Bacterial meningitis
- Visão geral
- Teoria
- Diagnóstico
- Tratamento
- ACOMPANHAMENTO
- Recursos
Algoritmo de tratamento
Observe que as formulações/vias e doses podem diferir entre nomes e marcas de medicamentos, formulários de medicamentos ou localidades. As recomendações de tratamento são específicas para os grupos de pacientes:ver aviso legal
≤1 month of age and immunocompetent
empiric antibiotic therapy
Until the causative organism and its sensitivities have been identified, broad-spectrum antimicrobials should be given as soon as possible parenterally.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [99]Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America's clinical practice guidelines for healthcare-associated ventriculitis and meningitis. Clin Infect Dis. 2017 Mar;64(6):701-6. https://academic.oup.com/cid/article/64/6/701/3060377 http://www.ncbi.nlm.nih.gov/pubmed/28203777?tool=bestpractice.com [104]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2008.02193.x http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com
The choice of empiric antibiotic depends on the patient's age and conditions that may have predisposed the patient to meningitis.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com The regimen chosen must be broad enough to cover the potential organisms for the age group affected, with consideration for regional susceptibility rates.[59]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22(suppl 3):S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com
The recommended regimen is ampicillin plus cefotaxime.[59]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22(suppl 3):S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com [104]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2008.02193.x http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com If a cephalosporin cannot be administered (e.g., patients with an allergy), an alternative regimen for neonates is ampicillin plus an aminoglycoside (e.g., gentamicin).[59]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22(suppl 3):S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to causative organism and its susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com
Opções primárias
ampicillin: consult specialist for guidance on neonatal dose
e
cefotaxime: consult specialist for guidance on neonatal dose
Opções secundárias
ampicillin: consult specialist for guidance on neonatal dose
e
gentamicin: consult specialist for guidance on neonatal dose
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
>1 month and <50 years of age and immunocompetent
empiric antibiotic therapy
Until the causative organism and its sensitivities have been identified, broad-spectrum antimicrobials should be given as soon as possible parenterally.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [99]Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America's clinical practice guidelines for healthcare-associated ventriculitis and meningitis. Clin Infect Dis. 2017 Mar;64(6):701-6. https://academic.oup.com/cid/article/64/6/701/3060377 http://www.ncbi.nlm.nih.gov/pubmed/28203777?tool=bestpractice.com [104]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2008.02193.x http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com
The choice of empiric antibiotic depends on the patient's age and conditions that may have predisposed the patient to meningitis.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com The regimen chosen must be broad enough to cover the potential organisms for the age group affected, with consideration for regional susceptibility rates.[59]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22(suppl 3):S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com
The recommended regimen is cefotaxime or ceftriaxone plus vancomycin.[59]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22(suppl 3):S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com [104]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2008.02193.x http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com If a cephalosporin cannot be administered (e.g., patients with an allergy), a carbapenem (e.g., meropenem) plus vancomycin can be considered.[1]Mace SE. Acute bacterial meningitis. Emerg Med Clin North Am. 2008 May;26(2):281-317. http://www.ncbi.nlm.nih.gov/pubmed/18406976?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to causative organism and its susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com
Opções primárias
vancomycin: children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours
Mais vancomycinAdjust dose according to serum vancomycin level.
--E--
ceftriaxone: children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours
ou
cefotaxime: children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours
Opções secundárias
vancomycin: children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours
Mais vancomycinAdjust dose according to serum vancomycin level.
e
meropenem: children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
dexamethasone
Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado
Ideally dexamethasone should be given to all patients older than 6 weeks who present with clinical features of bacterial meningitis.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [104]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2008.02193.x http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com [109]Ramirez D, Nigo M, Hasbun R. 1036. Timing and use of adjunctive steroids in adults with bacterial meningitis: compliance with International guidelines. Open Forum Infect Dis. 2022 Dec 15;9(Suppl 2):ofac492. https://pmc.ncbi.nlm.nih.gov/articles/PMC9751809
In the US, the Infectious Diseases Society of America recommends that dexamethasone be started immediately prior to, or in conjunction with, the first dose of antibiotics and continued for 2-4 days.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
Once the causative organism is isolated, the use of dexamethasone should be reviewed; guidelines recommend that it is only continued for bacterial meningitis caused by pneumococcus or Haemophilus influenzae type b (Hib) as these have the strongest evidence for benefit.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com [111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com
Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com An observational study of 1391 adults with community-acquired bacterial meningitis also showed that the proportion of patients with unfavorable outcomes was lower in individuals treated with adjunctive dexamethasone in patients with nonpneumococcal and non- Haemophilus meningitis (with the exception of Listeria).[112]van de Beek D, Brouwer MC, Koedel U, et al. Community-acquired bacterial meningitis. Lancet. 2021 Sep 25;398(10306):1171-83. http://www.ncbi.nlm.nih.gov/pubmed/34303412?tool=bestpractice.com
In children, studies have shown corticosteroids likely reduce severe hearing loss in patients with Hib meningitis, but not necessarily in children with meningitis due to non- Haemophilus species.[113]Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015 Sep 12;(9):CD004405. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004405.pub5/full http://www.ncbi.nlm.nih.gov/pubmed/26362566?tool=bestpractice.com In one meta-analysis of clinical studies published during 1988-1996, adjunctive dexamethasone had confirmed benefit for Hib meningitis and, if commenced with or before antimicrobial therapy, suggested benefit for pneumococcal meningitis in children.[114]McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA. 1997 Sep 17;278(11):925-31. http://www.ncbi.nlm.nih.gov/pubmed/9302246?tool=bestpractice.com One more recent large meta-analysis found administration of low-dose corticosteroids to be beneficial in children in reducing hearing loss and neurologic sequelae, as well as reducing the mean number of days before resolution of fever.[115]Tian C, Jin S, Zhao Z, et al. Association of corticosteroid treatment With outcomes in pediatric patients with bacterial meningitis: a systematic review and meta-analysis of randomized controlled trials. Clin Ther. 2022 Apr;44(4):551-64. http://www.ncbi.nlm.nih.gov/pubmed/35272859?tool=bestpractice.com
The use of adjunctive dexamethasone in Listeria meningitis is controversial, and until more studies are performed it is not recommended.[117]Charlier C, Perrodeau É, Leclercq A, et al. Clinical features and prognostic factors of listeriosis: the MONALISA national prospective cohort study. Lancet Infect Dis. 2017 May;17(5):510-9. https://hal.science/pasteur-01475849 http://www.ncbi.nlm.nih.gov/pubmed/28139432?tool=bestpractice.com [118]Brouwer MC, van de Beek D. Adjunctive dexamethasone treatment in adults with listeria monocytogenes meningitis: a prospective nationwide cohort study. EClinicalMedicine. 2023 Apr;58:101922. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00099-8/fulltext http://www.ncbi.nlm.nih.gov/pubmed/37007737?tool=bestpractice.com
Opções primárias
dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours
≥50 years of age or immunocompromised
empiric antibiotic therapy
Until the causative organism and antibiotic sensitivities have been identified, broad-spectrum antimicrobials should be given as soon as possible parenterally.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [99]Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America's clinical practice guidelines for healthcare-associated ventriculitis and meningitis. Clin Infect Dis. 2017 Mar;64(6):701-6. https://academic.oup.com/cid/article/64/6/701/3060377 http://www.ncbi.nlm.nih.gov/pubmed/28203777?tool=bestpractice.com [104]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2008.02193.x http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com
The choice of empiric antibiotic depends on the patient's age and conditions that may have predisposed the patient to meningitis.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com The regimen chosen must be broad enough to cover the potential organisms for the age group affected, with consideration for regional susceptibility rates.[59]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22(suppl 3):S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com
The recommended regimen is ampicillin plus cefotaxime or ceftriaxone plus vancomycin.[59]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22(suppl 3):S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com [104]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2008.02193.x http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com If ampicillin cannot be administered (e.g., patients with an allergy), trimethoprim/sulfamethoxazole could be considered as an alternative in place of ampicillin (excluding newborns where specialist advice should be sought).[1]Mace SE. Acute bacterial meningitis. Emerg Med Clin North Am. 2008 May;26(2):281-317. http://www.ncbi.nlm.nih.gov/pubmed/18406976?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and its susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com
Opções primárias
ampicillin: neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours
--E--
vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours
Mais vancomycinAdjust dose according to serum vancomycin level.
--E--
ceftriaxone: neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours
ou
cefotaxime: neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours
Opções secundárias
sulfamethoxazole/trimethoprim: children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours
Mais sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
--E--
vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults:15-20 mg/kg intravenously every 8-12 hours
Mais vancomycinAdjust dose according to serum vancomycin level.
--E--
ceftriaxone: neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours
ou
cefotaxime: neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
dexamethasone
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Ideally dexamethasone should be given to all patients older than 6 weeks of age who present with clinical features of bacterial meningitis.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [104]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2008.02193.x http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com [109]Ramirez D, Nigo M, Hasbun R. 1036. Timing and use of adjunctive steroids in adults with bacterial meningitis: compliance with International guidelines. Open Forum Infect Dis. 2022 Dec 15;9(Suppl 2):ofac492. https://pmc.ncbi.nlm.nih.gov/articles/PMC9751809
In the US, the Infectious Diseases Society of America recommends that dexamethasone be started immediately prior to, or in conjunction with, the first dose of antibiotics and continued for 2-4 days.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
