The Center For Disease Dynamics, Economics & Policy

Suspected Acute Bacterial Meningitis (Community-Acquired)

Clinical definition:

Inflammation of meninges of the brain and spinal cord. Clinical features may be non-specific in neonates and young infants (e.g. poor feeding, apathy, jaundice, apnoea, full fontanelle, fever, hypothermia) and in older infants may include irritability, drowsiness, poor feeding, high fever, and/or vomiting. Older children may present similarly to adults with headache, fever, photophobia, vomiting, neck stiffness, and/or altered level of consciousness. Common bacterial pathogens in neonates and young infants include Streptococcus agalactiae (Group B streptococcus), E. coli, Klebsiella species, L. monocytogenes, and in older infants and children: S. pneumoniae, H. influenzae, and N. meningitidis.

 

Neonate
Preferred antibiotic choice
Drug(s) Formulation Dosage Duration
Combination therapy with:

Cefotaxime (IV)

PLUS

Ampicillin (IV)

Cefotaxime- Powder for injection: 250 or 500 mg per vial (as sodium salt) o   First week of life (7 days or less): 50 mg/kg/dose 12 hourly

o   8-20 days: 50 mg/kg/dose 8 hourly

o   21 days & older: 50 mg/kg/dose 6 hourly

Treat with ampicillin (for Listeria coverage) until CSF culture results confirm aetiology. If CSF culture is not available, treat with cefotaxime plus ampicillin for 14 – 21 days.
Ampicillin- Powder for injection: 500mg, 1g (as sodium salt) in vial o   First week of life (7 days or less): 100 mg/kg/dose 8 hourly

o   8 days of age and older: 100 mg/kg/dose 6 hourly

If cefotaxime is not available, use
Combination therapy with:

Ceftriaxone (IV)

PLUS

Ampicillin (IV)

(Except in neonates with jaundice and neonates receiving calcium-containing IV fluids)

Powder for injection: 250 mg; 1 g (as sodium salt) in vial 50 mg/kg/dose 12 hourly Treat with ampicillin (for Listeria coverage) until CSF culture results confirm aetiology. If CSF culture is not available, treat with ceftriaxone plus ampicillin for 14-21 days.
Ampicillin- Powder for injection: 500mg, 1g (as sodium salt) in vial o   First week of life (7 days or less): 100 mg/kg/dose 8 hourly

o   8 days of age and older: 100 mg/kg/dose 6 hourly

Infant (Older than 28 days), Child & Adolescent
Preferred antibiotic choice
Drug Formulation1 Dosage Duration
Ceftriaxone (IV) Powder for injection: 250 mg; 1 g (as sodium salt) in vial 50 mg/kg/dose 12 hourly, maximum dose 2 g 12 hourly 10 – 14 days
Alternative antibiotic choice only if cefotaxime/ceftriaxone is not available
Ampicillin (IV) Powder for injection: 500 mg; 1 g (as sodium salt) in vial 50 mg/kg/dose 6 hourly, maximum dose: 2 g 6 hourly 10 – 14 days

Principles of Stewardship:

  • Acute meningitis may be caused by a range of pathogens, some of which are not bacteria. Microbiologic diagnosis, including CSF gram stain/microscopy, bacterial culture and AST should be obtained as soon as possible, if available, as this may allow empiric antibiotic treatment to be adjusted to target the specific pathogen identified and inform the duration of treatment. In the absence of a positive CSF culture or PCR result, a positive blood culture result together with a CSF cell count and chemistry suggestive of bacterial meningitis may be useful in guiding antibiotic selection and duration of treatment. Although guidelines differ in treatment duration recommendations for specific pathogens, a general recommendation for uncomplicated meningitis is Gram negative organisms and Listeria 21 days, Group B Streptococcus 14-21 days, pneumoniae 10-14 days, H. influenzae 7-10 days, N. meningitidis 5-7 days.
  • In patients with a positive CSF culture, repeat lumbar puncture 24-48 hours after initiation of antimicrobial treatment to document CSF sterilization is useful (particularly in neonates) as delayed sterilization may be an indication of complications such as a purulent focus requiring intervention or antibiotic resistance.
  • If CSF is obtained and is not consistent with meningitis (e.g. absence of cells and normal chemistry), antibiotics should be stopped or adjusted depending on whether an alternative diagnosis has been reached.
  • Consider diagnostic tests for tuberculous and cryptococcal meningitis, particularly in high HIV-burden areas.

Notes:

  • Complications include subdural empyema and brain abscess which may require neurosurgical intervention in addition to treatment with the above-mentioned antimicrobial therapy.
  • In children and adolescents with a ventriculoperitoneal (VP) shunt presenting with meningitis, seek expert opinion and refer patient to a specialist where possible.