Medication Summary
The most critical aspect of initial treatment of meningitis is prompt initiation of antimicrobial therapy, because any delay in treatment is associated with increased morbidity and mortality. Anti-inflammatory therapy remains controversial, but dexamethasone may help prevent hearing loss. When necessary, increased intracranial pressure (ICP) can be treated with mannitol. Vaccination may help in the prevention of Haemophilus meningitis. Patients may require care for the management of deficits resulting from Hib meningitis, including static encephalopathy, seizures, behavioral changes, or epilepsy.
Antimicrobial agents
Class Summary
The most critical aspect of initial treatment for meningitis is prompt initiation of antimicrobial therapy, because any delay in treatment is associated with increased morbidity and mortality. Chloramphenicol was previously used to treat HiB meningitis but has fallen out of favor because of increasing resistance, potential myelotoxicity, lack of availability, and, most importantly, the availability of alternatives with a better safety profile.
Ampicillin
Ampicillin is a broad-spectrum penicillin. It interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Ampicillin could be considered an option if HiB is known to be susceptible to the drug. Nontypable H influenzae strains, which are increasingly being encountered, tend to be susceptible to ampicillin.
Ceftriaxone
Ceftriaxone is a third-generation cephalosporin with broad-spectrum, gram-negative activity and lower efficacy against gram-positive organisms. It also has higher efficacy against resistant organisms. Bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin-binding proteins. It exerts antimicrobial effect by interfering with the synthesis of peptidoglycan, a major structural component of the bacterial cell wall. Bacteria eventually lyse due to the ongoing activity of cell wall autolytic enzymes, while cell wall assembly is arrested. It is highly stable in the presence of beta-lactamases, both penicillinase and cephalosporinase, of gram-negative and gram-positive bacteria.
Cefotaxime
Cefotaxime is a third-generation cephalosporin with a broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. It arrests bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins, which, in turn, inhibits bacterial growth. Its safety profile is more favorable than aminoglycosides. It is used to treat suspected or documented bacterial meningitis caused by susceptible organisms such as H influenzae or N meningitidis.
Meropenem (Merrem)
Meropenem is a carbapenem antibiotic and is considered an alternative to cephalosporins. It exerts its bactericidal activity by inhibiting cell wall synthesis and can be considered an option in patients who are intolerant of cephalosporins.
Anticonvulsants
Class Summary
Seizures that occur on presentation and during the earliest acute phase of Hib meningitis do so because of transient focal derangements in the cortex or because of metabolic disturbances such as hyponatremia or hypoglycemia. Treatment may require the administration of anticonvulsants, the choice of which involves consideration of the type of seizures, the age of the patient, and the route of drug administration.
Carbamazepine (Tegretol, Tegretol XR)
The anticonvulsant action of carbamazepine may involve depressing activity in the nucleus ventralis anterior of thalamus, resulting in reduction of polysynaptic responses and blocking of posttetanic potentiation. It reduces sustained high-frequency repetitive neural firing.
Lamotrigine (Lamictal, Lamictal XR, Lamictal ODT)
Lamotrigine is a triazine derivative that is effective as an adjunctive and primary drug in the management of partial seizures, generalized seizures, and neuralgia. It inhibits the release of glutamate and inhibits voltage-sensitive sodium channels, leading to stabilization of the neuronal membrane.
Topiramate (Topamax)
Topiramate is a sulfamate-substituted monosaccharide with a broad spectrum of antiepileptic activity that may have a state-dependent sodium channel blocking action, potentiating the inhibitory activity of the neurotransmitter gamma-amino butyric acid (GABA). It may block glutamate activity.
Gabapentin (Neurontin)
Gabapentin is a membrane stabilizer, a structural analogue of the inhibitory neurotransmitter GABA, which paradoxically is thought to not exert effects on GABA receptors. It appears to exert action via the alpha2-delta1 and alpha2-delta2 auxiliary subunits of voltage-gated calcium channels. It is as adjunctive therapy in the treatment of partial seizures.
Osmotic diuretics
Class Summary
These agents are used in an attempt to lower pressure in the subarachnoid space. As water diffuses from the subarachnoid space into the intravascular compartment, pressure in the subarachnoid compartment may decrease.
Mannitol (Osmitrol)
Mannitol can be used to treat increased ICP.
Anti-Inflammatory Agents
Class Summary
Anti-inflammatory therapy remains controversial, but dexamethasone may help prevent hearing loss. Administering the dexamethasone either before or concomitant with the first dose of antimicrobial therapy is likely of considerable importance if a positive effect is expected.
Dexamethasone (DexPak 10 Day, Dxevo, 11-Day, TaperDex 12-Day, Zcort 7-Day)
Dexamethasone has many pharmacologic benefits but significant adverse effects. It stabilizes cell and lysosomal membranes, increases surfactant synthesis, increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory cytokines (eg, TNF-alpha, IL-6, IL-2, and IFN-gamma). The inhibition of chemotactic factors and factors that increase capillary permeability inhibits the recruitment of inflammatory cells into affected areas. If dexamethasone treatment is elected, the recommended dose is 0.15 mg/kg every 6 hours for the first 2 days after the initial diagnosis and treatment. In addition, care must be exerted to avoid complications such as gastrointestinal hemorrhage.
Vaccines
Class Summary
Vaccines may be used in the prevention of Hib infection. Several studies in the United States and internationally have demonstrated a significant reduction in the incidence of invasive Hib infection soon after the introduction of the vaccine.
Haemophilus influenza type b vaccine (ActHIB, Hiberix, PedvaxHIB)
This vaccine is used for routine immunization of children against invasive diseases caused by Hib by decreasing nasopharyngeal colonization.
Diphtheria & tetanus toxoids/ acellular pertussis vaccine/poliovirus vaccine inactivated/haemophilus influenzae type b vaccine (DTaP/ IPV/ Hib, Pentacel)
This combination vaccine is used for active immunization against diphtheria, tetanus, pertussis, poliomyelitis, and haemophilus influenza type b in children aged 6 weeks to 4 years.
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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Empiric Antibiotic Therapy
- Adjunctive Corticosteroid Therapy
- General Supportive Care
- Monitoring for Increased Intracranial Volume
- Surgical Management of Increased Intracranial Pressure
- Prevention of Haemophilus Meningitis
- Dietary Measures
- Restriction of Physical Activity
- Consultations
- Long-term Monitoring
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- Medication
- Questions & Answers
- References
