Suggested regimens | Comments | |
Usual empiric regimen | Box A | This regimen covers pneumococcus and meningococcus (the two most common causes of bacterial meningitis in infants and children), Hib, and GBS. |
OR
| ||
Special circumstances | ||
CSF Gram stain shows GNR | Add an aminoglycoside to the regimen in Box A:
OR
If there is concern for resistant GNR infection, meropenem should be substituted for ceftriaxone/cefotaxime:
| |
Patients treated with adjunctive dexamethasone | Some experts suggest adding rifampin to the regimen in Box A:
| The rationale for adding rifampin is based on the concern that the entry of vancomycin into the CSF may be reduced by adjunctive dexamethasone. |
Neutropenic patients with malignancy | Box B | S. aureus and gram-negative organisms are potential pathogens (in addition to usual pathogens such as pneumococcus and meningococcus). |
OR
OR
OR
| ||
Impaired cell-mediated immunity (eg, renal transplant recipients) | Add high-dose ampicillin to the regimen in Box A:
| Listeria is a potential pathogen (in addition to usual pathogens such as pneumococcus and meningococcus). |
Recent neurosurgery and/or medical device in place (CSF drain, CSF shunt, or cochlear implant) | The regimen in Box A is adequate for most patients Alternative regimens:
OR
OR
Optimal management also includes removal/replacement of the CSF drain or shunt, if present | Coagulase-negative staphylococci, S. aureus, and enteric gram-negative rods are potential pathogens (in addition to usual pathogens like pneumococcus). |
Basilar skull fracture/CSF leak | The regimen in Box A is adequate for most patients | Pneumococcus is the most likely pathogen in this setting; H. influenzae is another potential pathogen. |
Penetrating head trauma | Same as in Box B | S. aureus, coagulase-negative staphylococci, and aerobic gram-negative bacilli (including P. aeruginosa) are potential pathogens (in addition to usual pathogens like pneumococcus). |
Anatomic defects (eg, dermal sinus) | The regimen in Box A is adequate for most patients An aminoglycoside is added if CSF Gram stain shows GNR | Coagulase-negative staphylococci, S. aureus, and enteric gram-negative rods are potential pathogens. |
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