eMedicine Specialties > Emergency Medicine > Infectious Diseases
Meningitis: Treatment & Medication
Updated: Jul 28, 2009
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Treatment
Prehospital Care
- Evaluate and treat patient for shock or hypotension. Infuse crystalloid until euvolemic.
- Consider seizure precautions. Treat seizures according to usual protocol.
- Consider airway protection in patients with altered mental status.
- For alert patients in stable condition with normal vital signs, administer oxygen, establish IV access, and transport rapidly to the ED.
Emergency Department Care
- Acute meningitis: Regardless of presentation, perform CSF examination in acute meningitis to identify the specific organism and susceptibilities. Institute treatment as early as possible in the disease course, since delay in instituting treatment may contribute significantly to morbidity and mortality.
- Subacute meningitis: Most patients with subacute bacterial meningitis present more of a diagnostic challenge than those with acute illness. In these patients, CSF examination constitutes the critical step in documenting the presence or absence of a CNS infection and type of infecting organism. If the patient's condition is serious and antibiotics have been given (arguably masking symptoms and hindering growth of organisms on culture), assume a bacterial infection is present, provide adequate antibiotic coverage, and admit the patient.
- The patient's condition and ED organization may warrant a watchful wait for 8-12 hours, then a reexamination of the CSF (sooner if patient's condition deteriorates). If initial granulocytosis changes to mononuclear predominance, CSF glucose remains normal, and patient continues to look well, the infection is most likely nonbacterial.
- In acutely ill patients, perform an LP (if appropriate) and administer first dose(s) of antibiotics +/- steroids within 30 minutes of presentation to ED.
- Consider instituting ED triage protocol to identify patients at risk.
- Initiate empiric therapy if LP cannot be performed within 30 minutes.
- Begin empiric therapy prior to head CT scan if a focal neurologic deficit is present. If no mass effect is present, perform LP to obtain microbiology studies.
- Treat systemic complications of acute bacterial meningitis: hypotension and/or shock, hypoxemia, hyponatremia (SIADH), cardiac arrhythmias and ischemia, cerebrovascular accident (CVA), and exacerbation of chronic diseases.
- Look for signs of hydrocephalus and increasing ICP.
- Manage fever and pain, control straining and coughing, avoid seizures, and avoid systemic hypotension.
- In otherwise stable patients, sufficient care includes elevating head and monitoring neurologic status.
- When more aggressive maneuvers are indicated, some authorities favor early use of diuresis (ie, furosemide 20 mg IV, mannitol 1 g/kg IV), provided circulatory volume is protected.
- Hyperventilation in intubated patients, with a goal of PaCO2 25-30 mm Hg, may briefly lower ICP; hyperventilation with PaCO2 <25 mm Hg may decrease CBF disproportionately and lead to CNS ischemia.
- Consider placing an ICP monitor in comatose patients or in those with signs of increased ICP.
- With elevated ICP, remove CSF until pressure decreases by 50% and maintain at less than 300 mg water.
- Seizure precautions in ED: Aggressively control seizures if present, since seizure activity increases ICP (ie, lorazepam 0.1 mg/kg IV and IV load with phenytoin 15 mg/kg or phenobarbital 5-10 mg/kg).
- Controversy surrounds the administration of dexamethasone, which is given with or just before antibiotics.5
- Dexamethasone may interrupt the cytokine-mediated neurotoxic effects of bacteriolysis, which are at maximum in the first days of antibiotic use.
- Recent meta-analysis of 10 years of clinical trials confirmed that dexamethasone decreases morbidity, especially incidence and severity of neurosensory hearing loss, for H influenzae meningitis and suggested comparable benefit for S pneumoniae meningitis in childhood. No adequate adult studies exist, although the pathophysiology is presumably similar. Meta-analysis suggests that limiting dexamethasone therapy to 2 days may be optimal. More recent studies conducted in Europe continue to support the use of dexamethasone in developed (as opposed to developing) countries, perhaps related to the relative incidence of TB meningitis.
- Theoretically, anti-inflammatory effects of steroids decrease blood-brain barrier permeability and impede penetration of antibiotics into CSF.
- Decreased CSF levels of vancomycin have been confirmed in steroid-treated animals yet not in human studies.
