Bacterial Meningitis: Bugs, drugs and steroids
Mortality: Untreated approaches 100%.
Risk factors for death/ neurologic deficits at presentation:1
1) Altered mental status
4) Delay in ABX resulting in development of the above risk factors
Bugs and Drugs:
• Empiric coverage – Ceftriaxone 2gm, Vanco 1gm. For elderly and immunosuppressed, add
ampicillin 2gm to cover listeria.
• S. pneumoniae – CTX and Vanco. Add rifampin to vanco if pen-resistant strain.
• SFGH high level pen-resistant rate is 2%, but rarely(never?) in CSF isolates.2
• H. influenzae – CTX for 5 days
• N. meningitides – CTX for 5 days
• Listeria – Ampicillin 2gm Q4-6 +/- gentamicin for synergy
• Enteric gram negatives – In newborns and hospitalized patients. Treat with CTX.
• Staph. Aureus – Can occur in neurosurgical patients. Treat with CTX and Vanco.
Head CT before LP?: Mass lesion can be ruled out clinically if 1) Overall clinic impression is against it 2)
No papilledema 3) No focal signs AND 4) No AMS.3
Steroids for bacterial meningitis:4
• Adults with suspected meningitis AND cloudy CSF, bacteria on Gram Stain or CSF WBC of
• Adjunctive dexamethasone 10 mg IV given 20 minutes before or at the time of antibiotics and
then Q6 hours for 4 days or placebo.
• Overall mortality reduction at 8 weeks reduced from 15 to 7%: 34 to 14% in the S. pneumo group
• Unfavorable outcome at 8 weeks reduced from 25 to 15%: 52 to 26% for s. pneumo group.
• Differences in neurologic deficits, including hearing loss were not significant at 8 weeks.
• No pen-resistant strains in this population. Steroids may reduce the efficacy of vancomycin
against pen-resistant strep pneumo by decreasing CSF vanco levels by reducing inflammation.
Prophylaxis in contacts: Call inefection control.Indicated only for N. Meningitidis to prevent further
cases and to eradicae pharyngeal carriage in close contacts (household