Once the causative organism is isolated, the use of dexamethasone should be reviewed; guidelines recommend that it is only continued for bacterial meningitis caused by pneumococcus or Haemophilus influenzae type b as these have the strongest evidence for benefit.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com [111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com
Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com An observational study of 1391 adults with community-acquired bacterial meningitis also showed that the proportion of patients with unfavorable outcomes was lower in individuals treated with adjunctive dexamethasone in patients with nonpneumococcal and non- Haemophilus meningitis (with the exception of Listeria).[112]van de Beek D, Brouwer MC, Koedel U, et al. Community-acquired bacterial meningitis. Lancet. 2021 Sep 25;398(10306):1171-83. http://www.ncbi.nlm.nih.gov/pubmed/34303412?tool=bestpractice.com
The use of adjunctive dexamethasone in Listeria meningitis is controversial, and until more studies are performed it is not recommended.[117]Charlier C, Perrodeau É, Leclercq A, et al. Clinical features and prognostic factors of listeriosis: the MONALISA national prospective cohort study. Lancet Infect Dis. 2017 May;17(5):510-9. https://hal.science/pasteur-01475849 http://www.ncbi.nlm.nih.gov/pubmed/28139432?tool=bestpractice.com [118]Brouwer MC, van de Beek D. Adjunctive dexamethasone treatment in adults with listeria monocytogenes meningitis: a prospective nationwide cohort study. EClinicalMedicine. 2023 Apr;58:101922. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00099-8/fulltext http://www.ncbi.nlm.nih.gov/pubmed/37007737?tool=bestpractice.com
Dexamethasone generally should not be withheld in immunocompromised patients. In studies where it has been given to patients with bacterial meningitis, including those with Listeria, mortality tended to be lower in those on adjunctive dexamethasone therapy as compared to those without dexamethasone therapy.[108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com [110]van Veen KEB, Brouwer MC, van der Ende A, et al. Bacterial meningitis in patients using immunosuppressive medication: a Population-based Prospective Nationwide Study. J Neuroimmune Pharmacol. 2017 Jun;12(2):213-8. https://link.springer.com/article/10.1007/s11481-016-9705-6 http://www.ncbi.nlm.nih.gov/pubmed/27613024?tool=bestpractice.com
Opções primárias
dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours
confirmed infection: Streptococcus pneumoniae
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and its susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Penicillin-susceptible Streptococcus pneumoniae (i.e., minimum inhibitory concentration <0.06 microgram/mL) should be treated with penicillin-G or ampicillin. Alternatives include a third-generation cephalosporin (e.g., ceftriaxone).[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com
Treatment course: 10-14 days.
Opções primárias
penicillin G potassium: neonates: consult specialist for guidance on dose; children: 250,000 to 400,000 units/kg/day intravenously given in divided doses every 4-6 hours, maximum 24 million units/day; adults: 2 million units intravenously every 2 hours
ou
ampicillin: neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours
Opções secundárias
ceftriaxone: neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
dexamethasone
Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado
Ideally dexamethasone should be given to all patients older than 6 weeks who present with clinical features of bacterial meningitis.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [104]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2008.02193.x http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com [109]Ramirez D, Nigo M, Hasbun R. 1036. Timing and use of adjunctive steroids in adults with bacterial meningitis: compliance with International guidelines. Open Forum Infect Dis. 2022 Dec 15;9(Suppl 2):ofac492. https://pmc.ncbi.nlm.nih.gov/articles/PMC9751809
In the US, the Infectious Diseases Society of America recommends that dexamethasone be started immediately prior to, or in conjunction with, the first dose of antibiotics and continued for 2-4 days.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
Once the causative organism is isolated, the use of dexamethasone should be reviewed; guidelines recommend that dexamethasone be continued for bacterial meningitis caused by pneumococcus.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com [111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com
Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com
In children, studies have shown corticosteroids have suggested benefit in pneumococcal meningitis.[114]McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA. 1997 Sep 17;278(11):925-31. http://www.ncbi.nlm.nih.gov/pubmed/9302246?tool=bestpractice.com In one meta-analysis of clinical studies published during 1988-1996, adjunctive dexamethasone had confirmed benefit for Haemophilus influenzae type b meningitis and, if commenced with or before antimicrobial therapy, suggested benefit for pneumococcal meningitis in children.[114]McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA. 1997 Sep 17;278(11):925-31. http://www.ncbi.nlm.nih.gov/pubmed/9302246?tool=bestpractice.com
One more recent large meta-analysis found administration of low-dose corticosteroids to be beneficial in children in reducing hearing loss and neurologic sequelae, as well as reducing the mean number of days before resolution of fever.[115]Tian C, Jin S, Zhao Z, et al. Association of corticosteroid treatment With outcomes in pediatric patients with bacterial meningitis: a systematic review and meta-analysis of randomized controlled trials. Clin Ther. 2022 Apr;44(4):551-64. http://www.ncbi.nlm.nih.gov/pubmed/35272859?tool=bestpractice.com
Corticosteroids are not currently recommended in neonates.[59]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22(suppl 3):S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com
Opções primárias
dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and its susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Penicillin-intermediate Streptococcus pneumoniae (i.e., minimum inhibitory concentration ≥0.12 microgram/mL) or ceftriaxone-intermediate (MIC <1 microgram/mL) should be treated with cefotaxime or ceftriaxone. Alternatives include a carbapenem (e.g., meropenem) or a fourth-generation cephalosporin (e.g., cefepime).[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com
Treatment course: 10-14 days.
