Treatment of bacterial meningitis focuses on sterilization of the CSF by antibiotics (Table 100-3) and maintenance of adequate cerebral and

systemic perfusion. Because of increasing resistance of S. pneumoniae, many of which are relatively resistant to penicillin or cephalosporins, cefotaxime (or ceftriaxone) plus vancomycin should be administered until antibiotic susceptibility testing is available. Cefotaxime or ceftriaxone also is adequate to cover N. meningitidis and H. influenzae types a through f. For infants younger than 2 months of age, ampicillin is added to cover the possibility of Listeria monocytogenes. Duration of treatment is 10 to 14 days for S. pneumoniae, 5 to 7 days for N. meningitidis, and 7 to 10 days for H. influenzae. Supportive therapy involves treatment of dehydration with replacement fluids and treatment of shock, disseminated intravascular coagulation, inappropriate antidiuretic hormone secretion, seizures, increased intracranial pressure, apnea, arrhythmias, and coma. Supportive therapy also involves the maintenance of adequate cerebral perfusion in the presence of cerebral edema.

With the exception of HSV and HIV, there is no specific therapy for viral encephalitis. Management is supportive and frequently requires ICU admission, which allows aggressive therapy for seizures, timely detection of electrolyte abnormalities, and, when necessary, airway monitoring and protection and reduction of increased intracranial pressure. IV acyclovir is the treatment of choice for HSV infections. HIV infections may be treated with a combination of antiretroviral agents. M. pneumoniae infections may be treated with doxycycline, erythromycin, azithromycin, or clarithromycin, although the value of treating CNS mycoplasmal disease with these agents is disputed. Supportive care is crucial to decrease elevated intracranial pressure and to maintain adequate cerebral perfusion pressure and oxygenation. ADEM has been treated with high-dose IV corticosteroids. It is unclear whether the improved outcome with corticosteroids reflects milder cases recognized by MRI, fewer cases of ADEM caused by measles (which causes severe ADEM), or improved supportive care.