- Many authorities believe that all other antibiotics achieve minimal inhibitory concentrations (MICs) in CSF regardless of steroid use.
- Dexamethasone may not clinically impede even vancomycin.
- In developing countries, the use of oral glycerol (rather than dexamethasone) has been studied as adjunctive therapy in the treatment of bacterial meningitis in children. In limited studies, it appears to reduce the incidence of neurologic sequelae with few side effects.6
- Ideal ED antibiotic therapy is based on a clearly identified organism on CSF Gram stain. Age and underlying conditions dictate empiric treatment in an ED patient without trauma or CNS instrumentation. Information presented in this article is taken from the 2003 edition of The Sanford Guide to Antimicrobial Therapy.
- In neonates to age 1 month, the most common microorganisms are group B or D streptococci, Enterobacteriaceae (eg, E coli), and L monocytogenes.
- Primary treatment is a combination of ampicillin (age 0-7 d: 50 mg/kg IV q8h; age 8-30 d: 50-100 mg/kg IV q6h) plus cefotaxime 50 mg/kg IV q6h (up to 12 g/d).
- Alternative treatment is ampicillin (age 0-7 d: 50 mg/kg IV q8h; age 8-30 d: 50-100 mg/kg IV q6h) plus gentamicin (age 0-7 d: 2.5 mg/kg IV or IM q12h; age 8-30 d: 2.5 mg/kg IV or IM q8h).
- Most authorities recommend adding acyclovir 10 mg/kg IV q8h for herpes simplex encephalitis.
- In infants (1-3 mo), the most common microorganisms are those listed under neonates above and under older infant/child below.
- Primary treatment is cefotaxime (50 mg/kg IV q6h, up to 12 g/d) or ceftriaxone (initial dose: 75 mg/kg, 50 mg/kg q12h up to 4 g/day) plus ampicillin (50-100 mg/kg IV q6h).
- Alternative treatment is chloramphenicol (25 mg/kg PO or IV q12h) plus gentamicin (2.5 mg/kg IV or IM q8h).
- If prevalence of cephalosporin-resistant S pneumoniae (DRSP) is >2%, add vancomycin (15 mg/kg IV q8h). Strongly consider dexamethasone (0.4 mg/kg IV q12h for 2 d or 0.15 mg/kg IV q6h for 4 d) starting 15-20 minutes before first dose of antibiotics.
- In older infants or young children (3 mo - 7 y), the most common microorganisms are S pneumoniae, N meningitidis, and H influenzae.
- Primary treatment is either cefotaxime (50 mg/kg IV q6h up to 12 g/d) or ceftriaxone (initial dose: 75 mg/kg, then 50 mg/kg q12h up to 4 g/d). If prevalence of DRSP is >2%, add vancomycin (15 mg/kg IV q8h). In countries with low prevalence of DRSP, consider penicillin G (250,000 U/kg/d IM/IV in 3-4 divided doses). Due to DRSP, penicillin G is no longer recommended in the US.
- Alternative treatment (or if severely penicillin allergic) is chloramphenicol (25 mg/kg PO/IV q12h) plus vancomycin (15 mg/kg IV q8h).
- Strongly consider dexamethasone (0.4 mg/kg IV q12h for 2 d or 0.15 mg/kg IV q6h for 4 d) starting 15-20 minutes before the first dose of antibiotics.
- In an older child or an otherwise healthy adult (7-50 y), the most common microorganisms are S pneumoniae, N meningitidis, and L monocytogenes.
- In areas where prevalence of DRSP is >2%, primary treatment is either cefotaxime (pediatric dose: 50 mg/kg IV q6h up to 12 g/d; adult dose: 2 g IV q4h) or ceftriaxone (pediatric dose: initial dose: 75 mg/kg, then 50 mg/kg q12h up to 4 g/day; adult dose: 2 g IV q12h) plus vancomycin (pediatric dose: 15 mg/kg IV q8h; adult dose: 750-1000 mg IV q12h or 10-15 mg/kg IV q12h). Some add rifampin (pediatric dose: 20 mg/kg/d IV; adult dose: 600 mg PO qd). If Listeria species is suspected, add ampicillin (50 mg/kg IV q6h).