Opções primárias
ceftriaxone: neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours
ou
cefotaxime: neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours
Opções secundárias
meropenem: children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours
ou
cefepime: children ≥2 months of age: 150 mg/kg/day intravenously given in divided doses every 8 hours; adults: 2 g intravenously every 8 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
dexamethasone
Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado
Ideally dexamethasone should be given to all patients older than 6 weeks who present with clinical features of bacterial meningitis.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [104]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2008.02193.x http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com [109]Ramirez D, Nigo M, Hasbun R. 1036. Timing and use of adjunctive steroids in adults with bacterial meningitis: compliance with International guidelines. Open Forum Infect Dis. 2022 Dec 15;9(Suppl 2):ofac492. https://pmc.ncbi.nlm.nih.gov/articles/PMC9751809
In the US, the Infectious Diseases Society of America recommends that dexamethasone be started immediately prior to, or in conjunction with, the first dose of antibiotics and continued for 2-4 days.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
Once the causative organism is isolated, the use of dexamethasone should be reviewed; guidelines recommend that dexamethasone be continued for bacterial meningitis caused by pneumococcus.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com [111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com
Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com
In children, studies have shown corticosteroids have suggested benefit in pneumococcal meningitis.[114]McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA. 1997 Sep 17;278(11):925-31. http://www.ncbi.nlm.nih.gov/pubmed/9302246?tool=bestpractice.com In one meta-analysis of clinical studies published during 1988-1996, adjunctive dexamethasone had confirmed benefit for Haemophilus influenzae type b meningitis and, if commenced with or before antimicrobial therapy, suggested benefit for pneumococcal meningitis in children.[114]McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA. 1997 Sep 17;278(11):925-31. http://www.ncbi.nlm.nih.gov/pubmed/9302246?tool=bestpractice.com
One more recent large meta-analysis found administration of low-dose corticosteroids to be beneficial in children in reducing hearing loss and neurologic sequelae, as well as reducing the mean number of days before resolution of fever.[115]Tian C, Jin S, Zhao Z, et al. Association of corticosteroid treatment With outcomes in pediatric patients with bacterial meningitis: a systematic review and meta-analysis of randomized controlled trials. Clin Ther. 2022 Apr;44(4):551-64. http://www.ncbi.nlm.nih.gov/pubmed/35272859?tool=bestpractice.com
Corticosteroids are not currently recommended in neonates.[59]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22(suppl 3):S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com
Opções primárias
dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and its susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [99]Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America's clinical practice guidelines for healthcare-associated ventriculitis and meningitis. Clin Infect Dis. 2017 Mar;64(6):701-6. https://academic.oup.com/cid/article/64/6/701/3060377 http://www.ncbi.nlm.nih.gov/pubmed/28203777?tool=bestpractice.com
Penicillin-resistant Streptococcus pneumoniae (minimum inhibitory concentration [MIC] ≥2.0 micrograms/mL) or cephalosporin-resistant organisms (MIC ≥1.0 microgram/mL) should be treated with vancomycin plus cefotaxime or ceftriaxone. Alternatives include vancomycin plus a fluoroquinolone (e.g., levofloxacin, moxifloxacin).[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com [137]Cabellos C, Guillem L, Pelegrin I, et al. Penicillin- and cephalosporin-resistant pneumococcal meningitis: treatment in the real world and in guidelines. Antimicrob Agents Chemother. 2022 Dec 20;66(12):e0082022. https://journals.asm.org/doi/10.1128/aac.00820-22 http://www.ncbi.nlm.nih.gov/pubmed/36326246?tool=bestpractice.com
Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[144]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.mdpi.com/1999-4923/15/3/804 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.
Treatment course: 10-14 days.
Opções primárias
vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours
Mais vancomycinAdjust dose according to serum vancomycin level.
--E--
ceftriaxone: neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours
ou
cefotaxime: neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours
Opções secundárias
vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours
Mais vancomycinAdjust dose according to serum vancomycin level.
--E--
levofloxacin: children: consult specialist for guidance on dose; adults 750 mg intravenously every 24 hours
ou
moxifloxacin: children: consult specialist for guidance on dose; adults 400 mg intravenously every 24 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
dexamethasone
Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado
Ideally dexamethasone should be given to all patients older than 6 weeks who present with clinical features of bacterial meningitis.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [104]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2008.02193.x http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com [109]Ramirez D, Nigo M, Hasbun R. 1036. Timing and use of adjunctive steroids in adults with bacterial meningitis: compliance with International guidelines. Open Forum Infect Dis. 2022 Dec 15;9(Suppl 2):ofac492. https://pmc.ncbi.nlm.nih.gov/articles/PMC9751809
In the US, the Infectious Diseases Society of America recommends that dexamethasone be started immediately prior to, or in conjunction with, the first dose of antibiotics and continued for 2-4 days.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
Once the causative organism is isolated, the use of dexamethasone should be reviewed; guidelines recommend that dexamethasone be continued for bacterial meningitis caused by pneumococcus.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com [111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com
Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com
In children, studies have shown corticosteroids have suggested benefit in pneumococcal meningitis.[114]McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA. 1997 Sep 17;278(11):925-31. http://www.ncbi.nlm.nih.gov/pubmed/9302246?tool=bestpractice.com In one meta-analysis of clinical studies published during 1988-1996, adjunctive dexamethasone had confirmed benefit for Haemophilus influenzae type b meningitis and, if commenced with or before antimicrobial therapy, suggested benefit for pneumococcal meningitis in children.[114]McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA. 1997 Sep 17;278(11):925-31. http://www.ncbi.nlm.nih.gov/pubmed/9302246?tool=bestpractice.com
One more recent large meta-analysis found administration of low-dose corticosteroids to be beneficial in children in reducing hearing loss and neurologic sequelae, as well as reducing the mean number of days before resolution of fever.[115]Tian C, Jin S, Zhao Z, et al. Association of corticosteroid treatment With outcomes in pediatric patients with bacterial meningitis: a systematic review and meta-analysis of randomized controlled trials. Clin Ther. 2022 Apr;44(4):551-64. http://www.ncbi.nlm.nih.gov/pubmed/35272859?tool=bestpractice.com
Corticosteroids are not currently recommended in neonates.[59]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22(suppl 3):S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com
Opções primárias
dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours
confirmed infection: Haemophilus influenzae
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and its susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Haemophilus influenzae beta lactamase negative patients should be treated with ampicillin. Alternatives include a third- or fourth-generation cephalosporin (e.g., ceftriaxone, cefepime) or a fluoroquinolone (e.g., levofloxacin, ciprofloxacin).[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com
Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[144]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.mdpi.com/1999-4923/15/3/804 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.
