Pediatric Guidelines: CNS Infections - Meningitis

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Condition Major Pathogens First Choice Therapy Alternative Therapy Comments
Meningitis 0-28 days old

Group B streptococcus

Enteric Gram negatives

Listeria monocytogenes

Ampicillin 

AND

Cefotaxime

Consider:                   Acyclovir 20mg/kg/dose IV q8h empirically while awaiting HSV PCR of CSF in neonate with CSF pleocytosis unless infant was symptomatic at < 48 hours of life; discontinue Acyclovir if bacterial pathogen identified or HSV PCR negative

 

Refer to Neonatal Dosing Guideline for antibiotic doses and intervals

ID consult recommended

LP is recommended before antibiotics for most cases

Bacterial meningitis > 28 days old, community-onset

Streptococcus pneumoniae

Neisseria meningitidis

Haemophilus influenzae

Group B streptococcus, enteric Gram negatives in young infants

Listeria monocytogenes in immunocompromised patients

Ceftriaxone 50mg/kg/dose IV q12h (max 2g/dose)

AND 

Vancomycin 20mg/kg/dose IV q6-8h (initial max 1g/dose)

Consider:                     Acyclovir 20mg/kg/dose IV q8h for infants <= 6 weeks old, discontinue if bacterial pathogen identified or HSV PCR negative

ADD Ampicillin 300mg/kg/day divided q4-6h (max 2g q4h) if patient immunocompromised (for Listeria)

For suspected bacterial meningitis in children >= 6 weeks old, consider:

Dexamethasone 0.15mg/kg/dose (max 10mg/dose) to start 10-20 minutes before or concurrently with the initial antibiotic dose and for the first 2-4 days of therapy

Corrected gestational age <44 weeks:

Cefotaxime per Neonatal Dosing Guideline in place of Ceftriaxone 

 

ID consult recommended

LP is recommended before antibiotics for most cases. If LP must be delayed due to cardiopulmonary instability, coagulopathy, elevated intracranial pressure or need for preceding neuroimaging (see below), blood culture should be drawn, antibiotics and steroids should be given promptly, and LP performed as soon as clinical condition stabilizes/contraindications resolve. 

Neuroimaging is recommended before LP for patients with immunodeficiency, papilledema or focal neurologic deficit on exam, CSF shunt, hydrocephalus, CNS trauma, history of neurosurgery, or space-occupying lesion

Severe beta lactam allergy:

Vancomycin 20mg/kg/dose IV q6-8h (initial max 1g/dose)

AND

Aztreonam 30mg/kg/dose IV q6h (max 2g/dose)

ADD Trimethoprim-Sulfamethoxazole (Bactrim) 5mg/kg/dose trimethoprim iV q8h if patient immunocompromised (for Listeria)

CNS infection, hospital-acquired or following neurosurgical intervention, or following trauma Variable based on risk factors Consult ID for recommendations   ID consult recommended
Reference: Tunkel, AR, et al. Practice guidelines for the management of bacterial meningitisClin Infect Dis 2004;39:1267-1284.

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP).