Microorganism, susceptibility | Standard therapy | Alternative therapies¶ |
Streptococcus pneumoniae | ||
Penicillin MIC | ||
≤0.06 mcg/mL | Penicillin G or ampicillin | Third-generation cephalosporinΔ, chloramphenicol |
≥0.12 mcg/mL | ||
Third-generation cephalosporinΔ MIC <1 mcg/mL | Third-generation cephalosporinΔ | Cefepime, meropenem |
Third-generation cephalosporinΔ MIC ≥1 mcg/mL | Vancomycin plus a third-generation cephalosporinΔ◊ | Fluoroquinolone§ |
Neisseria meningitidis | ||
Penicillin MIC | ||
<0.1 mcg/mL | Penicillin G or ampicillin | Third-generation cephalosporinΔ, chloramphenicol |
0.1 to 1.0 mcg/mL | Third-generation cephalosporinΔ | Fluoroquinolone, meropenem, chloramphenicol |
Listeria monocytogenes | Ampicillin¥ or penicillin G¥ | Trimethoprim-sulfamethoxazole |
Streptococcus agalactiae (group B Streptococcus) | Ampicillin or penicillin G | Third-generation cephalosporinΔ |
Escherichia coli and other Enterobacteriaceae‡ | Third-generation cephalosporinΔ | Aztreonam, fluoroquinolone, meropenem, trimethoprim-sulfamethoxazole, ampicillin |
Pseudomonas aeruginosa‡ | Cefepime or ceftazidime | Aztreonam, ciprofloxacin, meropenem |
Acinetobacter baumannii | Meropenem | Colistin (usually formulated as colistimethate sodium)† or polymyxin B† |
Haemophilus influenzae | ||
Beta-lactamase negative | Ampicillin | Third-generation cephalosporinΔ, cefepime, fluoroquinolone, aztreonam, chloramphenicol |
Beta-lactamase positive | Third-generation cephalosporinΔ | Cefepime, fluoroquinolone, aztreonam, chloramphenicol |
Staphylococcus aureus | ||
Methicillin susceptible | Nafcillin or oxacillin | Vancomycin, meropenem, linezolid, daptomycin** |
Methicillin resistant | Vancomycin¶¶ | Trimethoprim-sulfamethoxazole, linezolid, daptomycin** |
Staphylococcus epidermidis | Vancomycin¶¶ | Linezolid |
Enterococcus species | ||
Ampicillin susceptible | Ampicillin plus gentamicin | – |
Ampicillin resistant | Vancomycin plus gentamicin | – |
Ampicillin and vancomycin resistant | Linezolid | – |
MIC: minimum inhibitory concentration.
* For recommended dosages, refer to the UpToDate table on the recommended intravenous doses of antimicrobial therapy for adults with bacterial meningitis.
¶ There may not be clinical data to support all recommendations for alternative antibiotics in patients with bacterial meningitis, but specific agents are recommended based on cerebrospinal fluid (CSF) penetration in experimental animal models and in vitro activity against the offending organism.
Δ Ceftriaxone or cefotaxime.
◊ Consider addition of rifampin if the MIC of ceftriaxone is >2 mcg/mL.
§ Moxifloxacin is recommended given its excellent CSF penetration and in vitro activity against Streptococcus pneumoniae, although there are no clinical data available. If used, many authorities would combine moxifloxacin with vancomycin or a third-generation cephalosporin (cefotaxime or ceftriaxone).
¥ Addition of an aminoglycoside should be considered.
‡ Choice of a specific antimicrobial regimen must be guided by in vitro susceptibility test results.
† Should be administered not only by the intravenous route but also by the intraventricular or intrathecal route.
** Daptomycin has poor central nervous system penetration and is generally not recommended; if used because other alternatives are not available, it should be combined with rifampin therapy.
¶¶ Consider addition of rifampin.Modified with permission from: Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267. Copyright © 2004 University of Chicago Press.
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