Treatment course: 7-10 days.
Opções primárias
ampicillin: neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours
Opções secundárias
ceftriaxone: neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours
ou
cefepime: children ≥2 months of age: 150 mg/kg/day intravenously given in divided doses every 8 hours; adults: 2 g intravenously every 8 hours
ou
levofloxacin: children: consult specialist for guidance on dose; adults 750 mg intravenously every 24 hours
ou
ciprofloxacin: children: consult specialist for guidance on dose; adults 400 mg intravenously every 8-12 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
dexamethasone
Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado
Ideally dexamethasone should be given to all patients older than 6 weeks who present with clinical features of bacterial meningitis.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [104]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2008.02193.x http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com [109]Ramirez D, Nigo M, Hasbun R. 1036. Timing and use of adjunctive steroids in adults with bacterial meningitis: compliance with International guidelines. Open Forum Infect Dis. 2022 Dec 15;9(Suppl 2):ofac492. https://pmc.ncbi.nlm.nih.gov/articles/PMC9751809
In the US, the Infectious Diseases Society of America recommends that dexamethasone be started immediately prior to, or in conjunction with, the first dose of antibiotics and continued for 2-4 days.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
Once the causative organism is isolated, the use of dexamethasone should be reviewed; guidelines recommend that dexamethasone be continued for bacterial meningitis caused by Haemophilus influenzae type b (Hib).[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com [111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com
Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com
In children, studies have shown corticosteroids likely reduce severe hearing loss in patients with Hib meningitis.[113]Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015 Sep 12;(9):CD004405. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004405.pub5/full http://www.ncbi.nlm.nih.gov/pubmed/26362566?tool=bestpractice.com [114]McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA. 1997 Sep 17;278(11):925-31. http://www.ncbi.nlm.nih.gov/pubmed/9302246?tool=bestpractice.com
One large meta-analysis found administration of low-dose corticosteroids to be beneficial in children in reducing hearing loss and neurologic sequelae, as well as reducing the mean number of days before resolution of fever.[115]Tian C, Jin S, Zhao Z, et al. Association of corticosteroid treatment With outcomes in pediatric patients with bacterial meningitis: a systematic review and meta-analysis of randomized controlled trials. Clin Ther. 2022 Apr;44(4):551-64. http://www.ncbi.nlm.nih.gov/pubmed/35272859?tool=bestpractice.com
Corticosteroids are not currently recommended in neonates.[59]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22(suppl 3):S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com
Opções primárias
dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and its susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Haemophilus influenzae beta-lactamase-positive patients should be treated with cefotaxime or ceftriaxone. Alternatives include a fourth-generation cephalosporin (e.g., cefepime) or a fluoroquinolone (e.g., levofloxacin, ciprofloxacin).[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com
Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[144]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.mdpi.com/1999-4923/15/3/804 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.
Treatment course: 10-14 days.
