Empiric Therapy Regimens
Empiric therapeutic regimens for bacterial meningitis are presented below based on patient population. [1, 2, 6] 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.
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Ampicillin 100 mg/kg plus cefotaxime 50 mg/kg q6h or
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Ampicillin 100 mg/kg plus an aminoglycoside (gentamicin 2.5 mg/kg or tobramycin 2.5 mg/kg) q8h
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Cefotaxime 50 mg/kg q8 h
Age 1-23 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), Group B streptococcus (GBS), Haemophilus influenzae type b, and E coli.
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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)
Age 2-50 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).
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Children: Vancomycin 15 mg/kg q6h plus ceftriaxone 75-100 mg/kg q12-24h or cefotaxime 75-100 mg/kg q6-8h
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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.
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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) plus ampicillin 2 g q4h (hourly if Listeria is suspected) [1]
Predisposing conditions
Pregnancy:
Commonly observed pathogens include L monocytogenes.
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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.
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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.
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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.
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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.
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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
