Management of bacterial meningitis in secondary care

management in secondary care

Antibiotics for suspected bacterial meningitis or meningococcal disease (1)

• in children and young people aged 3 months or older with suspected bacterial meningitis - treat without delay using intravenous ceftriaxone
• in children younger than 3 months with suspected bacterial meningitis - treat without delay using intravenous cefotaxime plus either amoxicillin or ampicillin
  • ceftriaxone may be used as an alternative to cefotaxime (with or without ampicillin or amoxicillin), but be aware that ceftriaxone should not be used in premature babies or in babies with jaundice, hypoalbuminaemia or acidosis as it may exacerbate hyperbilirubinaemia
• treat children and young people with suspected bacterial meningitis who have recently travelled outside the UK or have had prolonged or multiple exposure to antibiotics (within the past 3 months) with vancomycin in addition to the above antibiotics
• where ceftriaxone is used, do not administer it at the same time as calcium-containing infusions, instead, use cefotaxime.
• if tuberculous meningitis is part of the differential diagnosis, use antibiotic treatment appropriate for tuberculous meningitis
• if herpes simplex meningoencephalitis is part of the differential diagnosis give appropriate antiviral treatment

Specific antibiotic treatment of bacterial meningitis based on causative organism:

All antibiotic treatment should be checked and discussed with a microbiologist.

• pneumococcus
  • treat S pneumoniae meningitis with intravenous ceftriaxone or cefotaxime
  • if organism is penicillin sensitive treatment may include: IV benzylpenicillin, IV ceftriaxone or IV cefotaxime
  • if penicillin resistant but cephalosporin sensitive then cefotaxime or ceftriaxone should be continued
  • add vancomycin if resistant to cephalosporin or penicillin
  • duration in confirmed pneumococcal meningitis
    • patients who have recovered by day 10, treatment could be stopped
    • patients who have not recovered by day 10, 14 days treatment should be given
    • patients with penicillin or cephalosporin resistant, treatment should be continued for 14 days
• meningococcus
  • in patients with confirmed meningococcal disease
    • ceftriaxone or cefotaxime can be used
    • alternative - benzylpenicillin
    • if recovered by day 5 treatment can be stopped
• H.influenzae
  • drug of choice - cefotaxime or ceftriaxone
  • moxifloxacin can be used as an alternative
  • should treat for at least 10 days
• Listeria
  • drug of choice - amoxicillin & gentamycin
  • needs to be treated at least for 21 days (2) plus gentamicin for at least the first 7 days (1)
• E.coli
  • third generation cephalosporin - cefotaxime or ceftriaxone
  • ampicillin or amoxicillin
• Staph aureus
  • Methicillin susceptible : nafcillin or oxacillin (vancomycin)
  • Methicillin resistant : vancomycin (trimethoprim-sulfamethoxazole)
• M.tuberculosis
  • rifampicin AND ethambutol AND isoniazid AND pyrazinamide
• Cryptococcus neoformans
  • amphotericin B and flucytosine

Note

• a lumbar puncture should be deferred until AFTER antibiotic administration.
• ampicillin may be used where amoxicillin is suggested

Reference:

1. NICE (June 2010). Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management. Available at https://www.nice.org.uk/guidance/cg102 (Accessed on June 2023)
2. McGill F et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016;72(4):405-38.