Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

≤1 month of age and immunocompetent

1st line – empiric antibiotic therapy

Back
INITIAL
|
≤1 month of age and immunocompetent
1st line – 

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][99][104]

The choice of empiric antibiotic depends on the patient's age and conditions that may have predisposed the patient to meningitis.​[107]​ The regimen chosen must be broad enough to cover the potential organisms for the age group affected, with consideration for regional susceptibility rates.[59]

The recommended regimen is ampicillin plus cefotaxime.[59][104][107]​​​ 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]

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][107]

Primary options

ampicillin: consult specialist for guidance on neonatal dose

and

cefotaxime: consult specialist for guidance on neonatal dose

Secondary options

ampicillin: consult specialist for guidance on neonatal dose

and

gentamicin: consult specialist for guidance on neonatal dose

Plus – supportive therapy

Back
INITIAL
|
≤1 month of age and immunocompetent
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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]

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

1st line – empiric antibiotic therapy

Back
INITIAL
|
>1 month and <50 years of age and immunocompetent
1st line – 

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][99][104]

The choice of empiric antibiotic depends on the patient's age and conditions that may have predisposed the patient to meningitis.[107] The regimen chosen must be broad enough to cover the potential organisms for the age group affected, with consideration for regional susceptibility rates.[59]

The recommended regimen is cefotaxime or ceftriaxone plus vancomycin.[59][104][107]​ If a cephalosporin cannot be administered (e.g., patients with an allergy), a carbapenem (e.g., meropenem) plus vancomycin can be considered.[1][108]

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][107]

Primary options

vancomycin: children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

More

-- AND --

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

or

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

Secondary options

vancomycin: children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

More

and

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

Plus – supportive therapy

Back
INITIAL
|
>1 month and <50 years of age and immunocompetent
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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.

Consider – dexamethasone

Back
INITIAL
|
>1 month and <50 years of age and immunocompetent
Consider – 

dexamethasone

Treatment recommended for SOME patients in selected patient group

Ideally dexamethasone should be given to all patients older than 6 weeks who present with clinical features of bacterial meningitis.[6][64][104]​​[109]

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][108]​​ European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64][108]​​

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][108][111]

Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111] 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]

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] 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] 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]

​The use of adjunctive dexamethasone in Listeria meningitis is controversial, and until more studies are performed it is not recommended.[117][118]

Primary options

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

1st line – empiric antibiotic therapy

Back
INITIAL
|
≥50 years of age or immunocompromised
1st line – 

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][99][104]

The choice of empiric antibiotic depends on the patient's age and conditions that may have predisposed the patient to meningitis.[107]​ The regimen chosen must be broad enough to cover the potential organisms for the age group affected, with consideration for regional susceptibility rates.[59]

The recommended regimen is ampicillin plus cefotaxime or ceftriaxone plus vancomycin.[59][104][107] 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][107]

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][107]

Primary options

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

-- AND --

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

More

-- AND --

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

or

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

Secondary options

sulfamethoxazole/trimethoprim: children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours

More

-- AND --

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

More

-- AND --

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

or

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

Plus – supportive therapy

Back
INITIAL
|
≥50 years of age or immunocompromised
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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.

Plus – dexamethasone

Back
INITIAL
|
≥50 years of age or immunocompromised
Plus – 

dexamethasone

Treatment recommended for ALL patients in selected patient group

Ideally dexamethasone should be given to all patients older than 6 weeks of age who present with clinical features of bacterial meningitis.[6][64]​​[104]​​[109]

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][108]​​ European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64][108]​​

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][108][111]

Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111] 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]

The use of adjunctive dexamethasone in Listeria meningitis is controversial, and until more studies are performed it is not recommended.[117][118]

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][110]​​

Primary options

dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours

ACUTE

confirmed infection: Streptococcus pneumoniae

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Streptococcus pneumoniae
|
penicillin-susceptible
1st line – 

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][107]​ 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]

Treatment course: 10-14 days.

Primary options

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

OR

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

Secondary options

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

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Streptococcus pneumoniae
|
penicillin-susceptible
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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.

Consider – dexamethasone

Back
ACUTE
|
confirmed infection: Streptococcus pneumoniae
|
penicillin-susceptible
Consider – 

dexamethasone

Treatment recommended for SOME patients in selected patient group

Ideally dexamethasone should be given to all patients older than 6 weeks who present with clinical features of bacterial meningitis.[6][64]​​[104]​​[109]

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][108]​​ European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64][108]​​

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][108][111]

Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111]

In children, studies have shown corticosteroids have suggested benefit in pneumococcal meningitis.[114] 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]

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]

Corticosteroids are not currently recommended in neonates.[59]

Primary options

dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Streptococcus pneumoniae
|
penicillin-intermediate sensitivity
1st line – 

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][107]​ 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]​ 

Treatment course: 10-14 days.

