Internal Medicine

0521779407-01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:45

20 Acute Bacterial Meningitis

■Blood culture× 2

■If increased ICP or focality, start empiric antibiotics based on

patient’s age and circumstances and send for CT of head without

contrast

■If CT nonfocal and safe for LP, proceed to lumbar puncture

■If neurologic exam normal, LP and base therapy on STAT Gram stain

of CSF

■If CSF consistent with bacterial meningitis and positive Gram stain,

start specific antibiotics. If consistent with bacterial meningitis with

a negative CSF Gram stain, start empiric antibiotics

General Measures

■Rigorous supportive care

■Dexamethasone IV before antibiotics and q6h×2 d for children

>1 mo and consider for adults with increased ICP or coma

specific therapy

Indications

■If strongly suspect meningitis, start IV antibiotics as soon as blood

cultures drawn

Treatment options

■Empiric antibiotics (1):

➣Age 18–50: ceftriaxone or cefotaxime+/−vancomycin (2)

➣>50 years: ampicillin+ceftriaxone or cefotaxime+/−van-

comycin (2)

➣Immunocompromised: vancomycin+ampicillin+cetazadime

➣Skull fracture: ceftriaxone or cefotaxime+/−vancomycin (2)

➣Head trauma, neurosurgery, CSF shunt: vancomycin+ceftaza-

dime

■Positive CSF Gram stain in community-acquired meningitis (1):

➣Gram-positive cocci: ceftriaxone or cefotaxime+vancomycin (1)

➣Gram-positive rods: ampicillin or penicillin G+/−gentamicin

➣Gram-negative rod: ceftriaxone or cefotaxime

(1) Modify antibiotics once organism and its susceptibility are

known; organism must be fully sensitive to antibiotic used.

(2) If prevalence of third-generation cephalosporin-interme-

diate+resistant S. pneumoniae exceeds 5%, add vancomy

cin until organism proved susceptible; if intermediate

or resistant to cephalosporins, continue vancomycin and cef

triaxone or cefotaxime for possible synergy; if penicillin-

susceptible, narrow to penicillin G; if penicillin-non-susceptible