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Empiric antibiotic regimens for bacterial meningitis in infants (age 1 to 12 months) and children

Empiric antibiotic regimens for bacterial meningitis in infants (age 1 to 12 months) and children
  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.
  • Vancomycin 60 mg/kg/day IV in 4 divided doses (maximum 4 g/day)
PLUS one of the following:
  • Ceftriaxone 100 mg/kg/day IV in 2 divided doses (maximum 4 g/day)

OR

  • Cefotaxime (if available) 300 mg/kg/day IV in 3 or 4 divided doses (maximum 12 g/day)
Special circumstances
CSF Gram stain shows GNR Add an aminoglycoside to the regimen in Box A:
  • Gentamicin 7.5 mg/kg/day IV in 3 divided doses

OR

  • Amikacin 15 to 22.5 mg/kg/day IV in 3 divided doses (maximum 1.5 g/day)

If there is concern for resistant GNR infection, meropenem should be substituted for ceftriaxone/cefotaxime:
  • Meropenem 120 mg/kg/day in 3 divided doses (maximum 6 g/day)
 
Patients treated with adjunctive dexamethasone Some experts suggest adding rifampin to the regimen in Box A:
  • Rifampin 20 mg/kg/day IV in 2 divided doses (maximum 900 mg/day)
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).
  • Vancomycin 60 mg/kg/day IV in 4 divided doses (maximum 4 g/day)
PLUS one of the following:
  • Cefepime 150 mg/kg/day IV in 3 divided doses (maximum 6 g/day)

OR

  • Ceftazidime 150 mg/kg/day IV in 3 divided doses (maximum 6 g/day)

OR

  • Meropenem 120 mg/kg/day IV in 3 divided doses (maximum 6 g/day)
PLUS an aminoglycoside:
  • Gentamicin 7.5 mg/kg/day IV in 3 divided doses

OR

  • Amikacin 15 to 22.5 mg/kg/day IV in 3 divided doses (maximum 1.5 g/day)
Impaired cell-mediated immunity (eg, renal transplant recipients) Add high-dose ampicillin to the regimen in Box A:
  • Ampicillin 300 to 400 mg/kg/day IV in 4 or 6 divided doses (maximum 12 g/day)
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:
  • Vancomycin 60 mg/kg/day IV in 4 divided doses (maximum 4 g/day)
PLUS one of the following:
  • Cefepime 150 mg/kg/day IV in 3 divided doses (maximum 6 g/day)

OR

  • Ceftazidime 150 mg/kg/day IV in 3 divided doses (maximum 6 g/day)

OR

  • Meropenem 120 mg/kg/day IV in 3 divided doses (maximum 6 g/day)
An aminoglycoside is added if CSF Gram stain shows GNR

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.
IV: intravenous; Hib: Haemophilus influenza type B; GBS: group B streptococcus; GNR: gram-negative rod; S. aureus: Staphylococcus aureus; CSF: cerebrospinal fluid; H. influenzae: Haemophilus influenzae; P. aeruginosa: Pseudomonas aeruginosa.
Graphic 130047 Version 1.0

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