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Antibiotic therapy - Age 50 years and older

In adults older than 50 years or adults with disabling disease or alcoholism, the most common microorganisms are S pneumoniae, coliforms, H influenzae, Listeria species, Pseudomonas aeruginosa, and N meningitidis.

Primary treatment if the prevalence of DRSP is greater than 2% is either cefotaxime (2 g IV q4h) or ceftriaxone (2 g IV q12h) plus vancomycin (750-1000 mg IV q12h or 10-15 mg/kg IV q12h). If CSF Gram stain shows gram-negative bacilli, use ceftazidime (2 g IV q8h). In areas of low prevalence of DRSP, use cefotaxime (2 g IV q4h) or ceftriaxone (2 g IV q12h) plus ampicillin (50 mg/kg IV q6h). Other options for treatment include meropenem, TMP/SMX, and doxycycline.

Data are limited on the need for dexamethasone in adults, although there is support for its use in developed countries when S pneumoniae is the suspected organism and suspicion for TB or fungal etiologies is low. Administer the first dose of dexamethasone (0.4 mg/kg q12h IV for 2 d or 0.15 mg/kg q6h for 4 d) 15-20 minutes before the first dose of antibiotics.

Go to the following articles for complete information on these topics:

• Meningococcal Meningitis
• Staphylococcal Meningitis
• Haemophilus Meningitis

· Steroid Therapy

· The present understanding of the pathogenesis of bacterial meningitis has led to multiple therapeutic trials that involve the means to attenuate the detrimental effects of the host’s defenses (eg, inflammatory response to the bacterial products and the products of neutrophil activation) while eradicating bacteria with antibiotics.

· Foremost among these measures is the use of steroids. However, in the experimental meningitis model, the use of steroids has been associated with decreased antimicrobial penetration into the CSF and decreased bactericidal activity of some antimicrobials, such as vancomycin. Clinical data, however, indicate that steroid use may offer benefit in certain cases of acute bacterial meningitis.

· Therefore, pharmacologic interventions to reduce the degree of inflammation may improve outcome. Strongly consider the use of steroids as adjunctive treatment for bacterial meningitis.

· If steroids are given, they should be administered prior to or during the administration of antimicrobial therapy. The use of steroids has been shown to improve the overall outcome of patients with certain types of bacterial meninigitis, such as H influenzae, tuberculous, and pneumococcal meningitis.

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