceptible bacteria; 90% protein bound.
Eliminated primarily in bile, 10-30% in urine as unchanged drug; undergoes enterohepatic recycling. Serum concentrations of PO dose peak within 2 h and IM dose within 0.5-1 h.
Adult
500-2000 mg IV q4-6h; 500 mg q4-6h IM for methicillin-sensitive S aureus
Pediatric
Neonates (administered IV/IM):
<7 days, <2000 g: 25 mg/kg/dose q12h
<7 days, >2000 g: 25 mg/kg/dose q8h
>7 days, <2000 g: 25 mg/kg/dose q8h
>7 days, >2000 g: 25 mg/kg/dose q6h
Children: 100-200 mg/kg/d IV/IM divided q4-6h; not to exceed 12 g/d in severe infections
Associated with warfarin resistance; chloramphenicol may decrease levels; bacteriostatic action of tetracycline derivatives may decrease effects; may decrease effectiveness of oral contraceptives; probenecid may increase levels
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Avoid extravasation of IV infusions; modify dosage in severe hepatic or renal impairment; elimination rate slow in neonates; caution in patients with cephalosporin hypersensitivity
Vancomycin (Vancocin, Vancoled, Lyphocin)
Inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization and binding tightly to D-alanyl-D-alanine portion of cell wall precursor. Used in treatment of infections resulting from documented or suspected methicillin-resistant S aureus or beta-lactam-resistant, coagulase-negative staphylococci. Also used for serious or life-threatening infections (eg, endocarditis, meningitis) due to documented or suspected staphylococcal or streptococcal infections in patients who are allergic to penicillins and/or cephalosporins.
Adult
15 mg/kg/dose IV q12h
Pediatric
Infants > 1 month and children with staphylococcal CNS infection: 15 mg/kg/dose IV q6h
Erythema, histaminelike flushing and anaphylactic reactions may occur when administered with anesthetic agents; aminoglycosides may increase risk of nephrotoxicity above that with aminoglycoside monotherapy; may enhance effects of neuromuscular blockade by nondepolarizing muscle relaxants
Documented hypersensitivity; avoid in patients with severe hearing loss
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in renal impairment or those receiving other nephrotoxic or ototoxic drugs; modify dosage in patients with impaired renal function (especially elderly); red man syndrome caused by too rapid IV infusion (ie, dose given over a few minutes) but rarely happens when dose given over 2 h or by PO or IP route; red man syndrome not an allergic reaction
Rifampin (Rifadin, Rimactane)
Inhibits bacterial RNA synthesis by binding to beta-subunit of DNA-dependent RNA polymerase, blocking RNA transcription. Used in combination with other anti-infectives in staphylococcal infections; management of active tuberculosis; to eliminate meningococci from asymptomatic carriers; and for prophylaxis of H influenzae type B infection.
Adult
Synergy for S aureus infections: 300-600 PO bid adjunct with other antibiotics
Pediatric
15 mg/kg/d PO divided bid for 5-10 d adjunct with other antibiotics
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; enalapril may increase blood pressure; concurrent isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Obtain CBCs and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Oxacillin (Bactocill, Prostaphlin)
Bactericidal antibiotic that inhibits cell wall synthesis. Used in treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when staphylococcal infection suspected.
Adult
500-1000 mg PO q4-6h
150-200 mg/kg/d IV/IM divided q6h
Pediatric
50-100 mg/kg/d PO divided q6h
150-200 mg/kg/d IV/IM divided q6h; not to exceed 12 g/d
Decreases effects of contraceptives and tetracycline; disulfiram and probenecid may increase levels; large IV doses increase effect of anticoagulants
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Caution in impaired renal function
Ceftazidime (Ceptaz, Fortaz, Tazicef)
Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to penicillin-binding proteins.
Adult
250-500 mg to 2 g IV/IM q8-12h
Pediatric
Neonates: 30 mg/kg IV q12h
Infants and children: 30-50 mg/kg/dose IV q8h; not to exceed 6 g/d
Adolescents: Administer as in adults
Nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase levels
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in renal impairment
Chloramphenicol (Chloromycetin)
Binds to 50 S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria.
Adult
50-100 mg/kg/d PO/IV divided q6h for 10 d; not to exceed 4 g/d
Pediatric
50-75 mg/kg/d PO/IV divided q6h
Concurrent barbiturates may decrease chloramphenicol serum levels while barbiturate levels may increase, causing toxicity; sulfonylureas may cause manifestations of hypoglycemia; rifampin may reduce serum levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity, and chloramphenicol levels may be increased or decreased
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Use only for indicated infections, or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d while in therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction; caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome)
Ampicillin (Marcillin, Omnipen)
Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.
Adult
250-500 mg PO q6h
500 mg to 1.5 g IM q4-6h
500 mg to 3 g IV q4-6h; not to exceed 12 g/d
Pediatric
50-100 mg/kg/d PO divided q4-6h
100-400 mg/kg/d IM/IV divided q4-6h
Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
More on Staphylococcal Meningitis |
| Overview: Staphylococcal Meningitis |
| Differential Diagnoses & Workup: Staphylococcal Meningitis |
 Treatment & Medication: Staphylococcal Meningitis |
| Follow-up: Staphylococcal Meningitis |
| References |
| « Previous Page | Next Page » |
References
Acar JF, Goldstein FW, Duval J. Use of rifampin for the treatment of serious staphylococcal and gram-negative bacillary infections. Rev Infect Dis. Jul-Aug 1983;5 Suppl 3:S502-6. [Medline].
Adams RD, Victor M, Ropper A. Principles of Neurology. 6th ed. 1997:695-741.
Adeloye A. Intracranial suppuration complicating tropical pyomyositis. Report of two cases. Trans R Soc Trop Med Hyg. 1982;76(4):463-4. [Medline].
Faville RJ, Zaske DE, Kaplan EL, et al. Staphylococcus aureus endocarditis. Combined therapy with vancomycin and rifampin. JAMA. Oct 27 1978;240(18):1963-5. [Medline].
Gordon JJ, Harter DH, Phair JP. Meningitis due to Staphylococcus aureus. Am J Med. Jun 1985;78(6 Pt 1):965-70. [Medline].
Isselbacher, Braunwald, Wilson, et al. Harrison's Principles of Internal Medicine. Vol 2. 13th ed. 1994:2296.
Jensen AG, Espersen F, Skinhoj P, et al. Staphylococcus aureus meningitis. A review of 104 nationwide, consecutive cases. Arch Intern Med. Aug 23 1993;153(16):1902-8. [Medline].
Kilpatrick ME, Girgis NI. Meningitis--a complication of spinal anesthesia. Anesth Analg. May 1983;62(5):513-5. [Medline].
Mandell GL, Bennett JE, Dolin R. Principles and Practice of Infectious Diseases. 1999:959-997; 2069-2092.
Millar MR, Keyworth N, Lincoln C, et al. ''Methicillin-resistant'' Staphylococcus aureus in a regional neonatology unit. J Hosp Infect. Sep 1987;10(2):187-97. [Medline].
Noel GJ, Kreiswirth BN, Edelson PJ, et al. Multiple methicillin-resistant Staphylococcus aureus strains as a cause for a single outbreak of severe disease in hospitalized neonates. Pediatr Infect Dis J. Mar 1992;11(3):184-8. [Medline].
Overturf GD. Indications for the immunological evaluation of patients with meningitis. Clin Infect Dis. Jan 15 2003;36(2):189-94. [Medline].
Quintiliani R, Cooper BW. Current concepts in the treatment of staphylococcal meningitis. J Antimicrob Chemother. Apr 1988;21 Suppl C:107-14. [Medline].
Roberts FJ, Smith JA, Wagner KR. Staphylococcus aureus meningitis: 26 years'' experience at Vancouver General Hospital. Can Med Assoc J. Jun 15 1983;128(12):1418-20. [Medline].
Rulison ET. Control of impetigo neonatorum. Advisability of a radical departure in obstetrical care. JAMA. 1929;93:903.
Schlesinger LS, Ross SC, Schaberg DR. Staphylococcus aureus meningitis: a broad-based epidemiologic study. Medicine (Baltimore). Mar 1987;66(2):148-56. [Medline].
Schwartz JF, Balentine JD. Recurrent meningitis due to an intracranial epidermoid. Neurology. Feb 1978;28(2):124-9. [Medline].
Shinefeld HR. Staphylococcal infections. In: Remington & Klein's Infectious Diseases of the Fetus and Newborn Infant. 4th ed. 1995:1105-1141.
Spotkov J, Garber SZ, Ruskin J. Staphylococcal meningitis: a complication of psoas abscess. Neurology. Jan 1985;35(1):110-1. [Medline].
Watanakunakorn C, Tisone JC. Antagonism between nafcillin or oxacillin and rifampin against Staphylococcus aureus. Antimicrob Agents Chemother. Nov 1982;22(5):920-2. [Medline].
Weinstein MP, LaForce FM, Mangi RJ, Quintiliani R. Non-pneumococcal Gram-positive coccal meningitis related to neurosurgery. J Neurosurg. Aug 1977;47(2):236-40. [Medline].
Worthington M, Hills J, Tally F, Flynn R. Bacterial meningitis after myelography. Surg Neurol. Oct 1980;14(4):318-20. [Medline].
Further Reading
Keywords
viral meningitis, immunocompromise, bacterial meningitis, cerebrospinal fluid shunt, coma, antistaphylococcal antibiotics
