| Condition | Major Pathogens | First-choice Therapy | Alternative Therapy | Comments |
|---|---|---|---|---|
|
Meningitis 0-28 days old This recommendation is for infants with suspected meningitis based on specific clinical signs (e.g. seizure, neurologic changes) or symptoms or CSF pleocytosis. For infants who don’t meet these criteria (most young febrile infants), refer to Fever Without a Source - Young Infant recommendations |
Group B streptococcus Enteric gram-negatives Listeria monocytogenes Herpes simplex virus |
Ampicillin AND Ceftazidime AND Acyclovir 20 mg/kg/dose IV q8h empirically while awaiting HSV PCR of CSF unless infant was symptomatic at < 48 hours of life (HSV unlikely); discontinue Acyclovir if bacterial pathogen identified or HSV PCR negative |
Ceftriaxone may be used in place of Ceftazidime if neonate meets specific safe use criteria |
Refer to Neonatal Dosing Guideline for antibiotic doses and intervals ID consult recommended LP is recommended before antibiotics if patient is clinically stable
|
|
Meningitis 29-60 days old This recommendation is for infants with suspected meningitis based on specific clinical signs (e.g. seizure, neurologic changes) or symptoms or CSF pleocytosis. For infants who don’t meet these criteria (most young febrile infants), refer to Fever Without a Source - Young Infant recommendations |
Group B streptococcus Enteric gram-negatives Streptococcus pneumoniae Neisseria meningitidis Herpes simplex virus |
Ceftriaxone AND Vancomycin AND Acyclovir |
ID consult recommended LP is recommended before antibiotics if patient is clinically stable |
|
| Bacterial meningitis > 60 days old, community-onset |
Streptococcus pneumoniae Neisseria meningitidis Listeria monocytogenes in immunocompromised patients |
Ceftriaxone AND Vancomycin ADD Ampicillin 300 mg/kg/day divided q4-6h (max 2000 mg/dose) if patient immunocompromised (for Listeria) Routine administration of adjunctive dexamethasone is no longer recommended for pediatric patients with bacterial meningitis. For adults (>=18 years): Dexamethasone 10 mg/dose q6h before or concurrently with the initial antibiotic dose and for the first 4 days of therapy (IV initially, okay to switch to enteral after improvement) |
Consider (see explanation) in patients without severe sepsis and without risk factors for antimicrobial-resistantS. pneumoniae: Ceftriaxone monotherapy without Vancomycin Penicillin or cephalosporin allergy with higher risk for allergic reaction: Vancomycin AND Aztreonam ADD Trimethoprim-Sulfamethoxazole (Bactrim) 5 mg trimethoprim/kg/ dose IV q8h if patient immunocompromised (for Listeria) |
ID consult recommended LP is recommended before antibiotics. 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 should be given promptly, and LP performed as soon as contraindications resolve Neuroimaging is recommended before LP for patients with, immunodeficiency, coma, papilledema or focal neurologic deficit on exam (or inability to evaluate for focal deficit on exam due to significantly altered mental status), CSF shunt, hydrocephalus, CNS trauma, history of neurosurgery, or space-occupying lesion Later neuroimaging may be indicated for other indications in consultation with Neurology |
| CNS infection, hospital-acquired or following neurosurgical intervention, or following trauma | Variable based on risk factors | Consult ID for recommendations | ID consult recommended |
Ceftriaxone Monotherapy Option
While national guidelines such as the 2021 AAP Red Book recommend vancomycin in addition to ceftriaxone for coverage of possible ceftriaxone-resistant S. pneumoniae, the incidence of ceftriaxone-intermediate and ceftriaxone-resistant isolates has substantially declined following introduction of PCV7 and PCV13 immunizations (recent data indicate ~ 1.5-3% ceftriaxone-intermediate and 0-0.2% ceftriaxone-resistant isolates in US surveillance studies). Some experts advocate that vancomycin should no longer be used routinely for empiric treatment of meningitis. Pending changes in national guidelines, our local consensus is that either regimen is reasonable and that ceftriaxone monotherapy should be considered for patients who meet these criteria:
- Do not present with severe sepsis
- PCV13 initial 3 doses received
- No identified risk factors for pneumococcal antimicrobial resistance such as
- Prolonged or multiple exposure(s) to cephalosporin antibiotics within the past 3 months OR
- Recent (within past 3 months) travel to a developing country (i.e. where pneumococcal conjugate vaccines are not routinely administered in childhood immunization series)
References:
American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.
Le Saux, N. Canadian Pediatric Society Infectious Diseases and Immunization Committee. Guidelines for the management of suspected and confirmed bacterial meningitis in Canadian children older than 2 months of age.
The following articles are paired as part of a pro-con debate on the use of vancomycin in empiric treatment of pediatric bacterial meningitis:
Jhaveri R. The time has come to stop using vancomycin as empiric therapy for meningitis. J Pediatr Infect Dis Soc 2019;8:92-3.
Olarte L. Vancomycin should be part of empiric therapy for suspected bacterial meningitis. J Pediatr Infect Dis Soc 2019;8:187-8.
Pediatric Empiric Antimicrobial Therapy Guidelines
This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites.
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. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.
For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK.
The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.