- Alternative treatment (or if severely penicillin allergic) is chloramphenicol (12.5 mg/kg IV q6h: not bactericidal) or clindamycin (pediatric dose: 40 mg/kg/day IV in 3-4 doses; adult dose: 900 mg IV q8h: active in vitro but no clinical data) or meropenem (pediatric dose: 20-40 mg/kg IV q8h; adult dose: 1 g IV q8h: active in vitro but few clinical data; avoid imipenem as it is proconvulsant).
- In areas with low prevalence of DRSP, use cefotaxime (pediatric dose: 50 mg/kg IV q6h up to 12 g/d; adult: 2 g IV q4h) or ceftriaxone (pediatric dose: 75 mg/kg initial dose then 50 mg/kg q12h up to 4 g/d; adult: 2 g IV q12h) plus ampicillin (50 mg/kg IV q6h).
- Alternative treatment (or if severely penicillin allergic) is chloramphenicol (12.5 mg/kg IV q6h) plus trimethoprim/sulfamethoxazole (TMP/SMX; TMP 5 mg/kg IV q6h) or meropenem (pediatric dose: 20-40 mg/kg IV q8h; adult dose: 1 g IV q8h).
- Data are limited on the need for dexamethasone in adults, although there is support for its use in developed countries when S. pneumoniae is the suspected organism. Administer first dose of dexamethasone (0.4 mg/kg q12h IV for 2 d or 0.15 mg/kg q6h for 4 d) 15-20 minutes before first dose of antibiotics.
- In adults older than 50 years or adults with disabling disease or alcoholism, the most common microorganisms are S pneumoniae, coliforms, H influenzae, Listeria species, Pseudomonas aeruginosa, and N meningitidis.
- Primary treatment if the prevalence of DRSP is >2% is either cefotaxime (2 g IV q4h) or ceftriaxone (2 g IV q12h) plus vancomycin (750-1000 mg IV q12h or 10-15 mg/kg IV q12h). If CSF Gram stain shows gram-negative bacilli, use ceftazidime (2 g IV g8h). In areas of low prevalence of DRSP, use cefotaxime (2 g IV q4h) or ceftriaxone (2 g IV q12h) plus ampicillin (50 mg/kg IV q6h).
- Other options for treatment include meropenem, TMP/SMX, and doxycycline.
- Data are limited on the need for dexamethasone in adults, although there is support for its use in developed countries when S. pneumoniae is the suspected organism. Administer first dose of dexamethasone (0.4 mg/kg q12h IV for 2 d or 0.15 mg/kg q6h for 4 d) 15-20 minutes before first dose of antibiotics.
- In HIV-positive/AIDS patients, consider cryptococci, Mycobacterium tuberculosis, syphilis, HIV aseptic meningitis, and Listeria species. If pathogen is unknown after an ED workup, draw a serum/CSF cryptococcal antigen and treat empirically as in adults older than 50 years pending results of all blood and CSF tests.
- In patients who have had trauma or neurosurgery, the most common microorganisms are S pneumoniae (if CSF leak is present), Staphylococcus aureus, coliforms, and P aeruginosa.
- Primary treatment is vancomycin (1 g IV q12h) plus ceftazidime (2 g IV q8h).
- Alternative treatment is meropenem (1 g IV q8h).
- In patients with infected ventriculoperitoneal (atrial) shunt, the most common microorganisms are Staphylococcus epidermidis, S aureus, coliforms, Propionibacterium acnes, and diphtheroids (rare). Consult a neurosurgeon, since early shunt removal is usually necessary for cure.
- Pediatric dose - Either cefotaxime (50 mg/kg IV q6h) or ceftriaxone (50 mg/kg IV q12h if gram-negative bacillus) plus vancomycin (15 mg/kg/d IV q6h)
- Adult dose - Vancomycin (1 g IV q12h) plus rifampin (600 mg PO qd). If CSF Gram stain shows gram-negative bacilli, use ceftazidime (2 g IV q8h) alone.
- In patients with aseptic meningitis (CSF pleocytosis and normal CSF glucose, negative bacteria on Gram stain), the most common microorganisms are enteroviruses, human herpesvirus-2 (HHV-2), lymphocytic choriomeningitis virus (LCM), HIV, and other viruses. Other etiologies include drugs (NSAIDs, metronidazole, IV immunoglobulin) and, rarely, leptospirosis.
