Central Nervous System Infections

Intracranial Abscess

Patient Population:
Pediatric
Condition Major Pathogens  First-choice Therapy Alternative Therapy Comments

Intracranial abscess or empyema (epidural, subdural, brain) > 3 months old, community-onset 

Includes intracranial extension of sinus, orbital or ear infections  

Streptococci (aerobic & anaerobic) 

Anaerobic oral and sinus flora 

Other organisms depending on source 

Ceftriaxone  
50 mg/kg/dose (max 2000 mg/dose) IV q12h  

AND 

Metronidazole  
10 mg/kg/dose (max 500 mg/dose) IV q8h  

AND  

Vancomycin  
(follow link for dosing & monitoring)   

Penicillin or cephalosporin allergy with higher risk for allergic reaction: 

Vancomycin  
(follow link for dosing & monitoring)  

AND 

Aztreonam  
30 mg/kg/dose (max 2000 mg/dose) IV q6h  

AND  

Metronidazole  
10 mg/kg/dose (max 500 mg/dose) IV q8h  

Neurosurgery and ID consults recommended 

Treatment is modified based on cultures, with vancomycin discontinued if MRSA is not identified 

Duration: Variable, guided by extent of drainage and response to therapy in follow-up assessments, usual range 4-8 weeks 
CNS infection in immunocompromised patient, or hospital-acquired, or following neurosurgical intervention, or following trauma  Variable based on risk factors  Consult ID for recommendations    Neurosurgery and ID consults recommended 
Central Nervous System Infections

Meningitis

Patient Population:
Pediatric
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  
50 mg/kg/dose IV q12h 

AND  

Vancomycin  
(follow link for dosing & monitoring)  

AND             

Acyclovir  
20 mg/kg/dose IV q8h, discontinue if bacterial pathogen identified or HSV PCR negative 

  

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  
50 mg/kg/dose (max 2000 mg/dose) IV q12h  

AND  

Vancomycin  
(follow link for dosing & monitoring)  

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  
(follow link for dosing & monitoring)   

AND 

Aztreonam  
30 mg/kg/dose (max 2000 mg/dose) IV q6h  

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. 

 

Central Nervous System Infections

Brain abscess

Patient Population:
Adult
Diagnosis Common Pathogens Drug(s) of First Choice Alternative Drug(s) Comments Expected Duration

Brain abscess (community-acquired)

Streptococci (anaerobic or aerobic)

Bacteroides spp

Prevotella spp

Enterobacterales

Ceftriaxone 2g IV q12h

PLUS

Metronidazole

PLUS

Vancomycin 

  

For severe PCN allergy:

Aztreonam

PLUS

Vancomycin

PLUS

Metronidazole

  

ID consultation recommended
Brain abscess (post-neurological procedure)

Streptococci (anaerobic or aerobic)

Anaerobes

Enterobacterales

S. aureus & coagulase-negative Staphylococcus spp

Pseudomonas aeruginosa

Acinetobacter spp.

Cefepime

PLUS

Vancomycin

PLUS

Metronidazole

 

For severe PCN allergy:

Aztreonam

PLUS

Vancomycin

PLUS

Metronidazole

   ID consultation recommended
Central Nervous System Infections

Meningitis

Patient Population:
Adult
Diagnosis Common Pathogens Drug(s) of First Choice Alternative Drug(s) Comments Expected Duration

Meningitis
Community-onset

S. pneumoniae
Neisseria meningitidis
Listeria (especially in immuno-compromised, elderly patients,  or have alcohol use disorder)

Ceftriaxone 2g IV q12h
PLUS
Vancomycin

WITH OR WITHOUT*
Ampicillin

For severe PCN allergy:
Vancomycin
PLUS
Aztreonam

WITH OR WITHOUT*:
Trimethoprim/ Sulfamethoxazole

Therapy should be guided by Gram stain

If bacterial meningitis suspected, dexamethasone 10 mg PO/IV q6h x 4 days given before or with initial dose of antibiotics

*Coverage for Listeria should be added for adult patients >50 years of age or immunocompromised

ID consultation recommended

Meningitis
Post-neurosurgical or device associated

S. aureus
Coagulase negative
staphylococci
Gram negative rods

Cefepime
PLUS
Vancomycin

For severe PCN allergy:
Aztreonam
PLUS
Vancomycin

  

ID consultation recommended

Tunkel AR, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84.

2017 Infectious Diseases Society of America’s Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clinical Infectious Diseases, Volume 64, Issue 6, 15 March 2017, Pages e34–e65, https://doi.org/10.1093/cid/ciw861

Central Nervous System Infections
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