Opções primárias
ceftriaxone: neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours
ou
cefotaxime: neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours
Opções secundárias
cefepime: children ≥2 months of age: 150 mg/kg/day intravenously given in divided doses every 8 hours; adults: 2 g intravenously every 8 hours
ou
levofloxacin: children: consult specialist for guidance on dose; adults 750 mg intravenously every 24 hours
ou
ciprofloxacin: children: consult specialist for guidance on dose; adults 400 mg intravenously every 8-12 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
dexamethasone
Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado
Ideally dexamethasone should be given to all patients older than 6 weeks who present with clinical features of bacterial meningitis.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [104]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul;15(7):649-59. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2008.02193.x http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com [109]Ramirez D, Nigo M, Hasbun R. 1036. Timing and use of adjunctive steroids in adults with bacterial meningitis: compliance with International guidelines. Open Forum Infect Dis. 2022 Dec 15;9(Suppl 2):ofac492. https://pmc.ncbi.nlm.nih.gov/articles/PMC9751809
In the US, the Infectious Diseases Society of America recommends that dexamethasone be started immediately prior to, or in conjunction with, the first dose of antibiotics and continued for 2-4 days.[6]Mount HR, Boyle SD. Aseptic and bacterial meningitis: evaluation, treatment, and prevention. Am Fam Physician. 2017 Sep 1;96(5):314-22. https://www.aafp.org/pubs/afp/issues/2017/0901/p314.html http://www.ncbi.nlm.nih.gov/pubmed/28925647?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
Once the causative organism is isolated, the use of dexamethasone should be reviewed; guidelines recommend that dexamethasone be continued for bacterial meningitis caused by Haemophilus influenzae type b (Hib).[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com [111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com
Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111]Evidence review for corticosteroids for treatment of bacterial meningitis: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management: Evidence review G4. London: National Institute for Health and Care Excellence (NICE); 2024 Mar. https://www.ncbi.nlm.nih.gov/books/NBK604108 http://www.ncbi.nlm.nih.gov/pubmed/38838177?tool=bestpractice.com
In children, studies have shown corticosteroids likely reduce severe hearing loss in patients with Hib meningitis.[113]Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015 Sep 12;(9):CD004405. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004405.pub5/full http://www.ncbi.nlm.nih.gov/pubmed/26362566?tool=bestpractice.com [114]McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA. 1997 Sep 17;278(11):925-31. http://www.ncbi.nlm.nih.gov/pubmed/9302246?tool=bestpractice.com
One large meta-analysis found administration of low-dose corticosteroids to be beneficial in children in reducing hearing loss and neurologic sequelae, as well as reducing the mean number of days before resolution of fever.[115]Tian C, Jin S, Zhao Z, et al. Association of corticosteroid treatment With outcomes in pediatric patients with bacterial meningitis: a systematic review and meta-analysis of randomized controlled trials. Clin Ther. 2022 Apr;44(4):551-64. http://www.ncbi.nlm.nih.gov/pubmed/35272859?tool=bestpractice.com
Corticosteroids are not currently recommended in neonates.[59]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22(suppl 3):S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com
Opções primárias
dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours
confirmed infection: Streptococcus agalactiae (group B streptococci)
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and its susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Streptococcus agalactiae (group B streptococci) should be treated with either ampicillin or penicillin-G. Alternatives include a third-generation cephalosporin (e.g., ceftriaxone, cefotaxime) or vancomycin.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com
Treatment course: 14-21 days.
Opções primárias
penicillin G potassium: neonates: consult specialist for guidance on dose; children: 250,000 to 400,000 units/kg/day intravenously given in divided doses every 4-6 hours, maximum 24 million units/day; adults: 2 million units intravenously every 2 hours
ou
ampicillin: neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours
Opções secundárias
ceftriaxone: neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours
ou
cefotaxime: neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours
ou
vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours
Mais vancomycinAdjust dose according to serum vancomycin level.
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
confirmed infection: Escherichia coli and other gram-negative Enterobacteriaceae
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and its susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Escherichia coli and other gram-negative Enterobacteriaceae should be treated with ceftriaxone or cefotaxime. Alternatives include aztreonam, a fluoroquinolone (e.g., ciprofloxacin), trimethoprim/sulfamethoxazole, meropenem, or ampicillin.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[144]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.mdpi.com/1999-4923/15/3/804 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.
Treatment course: 21-28 days.
Opções primárias
ceftriaxone: neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours
ou
cefotaxime: neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours
Opções secundárias
meropenem: children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours
ou
aztreonam: neonates: consult specialist for guidance on dose; children: 120-200 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 8 g/day, adults: 2 g intravenously every 6-8 hours
ou
ciprofloxacin: children: consult specialist for guidance on dose; adults 400 mg intravenously every 8-12 hours
ou
sulfamethoxazole/trimethoprim: children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours
Mais sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
ou
ampicillin: neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
confirmed infection: Listeria monocytogenes
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and antibiotic susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Listeria monocytogenes should be treated with gentamicin plus ampicillin or penicillin-G.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com Alternatives include trimethoprim/sulfamethoxazole.
Treatment course: 21-28 days.
Opções primárias
gentamicin: neonates: consult specialist for guidance on dose; children: 2 mg/kg intravenously every 8 hours; adults: 1 mg/kg intravenously every 8 hours
Mais gentamicinAdjust dose according to serum gentamicin level.
--E--
penicillin G potassium: neonates: consult specialist for guidance on dose; children: 250,000 to 400,000 units/kg/day intravenously given in divided doses every 4-6 hours, maximum 24 million units/day; adults: 2 million units intravenously every 2 hours
ou
ampicillin: neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours
Opções secundárias
sulfamethoxazole/trimethoprim: children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours
Mais sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
confirmed infection: Staphylococcus aureus
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and its susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Staphylococcus aureus that is methicillin-susceptible should be treated with nafcillin or oxacillin. Alternatives include vancomycin, linezolid, or daptomycin.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
Treatment course: depends on microbiologic response of cerebrospinal fluid and underlying illness.
