Neonatal Meningitis Medication

Updated: Feb 12, 2018
  • Author: Gaurav Gupta, MD, FAANS, FACS; Chief Editor: Stephen L Nelson, Jr, MD, PhD, FAACPDM, FAAN, FAAP, FANA  more...
  • Print

Medication Summary

Aggressive antimicrobial intervention is lifesaving in neonates with suspected meningitis. Because distinguishing viral from bacterial meningitis is difficult early in the clinical course, a combination of agents is often necessary, providing coverage for both types of infection.

In most institutions, acyclovir is the preferred antiviral therapy, but the best antibacterial therapy remains subject to debate. The combination of ampicillin and gentamicin is a common regimen. Many centers use cefotaxime in addition to or instead of gentamicin, particularly when gram-negative infections are suspected. Selection of antibiotics should be based on likely pathogens, local patterns of antibacterial drug sensitivities, and hospital policies.

In addition to the medications listed below, pleconaril is an experimental agent that interferes with attachment, entry, and uncoating of enteroviruses. It was shown to be well tolerated by neonates in a single, small, double-blinded study. Data supporting the efficacy of pleconaril are limited, although a larger clinical trial is currently under way. At present, this drug is available only for compassionate use or in clinical trials.


Antivirals, Other

Class Summary

Antiviral agents inhibit viral replication and activity.

Acyclovir (Zovirax)

Acyclovir is the preferred treatment for herpes simplex virus (HSV) meningitis. Intravenous (IV) therapy is treatment of choice for neonatal HSV infection, regardless of clinical presentation. Acyclovir is activated by herpes-specific thymidine kinase; it prevents viral replication by inhibiting viral DNA polymerase. Because it is excreted primarily by the kidneys, dosing must be modified in patients with renal impairment.


Antibiotics, Other

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Either gram-positive or gram-negative organisms may cause bacterial sepsis and meningitis. Combination therapy is necessary.


Ampicillin has bactericidal activity against susceptible organisms. The combination of ampicillin with an aminoglycoside is the initial treatment of choice for neonates with presumptive group B streptococcal (GBS) meningitis and for most other suspected bacterial infections of the central nervous system (CNS).

Penicillin G (Pfizerpen)

Penicillin G interferes with synthesis of cell-wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms. It can be given alone to treat GBS meningitis when susceptibility of CSF isolates to the drug has been demonstrated.

Cefotaxime (Claforan)

Cefotaxime is a third-generation cephalosporin with a gram-negative spectrum of activity; it has lower efficacy against gram-positive organisms. It arrests bacterial cell-wall synthesis, which, in turn, inhibits bacterial growth.

Whereas ampicillin plus an aminoglycoside remains the initial treatment of choice for bacterial meningitis, some investigators recommend ampicillin plus a cephalosporin (eg, cefotaxime) as initial treatment. The rapid emergence of cephalosporin-resistant strains limits the use of the latter combination, unless gram-negative bacterial meningitis strongly suspected. Treatment typically lasts 21 days, with most authorities recommending 14-21 days from the first negative CSF culture.


Gentamicin is the prototypical aminoglycoside for combining with ampicillin to treat neonatal meningitis, but organism sensitivities and hospital protocols vary widely. Evolving bacterial resistance may necessitate the use of higher doses.


Anticonvulsants, Other

Class Summary

Anticonvulsants prevent seizure recurrence and terminate clinical and electrical seizure activity.


Phenobarbital increases the activity of gamma-aminobutyric acid, an inhibitory neurotransmitter in the central nervous system. This medication is typically used as the first-line agent in the treatment of neonatal seizures. An IV dose may require approximately 15 minutes to attain peak levels in the brain. Typically, a loading dose of 20 mg/kg IV is given initially, with additional bolus doses of 5-10 mg/kg if seizure activity persists, to a maximum total dose of 40 mg/kg.

Fosphenytoin (Cerebyx)

Fosphenytoin is the diphosphate ester salt of phenytoin and acts as a water-soluble prodrug of that agent. After administration, plasma esterases convert fosphenytoin to phosphate, formaldehyde, and phenytoin. Phenytoin, in turn, stabilizes neuronal membranes and decreases seizure activity.

To eliminate the need to perform molecular weight-based adjustments when converting between fosphenytoin and phenytoin sodium doses, express the dose in terms of phenytoin sodium equivalents (PE). Although fosphenytoin can be administered either IV or IM, IV administration is preferable and should be used in emergency situations.

Fosphenytoin is typically considered the second choice of anticonvulsants in neonates if phenobarbital does not control seizures.

Lorazepam (Ativan)

Lorazepam is a benzodiazepine anticonvulsant that is used in cases that are refractory to phenobarbital and phenytoin. By increasing the action of gamma-aminobutyric acid (GABA) the major inhibitory neurotransmitter in the brain, lorazepam may depress all levels of the CNS, including the limbic system and the reticular formation.