- Manage by repeating LP if necessary to rule out partially treated bacterial meningitis.
- Treatment options for leptospirosis are doxycycline (100 mg PO/IV q12h), penicillin G (5 million U IV q6h), or ampicillin (500 mg IV q6h).
- For patients with symptoms lasting longer than 1 month with CSF pleocytosis, 40% have tuberculous meningitis, 7% cryptococci, 8% neoplastic, and 34% remain undiagnosed. Defer ED treatment until organism is identified.
- Most authorities recommend adding vancomycin when treating patients of all ages in the US with suspected S pneumoniae meningitis to cover drug-resistant strains (36% of S pneumoniae, according to 1995 data).
- Use of vancomycin may affect the decision to include dexamethasone (see above).
- Increase standard cefotaxime pediatric dosage by 50-100 mg/kg/d to overcome intermediate cephalosporin resistance found in some S pneumoniae.
- In neonates to age 1 month, the most common microorganisms are group B or D streptococci, Enterobacteriaceae (eg, E coli), and L monocytogenes.
- Prophylaxis for close contacts of patients with (suspected) N meningitidis
- Indicated for those at increased risk, such as those who were in close contact with patient for at least 4 hours during the week before onset (eg, house mates, daycare center, cell mates) or were exposed to patient's nasopharyngeal secretions (eg, kissing, mouth-to-mouth resuscitation, intubation, nasotracheal suctioning). Spread is via respiratory droplets, not aerosols, hence close contact is required for prophylactic consideration.
- Rifampin (pediatric dose: children <1 mo - 5 mg/kg q12h; children > 1 mo - 10 mg/kg q12h; adult dose: 600 mg PO bid) for 4 doses
- Alternative - Ciprofloxacin (adults) 500 mg PO single dose or ceftriaxone ( <15 y: 125 mg; >15 y: 250 mg) IM single dose
- Primary treatment in many European countries - Spiramycin (pediatric dose: 10 mg/kg; adult dose: 500 mg) PO q6h for 5 days
- Administer meningococcal vaccine only in established epidemics or in travelers to countries where meningococcal disease is currently epidemic. Vaccination does not replace prophylaxis.
- Prophylaxis for household or daycare contacts of patients with (suspected) H influenzae type b is controversial. Most authorities treat contacts to protect unvaccinated children, especially those younger than 4 years who are at risk.
- Indicated for those residing with the patient for at least 4 hours during the week before illness onset (if at least 1 unvaccinated child 4 years or younger, give prophylaxis to all except pregnant household contacts) or daycare contact with patient within 5-7 days (for single case: if all contacts at least 2 years, no prophylaxis; if unvaccinated children 2 years or younger attend, consider prophylaxis and vaccinate susceptible children. For 2 or more cases in 60 days: if unvaccinated children attend, prophylaxis recommended for children and personnel).
- Rifampin (pediatric dose: 10 mg/kg; adult dose: 600 mg) PO q12h x 4 doses.
Consultations
- Neurology
- Infectious diseases
Medication
Begin empiric antibiotic coverage according to age and presence of overriding physical conditions. Empiric therapy also depends on prevalence of cephalosporin-resistant S pneumoniae ( DRSP). In the United States, prevalence is considered high (>2-5%). Patients with severe penicillin (and presumed cephalosporin) allergies often require alternative therapy.
Antibiotics
Antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ampicillin (Marcillin, Omnipen)
Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. This drug is given in place of amoxicillin in patients unable to take medication orally.
Adult
50-100 mg/kg IV q6h
Pediatric
Neonates <1 month
Days <7: 50 mg/kg IV q8h
Days 7-30: 50-100 mg/kg IV q6h
Infants to young adults: Administer as in adults
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 - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Cefotaxime (Claforan)
Third-generation cephalosporin that has broad-spectrum activity against gram-negative organisms, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms.
By binding to one or more of the penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial replication.
Adult
2 g IV q4h
Pediatric
<12 years: 50 mg/kg IV q6h up to 12 g/d
>12 years: Administer as in adults
Probenecid may increase levels; coadministration with furosemide or aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; has been associated with severe colitis
Gentamicin (Garamycin, Gentacidin)
Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with agent against gram-positive organisms and one that covers anaerobes. Not DOC. Consider using this aminoglycoside when penicillins or other less toxic drugs contraindicated, when bacterial susceptibility tests and clinical judgment indicate its use, and in mixed infections caused by susceptible strains of staphylococci and gram-negative organisms.