Opções primárias
nafcillin: neonates: consult specialist for guidance on dose; children: 200 mg/kg/day intravenously given in divided doses every 6 hours, maximum 12 g/day; adults: 2 g intravenously every 4 hours
ou
oxacillin: neonates: consult specialist for guidance on dose; children: 200 mg/kg/day intravenously given in divided doses every 6 hours, maximum 12 g/day; adults: 2 g intravenously every 4 hours
Opções secundárias
vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours
Mais vancomycinAdjust dose according to serum vancomycin level.
ou
linezolid: neonates: consult specialist for guidance on dose; children: 10 mg/kg intravenously every 8 hours, maximum 600 mg/dose; adults: 600 mg intravenously every 12 hours
ou
daptomycin: children: consult specialist for guidance on dose; adults: 6-10 mg/kg intravenously every 24 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and its susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Staphylococcus aureus that is methicillin-resistant should be treated with vancomycin. Alternatives include trimethoprim/sulfamethoxazole, linezolid, or daptomycin.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
Treatment course: depends on microbiologic response of cerebrospinal fluid and underlying illness.
Opções primárias
vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours
Mais vancomycinAdjust dose according to serum vancomycin level.
Opções secundárias
sulfamethoxazole/trimethoprim: children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours
Mais sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
ou
linezolid: neonates: consult specialist for guidance on dose; children: 10 mg/kg intravenously every 8 hours, maximum 600 mg/dose; adults: 600 mg intravenously every 12 hours
ou
daptomycin: children: consult specialist for guidance on dose; adults: 6-10 mg/kg intravenously every 24 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
confirmed infection: Staphylococcus epidermidis
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and antibiotic susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Staphylococcus epidermidis should be treated with vancomycin. Alternatives include linezolid.[108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com [138]Noguchi T, Nagao M, Yamamoto M, et al. Staphylococcus epidermidis meningitis in the absence of a neurosurgical device secondary to catheter-related bloodstream infection: a case report and review of the literature. J Med Case Rep. 2018 Apr 25;12(1):106. https://jmedicalcasereports.biomedcentral.com/articles/10.1186/s13256-018-1646-7 http://www.ncbi.nlm.nih.gov/pubmed/29690925?tool=bestpractice.com
Treatment course: depends on microbiologic response of cerebrospinal fluid and underlying illness.
Opções primárias
vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours
Mais vancomycinAdjust dose according to serum vancomycin level.
Opções secundárias
linezolid: neonates: consult specialist for guidance on dose; children: 10 mg/kg intravenously every 8 hours, maximum 600 mg/dose; adults: 600 mg intravenously every 12 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
confirmed infection: Pseudomonas aeruginosa
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and its susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Pseudomonas aeruginosa should be treated with ceftazidime. Alternatives include meropenem.[108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com [139]Fong IW, Tomkins KB. Review of Pseudomonas aeruginosa meningitis with special emphasis on treatment with ceftazidime. Rev Infect Dis. 1985 Sep-Oct;7(5):604-12. http://www.ncbi.nlm.nih.gov/pubmed/3903939?tool=bestpractice.com [140]Pai S, Bedford L, Ruramayi R, et al. Pseudomonas aeruginosa meningitis/ventriculitis in a UK tertiary referral hospital. QJM. 2016 Feb;109(2):85-9. http://www.ncbi.nlm.nih.gov/pubmed/25991873?tool=bestpractice.com
Treatment course: 21 days.
Opções primárias
ceftazidime sodium: neonates: consult specialist for guidance on dose; children: 150-200 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 6 g/day; adults: 2 g intravenously every 8 hours
Opções secundárias
meropenem: children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
confirmed infection: Enterococcus species
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and antibiotic susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [99]Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America's clinical practice guidelines for healthcare-associated ventriculitis and meningitis. Clin Infect Dis. 2017 Mar;64(6):701-6. https://academic.oup.com/cid/article/64/6/701/3060377 http://www.ncbi.nlm.nih.gov/pubmed/28203777?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Enterococcus species should be treated with ampicillin plus gentamicin.[99]Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America's clinical practice guidelines for healthcare-associated ventriculitis and meningitis. Clin Infect Dis. 2017 Mar;64(6):701-6. https://academic.oup.com/cid/article/64/6/701/3060377 http://www.ncbi.nlm.nih.gov/pubmed/28203777?tool=bestpractice.com [141]Iaria C, Stassi G, Costa GB, et al. Enterococcal meningitis caused by Enterococcus casseliflavus. First case report. BMC Infect Dis. 2005 Jan 14;5(1):3. https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-5-3 http://www.ncbi.nlm.nih.gov/pubmed/15649336?tool=bestpractice.com [142]Khanum I, Anwar S, Farooque A. Enterococcal meningitis/ventriculitis: a tertiary care experience. Asian J Neurosurg. 2019 Jan-Mar;14(1):102-5. https://pmc.ncbi.nlm.nih.gov/articles/PMC6417351 http://www.ncbi.nlm.nih.gov/pubmed/30937018?tool=bestpractice.com Alternatives include vancomycin plus gentamicin (if ampicillin resistant), or linezolid (if ampicillin and vancomycin resistant).[108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
Treatment course: 21 days.