Primary options

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

OR

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

Secondary options

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

OR

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

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Streptococcus pneumoniae
|
penicillin-intermediate sensitivity
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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.

Consider – dexamethasone

Back
ACUTE
|
confirmed infection: Streptococcus pneumoniae
|
penicillin-intermediate sensitivity
Consider – 

dexamethasone

Treatment recommended for SOME patients in selected patient group

Ideally dexamethasone should be given to all patients older than 6 weeks who present with clinical features of bacterial meningitis.[6][64]​​[104]​​[109]

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][108]​​ European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64][108]​​

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][108][111]

Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111]

In children, studies have shown corticosteroids have suggested benefit in pneumococcal meningitis.[114]​ 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]

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]

Corticosteroids are not currently recommended in neonates.[59]

Primary options

dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Streptococcus pneumoniae
|
penicillin-resistant
1st line – 

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][99]

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]​​[108]​​[137]

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]​ 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.

Primary options

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

More

-- AND --

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

or

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

Secondary options

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

More

-- AND --

levofloxacin: children: consult specialist for guidance on dose; adults 750 mg intravenously every 24 hours

or

moxifloxacin: children: consult specialist for guidance on dose; adults 400 mg intravenously every 24 hours

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Streptococcus pneumoniae
|
penicillin-resistant
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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.

Consider – dexamethasone

Back
ACUTE
|
confirmed infection: Streptococcus pneumoniae
|
penicillin-resistant
Consider – 

dexamethasone

Treatment recommended for SOME patients in selected patient group

Ideally dexamethasone should be given to all patients older than 6 weeks who present with clinical features of bacterial meningitis.[6][64]​​[104]​​​[109]

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][108]​​ European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64][108]​​

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][108][111]

Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111]

In children, studies have shown corticosteroids have suggested benefit in pneumococcal meningitis.[114] 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]

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]

Corticosteroids are not currently recommended in neonates.[59]

Primary options

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

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Haemophilus influenzae
|
beta-lactamase-negative
1st line – 

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][107] 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]

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] 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.

Primary options

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

Secondary options

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

OR

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

OR

levofloxacin: children: consult specialist for guidance on dose; adults 750 mg intravenously every 24 hours

OR

ciprofloxacin: children: consult specialist for guidance on dose; adults 400 mg intravenously every 8-12 hours

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Haemophilus influenzae
|
beta-lactamase-negative
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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.

Consider – dexamethasone

Back
ACUTE
|
confirmed infection: Haemophilus influenzae
|
beta-lactamase-negative
Consider – 

dexamethasone

Treatment recommended for SOME patients in selected patient group

Ideally dexamethasone should be given to all patients older than 6 weeks who present with clinical features of bacterial meningitis.[6][64]​​[104]​​[109]

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][108]​​​ European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64][108]​​

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][108][111]

Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111]

In children, studies have shown corticosteroids likely reduce severe hearing loss in patients with Hib meningitis.[113][114]

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]

Corticosteroids are not currently recommended in neonates.[59]

Primary options

dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Haemophilus influenzae
|
beta-lactamase-positive
1st line – 

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][107]​ 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]

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] 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.

Primary options

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

OR

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

Secondary options

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

OR

levofloxacin: children: consult specialist for guidance on dose; adults 750 mg intravenously every 24 hours

OR

ciprofloxacin: children: consult specialist for guidance on dose; adults 400 mg intravenously every 8-12 hours

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Haemophilus influenzae
|
beta-lactamase-positive
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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.

Consider – dexamethasone

Back
ACUTE
|
confirmed infection: Haemophilus influenzae
|
beta-lactamase-positive
Consider – 

dexamethasone

Treatment recommended for SOME patients in selected patient group

Ideally dexamethasone should be given to all patients older than 6 weeks who present with clinical features of bacterial meningitis.[6][64]​​[104]​​​[109]

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]​​[108]​​ European and UK guidelines recommend starting dexamethasone shortly before or in conjunction with antibiotics, or within 4-12 hours if already commenced, respectively.[64][108]​​

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][108][111]

Evidence suggests that there is benefit from high-dose dexamethasone in reducing mortality and hearing impairment in adults with bacterial meningitis.[111]

In children, studies have shown corticosteroids likely reduce severe hearing loss in patients with Hib meningitis.[113][114]

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]

Corticosteroids are not currently recommended in neonates.[59]

Primary options

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)

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Streptococcus agalactiae (group B streptococci)
1st line – 

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][107]​ 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]

Treatment course: 14-21 days.

Primary options

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

OR

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

Secondary options

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

OR

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

OR

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

More

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Streptococcus agalactiae (group B streptococci)
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Escherichia coli and other gram-negative Enterobacteriaceae
1st line – 

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][107]​ 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][108]​​ 

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] 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.

