Medication Summary
Symptomatic control with antipyretics, analgesics, and antiemetics is usually all that is needed in the management of uncomplicated viral meningitis.
The decision to start antibacterial therapy for treatment of possible bacterial meningitis is the most crucial; empiric antibacterial therapy for likely pathogens should be considered in the context of the clinical setting.
Acyclovir should be used in cases suspicious for HSV (patients with herpetic lesions), and is usually used empirically in more severe cases complicated by encephalitis or sepsis.
Anti-HIV therapy is initiated when the patient’s history strongly suggests the presence of HIV infection and/or confirmatory tests have proven that an infection exists. Ganciclovir for CMV-related infections is reserved for severe cases with positive CMV culture or congenital infection, or for immunocompromised patients.
Administration of IVIg to neonates with overwhelming enteroviral meningitis has met with only occasional success and is not covered in this section.
Antiemetic Agents
Class Summary
These agents are used mostly to prevent chemotherapy-induced nausea and vomiting.
Ondansetron (Zofran, Zofran ODT, Zuplenz)
This is a selective 5-HT3-receptor antagonist that blocks serotonin peripherally and centrally. It has efficacy in patients who do not respond well to other antiemetics.
Droperidol (Inapsine)
Droperidol is a neuroleptic agent that may reduce emesis by blocking dopamine stimulation of the chemoreceptor trigger zone. It also has antipsychotic and sedative properties.
Promethazine (Phenergan, Promethegan)
Promethazine is used for symptomatic treatment of nausea in vestibular dysfunction. It is an antidopaminergic agent effective in treating emesis. It blocks postsynaptic mesolimbic dopaminergic receptors in the brain and reduces stimuli to brainstem reticular system.
Antiviral Agents
Class Summary
Antienteroviral therapy is under investigation for viral meningitis and may soon become available. Anti-HIV and antituberculosis regimens are not covered here, but they should be instituted if infection with HIV or tuberculosis is strongly suggested clinically or is confirmed by testing. Empiric therapy can be discontinued once the cause of viral meningitis has been established and bacterial meningitis excluded.
Acyclovir (Zovirax)
Acyclovir is to be started as soon as the diagnosis of herpetic meningoencephalitis is suspected. The drug inhibits the activity of HSV-1 and HSV-2.
Analgesics
Class Summary
Symptomatic control with antipyretics and analgesics is needed in the management of uncomplicated viral meningitis.
Acetaminophen (Tylenol, FeverAll)
Acetaminophen inhibits action of endogenous pyrogens on heat-regulating centers. It reduces fever by a direct action on the hypothalamic heat-regulating centers, which, in turn, increase the dissipation of body heat via sweating and vasodilation.
Ibuprofen (Motrin, Advil)
Ibuprofen is the drug of choice for patients with mild-to-moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Naproxen (Aleve, Naprosyn)
Naproxen is used for relief of mild-to-moderate pain. It inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
Antibiotics
Class Summary
Empiric therapy for likely pathogens should be considered in the context of the clinical setting. Broad-spectrum coverage is attained with ampicillin and a third-generation cephalosporin (ceftriaxone or cefotaxime; ceftazidime can also be used). Aminoglycosides are used in severe infections in neonates or children.
Ampicillin
Ampicillin is a broad-spectrum penicillin. It interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. It is an alternative to amoxicillin when unable to take medication orally. It is indicated for L monocytogenes and S agalactiae meningitis, usually in combination with gentamicin.
Ceftriaxone (Rocephin)
Ceftriaxone is a third-generation cephalosporin with broad-spectrum, gram-negative activity. It has lower efficacy against gram-positive organisms and 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 synthesis of peptidoglycan, a major structural component of bacterial cell wall. Bacteria eventually lyse due to the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Cefotaxime (Claforan)
Cefotaxime is a third-generation cephalosporin with 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. 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 meningitides.
Ceftazidime (Fortaz, Tazicef)
Ceftazidime is a third-generation cephalosporin with broad-spectrum, gram-negative activity, including pseudomonas; lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. It arrests bacterial growth by binding to one or more penicillin-binding proteins, which, in turn, inhibit the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall synthesis, thus inhibiting cell wall biosynthesis. The condition of the patient, severity of the infection, and susceptibility of the microorganism should determine the proper dose and route of administration.
Gentamicin
Gentamicin is an aminoglycoside antibiotic that inhibits protein synthesis by irreversibly binding to 30s ribosome. Aminoglycosides are used in severe infections in neonates or children.
Anticonvulsants
Class Summary
Seizures should be treated immediately with IV anticonvulsants, such as lorazepam, phenytoin, midazolam, or a barbiturate.
Lorazepam (Ativan)
Lorazepam is a benzodiazepine and sedative hypnotic with short onset of effects and relatively long half-life. It increases the action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter in the brain, and may depress all levels of CNS, including limbic and reticular formation. It is important to monitor patient's blood pressure after administering dose and adjust as necessary.
Midazolam
Midazolam is a shorter-acting benzodiazepine sedative-hypnotic useful in patients requiring acute and/or short-term sedation.
Phenytoin
Phenytoin is a hydantoin that may act in motor cortex, where it may inhibit spread of seizure activity. Activity of brain stem centers responsible for tonic phase of grand mal seizures may also be inhibited. Phenytoin doses should be individualized.
Phenobarbital
Phenobarbital is a barbiturate that elevates seizure threshold, limits the spread of seizure activity, and has sedative effects.
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T1-weighted MRI of brain demonstrates diffuse enhancement of the meninges in viral meningoencephalitis.
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This rash consists of an enlarging annular plaque. Image courtesy of Lyme Disease Network (http://www.lymenet.org/).