Opções primárias
gentamicin: neonates: consult specialist for guidance on dose; children: 2 mg/kg intravenously every 8 hours; adults: 1 mg/kg intravenously every 8 hours
Mais gentamicinAdjust dose according to serum gentamicin level.
e
ampicillin: neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours
Opções secundárias
gentamicin: neonates: consult specialist for guidance on dose; children: 2 mg/kg intravenously every 8 hours; adults: 1 mg/kg intravenously every 8 hours
Mais gentamicinAdjust dose according to serum gentamicin level.
e
vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours
Mais vancomycinAdjust dose according to serum vancomycin level.
ou
linezolid: neonates: consult specialist for guidance on dose; children: 10 mg/kg intravenously every 8 hours, maximum 600 mg/dose; adults: 600 mg intravenously every 12 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
confirmed infection: Acinetobacter species
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and antibiotic susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Acinetobacter species should be treated with meropenem with or without gentamicin. An alternative regimen (in cases of resistance) includes polymyxin B (given intrathecally) plus an aminoglycoside with or without rifampin.[143]Kim BN, Peleg AY, Lodise TP, et al. Management of meningitis due to antibiotic-resistant Acinetobacter species. Lancet Infect Dis. 2009 Apr;9(4):245-55. https://pmc.ncbi.nlm.nih.gov/articles/PMC2760093 http://www.ncbi.nlm.nih.gov/pubmed/19324297?tool=bestpractice.com
Treatment course: 21 days.
Opções primárias
meropenem: children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours
ou
meropenem: children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours
e
gentamicin: children: 2 mg/kg intravenously every 8 hours; adults: 1 mg/kg intravenously every 8 hours
Mais gentamicinAdjust dose according to serum gentamicin level.
Opções secundárias
polymyxin B: children <2 years of age: 25,000 units intrathecally once daily on alternate days; children ≥2 years of age: 50,000 units intrathecally once daily for 3-4 days, followed by 50,000 units once daily on alternate days; adults: 50,000 units intrathecally once daily
e
gentamicin: neonates: consult specialist for guidance on dose; children: 2 mg/kg intravenously every 8 hours; adults: 1 mg/kg intravenously every 8 hours
Mais gentamicinAdjust dose according to serum gentamicin level.
ou
polymyxin B: children <2 years of age: 25,000 units intrathecally once daily on alternate days; children ≥2 years of age: 50,000 units intrathecally once daily for 3-4 days, followed by 50,000 units once daily on alternate days; adults: 50,000 units intrathecally once daily
e
gentamicin: neonates: consult specialist for guidance on dose; children: 2 mg/kg intravenously every 8 hours; adults: 1 mg/kg intravenously every 8 hours
Mais gentamicinAdjust dose according to serum gentamicin level.
e
rifampin: children: consult specialist for guidance on dose; adults: 600 mg intravenously every 12 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
confirmed infection: Neisseria meningitidis
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and antibiotic susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Neisseria meningitidis that is penicillin-susceptible (MIC <0.1 microgram/mL) should be treated with ampicillin or penicillin-G. Alternatives include a third-generation cephalosporin (e.g., ceftriaxone).[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
Treatment course: 7 days.
Opções primárias
penicillin G potassium: neonates: consult specialist for guidance on dose; children: 250,000 to 400,000 units/kg/day intravenously given in divided doses every 4-6 hours, maximum 24 million units/day; adults: 2 million units intravenously every 2 hours
ou
ampicillin: neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours
Opções secundárias
ceftriaxone: neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
targeted antibiotic therapy
After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and antibiotic susceptibilities.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com [107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started.
Neisseria meningitidis that is penicillin-intermediate susceptible (MIC=0.1 to 1.0 microgram/mL) should be treated with cefotaxime or ceftriaxone. Alternatives include a fluoroquinolone (e.g., levofloxacin, ciprofloxacin) or meropenem.[107]Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA. 2022 Dec 6;328(21):2147-54. http://www.ncbi.nlm.nih.gov/pubmed/36472590?tool=bestpractice.com [108]Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. https://academic.oup.com/cid/article/39/9/1267/402080 http://www.ncbi.nlm.nih.gov/pubmed/15494903?tool=bestpractice.com
Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[144]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.mdpi.com/1999-4923/15/3/804 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.
Treatment course: 7 days.
Opções primárias
ceftriaxone: neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours
ou
cefotaxime: neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours
Opções secundárias
meropenem: children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours
ou
levofloxacin: children: consult specialist for guidance on dose; adults: 750 mg intravenously every 24 hours
ou
ciprofloxacin: children: consult specialist for guidance on dose; adults: 400 mg intravenously every 8-12 hours
supportive therapy
Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado
Patients with symptoms of compensated shock (neurologic status usually remains normal, but the pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive supplemental oxygen. Those with decompensated shock (signs of compensated shock plus hypotension), hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy to control and prevent seizures (e.g., lorazepam, diazepam, phenytoin), and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[9]Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003 Jun 21;361(9375):2139-48. http://www.ncbi.nlm.nih.gov/pubmed/12826449?tool=bestpractice.com
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. Consult a specialist for guidance on suitable vasopressor/inotrope regimens.
If the patient is hypovolemic or in shock, additional intravenous fluids must be given.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
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Observe que as formulações/vias e doses podem diferir entre nomes e marcas de medicamentos, formulários de medicamentos ou localidades. As recomendações de tratamento são específicas para os grupos de pacientes. Ver aviso legal
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