Bacterial Meningitis Empiric Therapy 

Updated: Apr 25, 2016
  • Author: Darvin Scott Smith, MD, MSc, DTM&H; Chief Editor: Michael Stuart Bronze, MD  more...
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Empiric Therapy Regimens

Empiric therapeutic regimens for bacterial meningitis are presented below based on patient population. [1, 2] All drugs should be administered intravenously (IV). 

Age

Younger than 1 month:

Commonly observed pathogens include group B Streptococcus (GBS) (cases lack characteristic stiff neck of more typical bacterial meningitis), Escherichia coli, Listeria monocytogenes, and Klebsiella species.

  • Ampicillin 100 mg/kg plus  cefotaxime 50 mg/kg q6h or
  • Ampicillin 100 mg/kg plus an aminoglycoside (gentamicin 2.5 mg/kg or tobramycin 2.5 mg/kg) q8h

One to 23 months:

Commonly observed pathogens include Streptococcus pneumoniae, Neisseria meningitidis (rapidly evolving skin rash indicative of infection with Meningococcus species; immediately begin a regimen of benzyl penicillin, ceftriaxone, or cefotaxime), GBS, Haemophilus influenzae type b, and E coli.

  • Vancomycin 15 mg/kg q6h plus a third-generation cephalosporin (ceftriaxone 75-100 mg/kg q12-24h or cefotaxime 75-100 mg/kg q6-8h

Two to 50 years:

Commonly observed pathogens include N meningitides, and S pneumoniae. Adult and pediatric dosing should include vancomycin plus a third-generation cephalosporin (eg, ceftriaxone, cefotaxime).

  • Children: Vancomycin 15 mg/kg q6h plus  ceftriaxone 75-100 mg/kg q12-24h or cefotaxime 75-100 mg/kg q6-8h
  • Adults: Vancomycin 15 mg/kg q8h (to achieve trough levels of 15-20 ug/mL) plus  ceftriaxone 2 g q12h or cefotaxime 2 g q4h

Older than 50 years:

Commonly observed pathogens include S pneumoniae, N meningitidis, L monocytogenes, and aerobic gram-negative rods.

  • Vancomycin 15 mg/kg q8h (to achieve trough levels of 15-20 ug/mL) plus  ampicillin 2 g q4h (hourly if Listeria is suspected) [1] plus  a third-generation cephalosporin (ceftriaxone 2 g q12h or cefotaxime 2 g q4-6h)

Predisposing conditions

Pregnancy:

Commonly observed pathogens include L monocytogenes.

  • Ampicillin 2 g q4h or penicillin G 4 mU q4h

Immunocompromised (eg, chemotherapy, steroids):

Commonly observed pathogens include S pneumoniae, N meningitidis, Listeria species, and anaerobic gram-negative bacilli.

  • Vancomycin 15 mg/kg q8h (to achieve trough levels of 15-20 ug/mL) plus  ampicillin 2 g q4h plus a third-generation cephalosporin (ceftriaxone 2 g q12h or cefotaxime 2 g q4-6h)

Basilar skull fracture:

Commonly observed pathogens include S pneumoniae, H influenzae, and Streptococcus pyogenes.

  • Vancomycin 15 mg/kg q8h (to achieve trough levels of 15-20 ug/mL) plus a third-generation cephalosporin (ceftriaxone 2 g q12h or cefotaxime 2 g q4-6h)

Penetrating trauma or post neurosurgery:

Commonly observed pathogens include Staphylococcus aureus, Staphylococcus epidermidis, and aerobic gram-negative bacilli.

  • Vancomycin 15 mg/kg q8h (to achieve trough levels of 15-20 ug/mL) plus  cefepime 2 g q8h or  ceftazidime 2 g q8h or meropenem 2 g q8h

Cerebrospinal fluid (CSF) shunt:

Commonly observed pathogens include S epidermidis, S aureus, aerobic gram-negative bacilli, and Propionibacterium acnes.

  • Vancomycin 15 mg/kg q8h (to achieve trough levels of 15-20 ug/mL) plus  cefepime 2 g q8h or  ceftazidime 2 g q8h or meropenem 2 g q8h