Dosing regimens numerous and adjusted on basis of CrCl and changes in volume of distribution. Administer IV/IM.
Follow each regimen by at least trough level drawn on third or fourth dose (0.5 h before dosing); may draw peak level 0.5 h after 30-min infusion.
Adult
Serious infections and normal renal function: 3 mg/kg/d IV/IM q8h
Extended dosing regimen for life-threatening infections: 5 mg/kg/d IV q6-8h
Loading dose: 1-2.5 mg/kg IV q8h
Maintenance dose: 1-1.5 mg/kg IV q8h
Pediatric
Neonates:
Days 0-7: 2.5 mg/kg IV/IM q12h
Days 8-30: 2.5 mg/kg IV/IM q8h
Infants, older children, adolescents: Administer as in adults
Other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; loop diuretics may increase auditory toxicity—irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum activity against gram-negative organisms, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms.
By binding to one or more of the penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial replication.
Adult
2 g IV q12h
Pediatric
75 mg/kg IV initially followed by 50 mg/kg q12h up to 4 g/d
Probenecid may increase levels; ethacrynic acid, furosemide, or aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin
Chloramphenicol (Chloromycetin)
Binds to 50 S bacterial-ribosomal subunits and inhibits bacterial replication 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
12.5-25 mg/kg IV q6h
With concurrent barbiturates, chloramphenicol serum levels may decrease 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; hydantoin may increase or decrease levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
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)
Vancomycin (Vancocin)
Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Also useful in treatment of septicemia and skin structure infections. Indicated for patients who cannot receive, or have failed to respond to, penicillins and cephalosporins, or for those who have resistant staphylococcal infections. For penetrating abdominal injuries, combined with agent active against enteric flora and/or anaerobes.
To avoid toxicity, assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use CrCl to adjust dose in patients with renal impairment.
Adult
1 g IV q12h
Pediatric
10-15 mg/kg IV q8h
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced, when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; red man syndrome caused by too rapid IV infusion (dose given over few minutes) but rarely happens when dose given over 2 h or by PO or IP route; red man syndrome not allergic reaction
Trimethoprim/sulfamethoxazole (Bactrim)
Inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid, inhibiting folic acid synthesis. This results in inhibition of bacterial replication.
Adult
20 mg TMP/kg/d IV divided tid/qid
Pediatric
5-20 mg/kg/d IV divided tid/qid based on TMP
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); dapsone may increase blood levels of both drugs; concurrent diuretics increase incidence of thrombocytopenia purpura in elderly; may increase phenytoin levels; may potentiate effects of methotrexate in bone marrow depression; may increase hypoglycemic response to sulfonylureas; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Do not administer to infants <2 months
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD-deficient individuals; AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Meropenem (Merrem)
Broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis and has bactericidal activity. Effective against most gram-positive and gram-negative bacteria.
Has slightly increased activity against gram-negative organisms and slightly decreased activity against staphylococci and streptococci compared to imipenem.
Adult
1 g IV q8h
Pediatric
20-40 mg/kg IV q8h
Alcohol may cause severe hypotension and cardiovascular collapse; calcium channel blockers may produce symptomatic orthostatic hypotension; aspirin may increase serum nitrate concentrations
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation of medication
Ceftazidime (Ceptaz, Fortaz)
Third-generation cephalosporin with broad-spectrum activity against gram-negative organisms, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms.
By binding to one or more of the penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial replication.
Adult
0.5-2 g IV/IM q8-12h
Pediatric
Neonates 1-4 weeks: 30 mg/kg IV q12h
Infants and children 1 month to 12 years: 30-50 mg/kg/dose IV q8h; not to exceed 6 g/d
Aminoglycosides, furosemide, and ethacrynic acid may increase nephrotoxicity; probenecid may increase levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
Doxycycline (Doryx, Bio-Tab)
Inhibits protein synthesis and thus bacterial growth by binding with 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
100 mg IV q12h
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d IV in 1-2 divided doses; not to exceed 200 mg/d
Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate decrease bioavailability; can increase hypoprothrombinemic effects of anticoagulants; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Penicillin G (Pfizerpen)
Interferes with synthesis of cell wall mucopeptide during active replication, resulting in bactericidal activity against susceptible microorganisms.