Primary options

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

OR

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

Secondary options

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

OR

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

OR

ciprofloxacin: children: consult specialist for guidance on dose; adults 400 mg intravenously every 8-12 hours

OR

sulfamethoxazole/trimethoprim: children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours

More

OR

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

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Escherichia coli and other gram-negative Enterobacteriaceae
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Listeria monocytogenes
1st line – 

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][107] 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][108]​ Alternatives include trimethoprim/sulfamethoxazole.

Treatment course: 21-28 days.

Primary options

gentamicin: neonates: consult specialist for guidance on dose; children: 2 mg/kg intravenously every 8 hours; adults: 1 mg/kg intravenously every 8 hours

More

-- AND --

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

or

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

Secondary options

sulfamethoxazole/trimethoprim: children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours

More

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Listeria monocytogenes
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Staphylococcus aureus
|
methicillin-susceptible
1st line – 

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][107] 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][108]

Treatment course: depends on microbiologic response of cerebrospinal fluid and underlying illness.

Primary options

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

OR

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

Secondary options

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

More

OR

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

OR

daptomycin: children: consult specialist for guidance on dose; adults: 6-10 mg/kg intravenously every 24 hours

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Staphylococcus aureus
|
methicillin-susceptible
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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.

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Staphylococcus aureus
|
methicillin-resistant
1st line – 

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][107]​ 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][108]

Treatment course: depends on microbiologic response of cerebrospinal fluid and underlying illness.

Primary options

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

More

Secondary options

sulfamethoxazole/trimethoprim: children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours

More

OR

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

OR

daptomycin: children: consult specialist for guidance on dose; adults: 6-10 mg/kg intravenously every 24 hours

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Staphylococcus aureus
|
methicillin-resistant
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Staphylococcus epidermidis
1st line – 

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][107]​ 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][138]​​​

Treatment course: depends on microbiologic response of cerebrospinal fluid and underlying illness.

Primary options

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

More

Secondary options

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

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Staphylococcus epidermidis
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Pseudomonas aeruginosa
1st line – 

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][107]​ 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][139][140]​​​​ ​

Treatment course: 21 days.

Primary options

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

Secondary options

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

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Pseudomonas aeruginosa
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Enterococcus species
1st line – 

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][99] 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][141][142]​​ ​Alternatives include vancomycin plus gentamicin (if ampicillin resistant), or linezolid (if ampicillin and vancomycin resistant).[108]

Treatment course: 21 days.

Primary options

gentamicin: neonates: consult specialist for guidance on dose; children: 2 mg/kg intravenously every 8 hours; adults: 1 mg/kg intravenously every 8 hours

More

and

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

Secondary options

gentamicin: neonates: consult specialist for guidance on dose; children: 2 mg/kg intravenously every 8 hours; adults: 1 mg/kg intravenously every 8 hours

More

and

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

More

OR

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

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Enterococcus species
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Acinetobacter species
1st line – 

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][107]​ 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]

Treatment course: 21 days.

Primary options

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

OR

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

and

gentamicin: children: 2 mg/kg intravenously every 8 hours; adults: 1 mg/kg intravenously every 8 hours

More

Secondary options

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

and

gentamicin: neonates: consult specialist for guidance on dose; children: 2 mg/kg intravenously every 8 hours; adults: 1 mg/kg intravenously every 8 hours

More

OR

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

and

gentamicin: neonates: consult specialist for guidance on dose; children: 2 mg/kg intravenously every 8 hours; adults: 1 mg/kg intravenously every 8 hours

More

and

rifampin: children: consult specialist for guidance on dose; adults: 600 mg intravenously every 12 hours

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Acinetobacter species
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Neisseria meningitidis
|
penicillin-susceptible
1st line – 

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][107]​ 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][108]​​ 

Treatment course: 7 days.

Primary options

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

OR

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

Secondary options

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

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Neisseria meningitidis
|
penicillin-susceptible
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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.

1st line – targeted antibiotic therapy

Back
ACUTE
|
confirmed infection: Neisseria meningitidis
|
penicillin-intermediate sensitivity
1st line – 

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][107]​ 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][108]

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] 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.

Primary options

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

OR

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

Secondary options

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

OR

levofloxacin: children: consult specialist for guidance on dose; adults: 750 mg intravenously every 24 hours

OR

ciprofloxacin: children: consult specialist for guidance on dose; adults: 400 mg intravenously every 8-12 hours

Plus – supportive therapy

Back
ACUTE
|
confirmed infection: Neisseria meningitidis
|
penicillin-intermediate sensitivity
Plus – 

supportive therapy

Treatment recommended for ALL patients in selected patient group

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.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

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]

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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