IDSA GUIDELINES: Practice Guidelines for the Management of Bacterial Meningitis (with a focus on pediatric population) Initial Management

Approach A. On suspicion of acute bacterial meningitis: Draw blood cultures and perform lumbar puncture immediately; EXCEPTION: some patients may not perform lumbar puncture right away secondary to inability to obtain CSF or clinician may perceive cause is a CNS mass lesion or another cause of increased intracranial pressure (ICP) therefore a CT scan to the head is ordered before lumbar puncture. Such patients include those with elevated intracranial pressure or intracranial space occupying lesions where a lumbar puncture could precipitate brain herniation. I. Dilemma: the yield of CSF cultures and CSF gram stain may be diminished by antimicrobial therapy prior to lumbar puncture. HOWEVER, predrawn blood cultures and CSF findings (elevated WBC, diminished glucose concentration, elevated protein concentration). II. Some clinicians will delay lumbar puncture for 30 minutes in patients with short, convulsive seizures or may not perform it at all in patient with prolonged seizures. This is NOT practice for children because seizures occur in up to 30% of children with bacterial meningitis before admission. B. Blood culture is needed immediately to obtain culture samples and to determine appropriate antimicrobial and adjunctive therapy prior to lumbar puncture or before CT scan. Delay in therapy increases morbidity/mortality. C. Choice of empiric therapy: based on age and conditions that predispose the patient to meningitis. Once CSF analysis is performed more targeted therapy can be initiated. General Recommendation: In children>1 month empiric therapy with vancomycin combined with either cefotaxime or ceftriaxone empirically; If a positive gram stain results add another agent for the presence of a gram-positive organism i.e. Ampicillin. If the gram stain is negative chose agents based on age and predisposing factors as stated above. I. Example empiric regimen for infants and children (Table 6 in guideline) a. IV vancomycin 60 mg/kg every 6 hours b. 3rd generation cephalosporin: IV cefotaxime (Claforan) 225 mg/kg every 6 hours c. Dexamethasone (Decadron) 0.15 mg/kg every 6 hours for 2-4 days 10-20 minutes before or with the first antimicrobial dose (dexamethasone is unlikely to improve patient outcome in those who received antimicrobial therapy) D. CSF findings consistent with bacterial meningitis: cloudy appearance (may be due to increased WBC, RBC, bacteria, protein), WBC elevation (1000-5000 cells/mm3), neutrophil predominance, CSF glucose: serum glucose <4 in children>2 and <0.6 in term neonates; CSF protein elevation. Cultures take up to 48 hours therefore rapid diagnostic tests can be done to determine bacterial etiology. E. Rapid Diagnostic tests: Gram stain Latex agglutination, Polymerase Chain Reaction (PCR) F. There is NO laboratory test that is definitive for or against the diagnosis of bacterial meningitis but a combination of test results aid distinguishing viral versus bacterial meningitis. Such laboratory testing includes: elevated CSF lactate concentration, C-reactive protein concentration, and procalcitonin concentration. G. How quickly to administer antimicrobial therapy in suspected bacterial meningitis? I. The key factor is the need to administer antimicrobial therapy before the patient's clinical condition advances to a high level of clinical severity, at which point the patient is less likely to have a full recovery after treatment with appropriate antimicrobial. The logical and intuitive approach is to administer antimicrobial therapy as soon as possible after the diagnosis is suspected or proven. H. Dexamethasone's role: treats the subarachnoid space inflammation of bacterial meningitis thhat is a contrributing factor to morbidity and mortality. I. At present insufficient data to recommend dexamethasone as adjunctive therapy in neonates. Adjunctive dexamethasone can be initiated in infants and children (possible protection for severe hearing loss). I. Once etioloy of bacterial meningitis is established the choice of antimicrobial agent is based on knowledge of in vitro susceptibility and relative penetration into CSF in the presence of meningeal inflammation. I. Cephalosporins: third-generation are recommended for treatment of childhood bacterial meningitis because of their effectiveness in meningitis caused by gram negative bacilli (Escherichia, klebsiella). Ceftazidime has activity against Pseudomonas aeruginosa. The fourth generation cephalosporin cefepime has activity than third-generation against Enterobacter species and P. aeruginosa. II. Vancomycin: Beneficial in meningitis caused by penicillin-resistant pneumococci and is NOT recommended to treat isolates susceptibile to other agents (cephalosporins/penicllins).

III. Rifampin: Excellent CSF penetration property but MUST be used in combination with other agents (i.e. third generation with/with out vancomycin). Rifampin SHOULD be used in combination with vancomycin in CSF shunt infections caused by staphylococcus, especially if the shunt cannot be removed. IV. Carbapenems: Imipenem and meropenem both have the potentisl for seizure activity but it is greter in imipenem. Meningitis caused by gram negative bacilli that produce extended-spectrum betalactamase or those that may hyperproduce beta lactamases (Enterobacter, Citrobacter species, Serratia marcescens) may best be treated with a regimen containing meropenem. V. Fluoroquinolones: These agents should only be used as alternatives in patients who are not responding to standard therapies. J. CSF shunts are used to treat hydrocephlaus (build up of fluid in the brain). Removal of all components of the infected shunt and SOME component of external drainage (sometimes excluding the drainage cathether) in combination with appropriate antimicrobial therapy is most effect in CSF shunt infections. The drainage cathether clears the ventriculitis of the shunt infection more rapidly by allowing continued treatment of the hydrocephalus until the infection is cleared. K. Repeated CSF lumbar puncture for CSF analysis should be performed for any patient who has not responded clinically after 48 hours of appropriate antimicrobial therapy. Neonates with meningitis due to gram negative bacilli should undergo repeated lumbar punctures to document CSF sterilization, because the duration of therapy is determined by the results. The presence of a drainage cathether in patients with CSF shunts allowd for monitoring of CSF parameters therefore repeated lumbar puncture is not necessary in the subcategory. L. Look at charts for duration of therapy and outpatient microbial therapy.