Adult
5 million U IV q6h
Pediatric
50,000 U/kg IM; not to exceed 2.4 million U
Probenecid can increase effects; tetracyclines can decrease effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
Rifampin (Rifadin, Rimactane)
Inhibits DNA-dependent RNA polymerase activity in susceptible cells. Specifically, interacts with bacterial RNA polymerase but does not inhibit mammalian enzyme. Cross-resistance has been shown only with other rifamycins.
Adult
600 mg PO/IV qd
Pediatric
10-20 mg/kg PO/IV; not to exceed 600 mg/d
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 BP; 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 - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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 associated with thrombocytopenia that is reversible if therapy discontinued as soon as purpura occurs; if treatment continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Amphotericin B (AmBisome)
Depending on concentration attained in body fluids and on susceptibility of fungus, can be fungistatic or fungicidal. Polyene antibiotic produced by strain of Streptomyces nodosus.
Changes membrane permeability by binding to sterols, such as ergosterol, in fungal cell membrane, causing variety of intracellular components to leak, leading to fungal cell death.
Adult
3 mg/kg/d IV of liposomal amphotericin B over approximately 120 min
Pediatric
Administer as in adults
Antineoplastic agents may enhance potential of amphotericin B for renal toxicity, bronchospasm, and hypotension; corticosteroids, digitalis, and thiazides may potentiate hypokalemia; risk of renal toxicity increased with cyclosporine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Monitor renal function, serum electrolytes such as magnesium and potassium, liver function, CBC, and hemoglobin concentrations; resume therapy at lowest level (eg, 0.25 mg/kg) when therapy interrupted for more than 7 d; hypoxemia, acute dyspnea, and interstitial infiltrates may occur in neutropenic patients receiving leukocyte transfusions (separate time of amphotericin infusion from time of leukocyte transfusion); fever and chills not uncommon after first few administrations of drug; rare acute reactions may include hypotension, bronchospasm, arrhythmias, and shock
Flucytosine (Ancobon)
Converted to fluorouracil after penetrating fungal cells and inhibits RNA and protein synthesis. Active against candidal and cryptococcal species and used in combination with amphotericin B.
Adult
50-150 mg/kg/d IV divided q6h
Pediatric
Not established
Amphotericin B may increase toxicity; cytosine may inactivate flucytosine
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in bone marrow suppression; adjust dose in renal impairment
Fluconazole (Diflucan)
Synthetic broad-spectrum bistriazole oral antifungal agent that is highly selective inhibitor of fungal cytochrome P-450 and sterol C-14 alpha-demethylation.
Adult
400 mg PO qd
Pediatric
6-12 mg/kg PO qd
Hydrochlorothiazides may increase levels; long-term use of rifampin may decrease levels; may decrease phenytoin concentrations; may increase concentrations of theophylline, tolbutamide, cyclosporine, glyburide, and glipizide; may increase effects of anticoagulants
Documented hypersensitivity; breastfeeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor patients who develop rashes during treatment; discontinue drug if lesions progress
May cause clinical hepatitis, cholestasis, and fulminant hepatic failure, including fatalities, especially when (1) patient has serious underlying medical condition such as AIDS or malignancy and (2) patient is taking multiple concomitant medications
Do not administer fluconazole in breastfeeding mothers
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 Treatment & Medication: Meningitis |
| Follow-up: Meningitis |
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References
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Further Reading
Keywords
inflammation of the leptomeninges, inflammation of the underlying subarachnoid cerebrospinal fluid, bacterial meningitis, meningococcal meningitis, pneumococcal meningitis, Neisseria meningitidis, N meningitidis, Streptococcus pneumoniae, S pneumoniae, Listeria monocytogenes, L monocytogenes, group B streptococci, Haemophilus influenzae, H influenzae , Haemophilus influenzae type b, H influenzae type b, brain edema, nuchal rigidity, fungalmeningitis, tuberculous meningitis, Kernig sign, Brudzinski sign, papilledema, increased intracranial pressure, increased ICP
