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©2013 UpToDate ® Print Email Recommendations for antimicrobial therapy of bacterial meningitis in adults with presumptive pathogen identification by positive Gram stain* Microorganism Recommended therapy Alternative therapies Streptococcus pneumoniae Vancomycin plus a third-generation cephalosporin•Δ Fluoroquinolone◊ Neisseria meningitidis Third-generation cephalosporin• Chloramphenicol, fluoroquinolone, aztreonam Listeria monocytogenes Ampicillin§ or penicillin G§ Trimethoprim-sulfamethoxazole Haemophilus influenzae Third-generation cephalosporin• Chloramphenicol, cefepime, meropenem, fluoroquinolone * For recommended dosages, see the table "Recommended intravenous dosages of antimicrobial therapy for adults with bacterial meningitis". • Ceftriaxone or cefotaxime. Δ Some experts would add rifampin if dexamethasone is also given. ◊ Moxifloxacin is recommended given its excellent CSF penetration and in vitro activity against Streptococcus pneumoniae , although there are no clinical data available. If used, many authorities would combine moxifloxacin with vancomycin or a third-generation cephalosporin (cefotaxime or ceftriaxone). § Addition of an aminoglycoside should be considered. Modified with permission from: Tunkel, AR, Hartman, BJ, Kaplan, SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267. Copyright ©2004 University of Chicago Press. file://www.journals.uchicago.edu/ Recommended intravenous dosages of antimicrobial therapy for adults with bacterial meningitis who have normal renal and hepatic function Antimicrobial agent Dose (adult) Amikacin 5 mg/kg every 8 hours* Ampicillin 2 g every 4 hours Aztreonam 2 g every 6 to 8 hours Cefepime 2 g every 8 hours Cefotaxime 2 g every 4 to 6 hours Ceftazidime 2 g every 8 hours Ceftriaxone 2 g every 12 hours Chloramphenicol 1 to 1.5 g every 6 hours • Ciprofloxacin 400 mg every 8 to 12 hours Gentamicin 1.7 mg/kg every 8 hours* Meropenem 2 g every 8 hours Moxifloxacin 400 mg every 24 hours Δ Nafcillin 1.5 to 2 g every 4 hours Oxacillin 1.5 to 2 g every 4 hours Penicillin G potassium 4 million units every 4 hours Rifampin 600 mg every 24 hours ◊ Tobramycin 1.7 mg/kg every 8 hours* Trimethoprim-sulfamethoxazole (cotrimoxazole) 5 mg/kg every 6 to 12 hours §¥ Vancomycin 15 to 20 mg/kg every 8 to 12 hours ������

Moxifloxacin 400 mg every 24 hours Δ Nafcillin 1.5 to 2 g every 4 hours Oxacillin 1.5 to 2 g every 4 hours Penicillin G potassium 4 million units every 4 hours Rifampin 600 mg every 24 hours ◊ Tobramycin 1.7 mg/kg every 8 hours* Trimethoprim-sulfamethoxazole (cotrimoxazole) 5 mg/kg every 6 to 12 hours §¥ Vancomycin 15 to 20 mg/kg every 8 to 12 hours ������ MRSA: methicillin-resistant Staphylococcus aureus * Dose based on ideal body weight or dosing weight, except in underweight patients. A calculator for ideal body weight and dosing weight is available in UpToDate. Dosage and interval must be individualized to produce a peak serum concentration of 7-9 mg/L and trough <1-2 mg/L for gentamicin or tobramycin and a peak of 25-40 mg/L and trough <4-8 mg/L for amikacin. For additional information, see the topic review on aminoglycosides. • The higher dose is recommended for patients with pneumococcal meningitis. Δ No data on optimal dosage needed in patients with bacterial meningitis. ◊ For the treatment of MRSA meningitis, the Infectious Diseases Society of America (IDSA) suggests a rifampin dose of 600 mg orally once daily or 300 to 450 mg twice daily. [1] § Dosage is based on the trimethoprim component. ¥ For the treatment of MRSA meningitis, the IDSA suggests a trimethoprim-sulfamethoxazole dose of 5 mg/kg (based on the trimethoprim component) IV twice or three times daily. [1] ‡ The vancomycin dose should not exceed 2 g per dose or a total daily dose of 60 mg/kg. Adjust dose to achieve vancomycin serum trough concentrations of 15 to 20 mcg/mL. [1] Modified with permission from: Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267. Copyright © 2004 University of Chicago Press. Additional data from: [1] Liu C, Bayer A, Cosgrove SE, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children: Executive Summary. Clin Infect Dis 2011; 52:285. file://www.journals.uchicago.edu/

©2013 UpToDate ® Print Email Recommendations for antimicrobial therapy of bacterial meningitis in adults with presumptive pathogen identification by positive Gram stain* Microorganism Recommended therapy Alternative therapies Streptococcus pneumoniae Vancomycin plus a third-generation cephalosporin•Δ Fluoroquinolone◊ Neisseria meningitidis Third-generation cephalosporin• Chloramphenicol, fluoroquinolone, aztreonam Listeria monocytogenes Ampicillin§ or penicillin G§ Trimethoprim-sulfamethoxazole Haemophilus influenzae Third-generation cephalosporin• Chloramphenicol, cefepime, meropenem, fluoroquinolone * For recommended dosages, see the table "Recommended intravenous dosages of antimicrobial therapy for adults with bacterial meningitis". • Ceftriaxone or cefotaxime. Δ Some experts would add rifampin if dexamethasone is also given. ◊ Moxifloxacin is recommended given its excellent CSF penetration and in vitro activity against Streptococcus pneumoniae , although there are no clinical data available. If used, many authorities would combine moxifloxacin with vancomycin or a third-generation cephalosporin (cefotaxime or ceftriaxone). § Addition of an aminoglycoside should be considered. Modified with permission from: Tunkel, AR, Hartman, BJ, Kaplan, SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267. Copyright ©2004 University of Chicago Press. file://www.journals.uchicago.edu/