Empiric antimicrobial therapy
›Time-critical antibiotics
›Immediate empiric therapy when suspected
›Do not wait for LP results
›Blood cultures first when feasible without delay
›WHO good practice statement
›Community-acquired adult regimens
›Age 18 to 50 years
›Vancomycin
›15 to 20 mg/kg IV every 8 to 12 hours
›Trough target 15 to 20 mg/L for CNS infection
›Ceftriaxone
›2 g IV every 12 hours
›Alternative cefotaxime 2 g IV every 4 to 6 hours
›Age over 50 years
›Vancomycin
›15 to 20 mg/kg IV every 8 to 12 hours
›Trough target 15 to 20 mg/L
›Ceftriaxone
›2 g IV every 12 hours
›Ampicillin
›2 g IV every 4 hours
›Listeria coverage
›Severe penicillin anaphylaxis
›Vancomycin
›15 to 20 mg/kg IV every 8 to 12 hours
›Moxifloxacin
›400 mg IV daily
›Trimethoprim sulfamethoxazole
›TMP 10 to 20 mg/kg/day IV divided every 6 to 12 hours
›Listeria alternative
›Healthcare-associated or post-neurosurgery regimens
›Vancomycin
›15 to 20 mg/kg IV every 8 to 12 hours
›Trough target 15 to 20 mg/L
›Antipseudomonal beta lactam
›Cefepime
›2 g IV every 8 hours
›Ceftazidime
›2 g IV every 8 hours
›Meropenem
›2 g IV every 8 hours
›Pediatric regimens
›Age over 1 month
›Ceftriaxone
›50 mg/kg IV every 12 hours
›Maximum 2 g per dose
›Vancomycin
›15 mg/kg IV every 6 hours
›Trough target 15 to 20 mg/L for CNS infection
›Neonate
›Ampicillin
›50 mg/kg IV every 6 hours
›Adjust by gestational and postnatal age
›Cefotaxime
›50 mg/kg IV every 6 to 8 hours
›Avoid ceftriaxone in neonates when possible
Targeted therapy after identification
›Narrowing strategy
›Culture and susceptibility guided de-escalation
›Stop vancomycin when pneumococcus susceptible to beta lactam
›Duration by pathogen
›Neisseria meningitidis 7 days
›Haemophilus influenzae 7 days
›Streptococcus pneumoniae 10 to 14 days
›Listeria monocytogenes 21 days or longer
›Gram negative bacilli 21 days or longer
Adjunctive corticosteroids
›Dexamethasone strategy
›Adult suspected or proven pneumococcal meningitis
›Dexamethasone 0.15 mg/kg IV every 6 hours
›Maximum 10 mg per dose
›Start 15 to 20 minutes before or with first antibiotic dose
›Continue 2 to 4 days per local protocol
›Continuation decision
›Continue if pneumococcal meningitis confirmed or strongly suspected
›Stop if alternative pathogen identified where no benefit expected
Antiviral and other coverage when uncertain
›Encephalitis overlap concern
›Acyclovir
›10 mg/kg IV every 8 hours
›Renal adjustment required
›Add when prominent altered mental status or focal temporal features
Supportive and complication management
›Seizure management
›Benzodiazepine first-line
›Lorazepam 0.1 mg/kg IV
›Maximum 4 mg per dose
›Second-line antiseizure medication
›Levetiracetam 60 mg/kg IV
›Maximum 4500 mg
›Fever and pain control
›Acetaminophen
›15 mg/kg PO or PR every 6 hours
›Maximum 1000 mg per dose
›Raised intracranial pressure management
›Head of bed elevation
›30 degrees
›Hyperosmolar therapy for herniation physiology
›Hypertonic saline 3 percent
›2 mL/kg IV bolus
›Repeat based on neurologic response
›Mannitol
›0.5 to 1 g/kg IV bolus
›Avoid in hypotension
›Shock management
›Norepinephrine infusion
›Initiate 0.05 microgram/kg/min
›Titrate every 2 to 5 minutes to MAP 65 mmHg