Bacterial Meningitis: Drug Therapy

Therapeutic targets

  • Elimination of the pathogens
  • Avoidance of complications

Therapy recommendations

  • In case of suspicion, immediate hospitalization (emergency) → Collection of two blood cultures.
  • Bacterial meningitis: antibiosis (antibiotic therapy) after pathogen determination and resistogram (test for sensitivity to antibiotics)Before final diagnosis, immediate calculated or empirical antibiotic therapy + dexamethasone 10 mg i.v. must be started! (Maximum 30 min after hospital admission); therapy as follows:
    • Community-acquired infection (N. meningitidis, L. monocytogenes, H. influenzae, streptococci, coagulase-negative staphylococci, aerobic gram-negative bacteria): Ceftriaxone 2 times 2 g/day (with 4 g as a starting dose) plus ampicillin 12-15 g/day, ideally at 4-hour intervals.
    • Nosocomial (hospital-acquired) or per continuitatem (“spreading to the neighborhood”) infection: vancomycin 2 times 1 g/day plus meropenem 3 times 2 g/day.
    • Drug groups depending on age.
    • After neurosurgical procedures or post-traumatic (“after an injury”, e.g., after open craniocerebral trauma) (pneumococci, staphylococci, Pseudomonas aeroginosa, gram-neg. bacteria) in shunts (coagulase-negative staphylococci, Propionibacterium acnes, gram-neg. bacteria) (specific antibiotic therapy)

    After antibiogram should then be de-escalated.

  • Duration of therapy:
    • Meningococcal: 10 days
    • Pneumococcus: 14 days
    • Enterobacteriaceae or listeria: 3 weeks
    • Mycobacterium tuberculosis: 12 months of chemotherapy and concomitant immunomodulatory therapy with steroids (see tuberculosis below).
  • Epileptic seizures in the acute phase: lorazepam (benzodiazepine) 2-4 mg i.v.
  • Postexposure prophylaxis: meningococcal infection and H. influenzae infection (specific antibiotic therapy).
  • See also under “Further therapy”.

* Note: For every hour of delay in antibiotic therapy, mortality (mortality) increases by approximately 12.5%.

Postexposure prophylaxis (PEP)

Meningococcal Infection

Postexposure prophylaxis is the provision of medication to prevent disease in persons who are not protected against a particular disease by vaccination but who have been exposed to it. Persons with close contact with a diseased person with an invasive meningococcal infection – this includes (according to STIKO):

  • All household contact members
  • Persons in contact with oropharyngeal secretions (secretions from the oral and pharyngeal cavities) of a patient
  • Contact persons in children’s facilities with children under 6 years of age (with good group separation only the affected group).
  • Persons with close contacts in community facilities with household-like character (boarding schools, dormitories as well as barracks).

Rifampicin prophylaxis as follows:

  • In persons who are in close contact with diseased persons in the last 7 days before the onset of the latter’s illness, prophylaxis with rifampicin is
    • Neonates: 10 mg/kg/day in 2 ED p. o. for 2 days.
    • Infants, children and adolescents up to 60 kg: 20 mg/kg/day in 2 ED p. o. for 2 days (maximum ED 600 mg).
    • Adolescents and adults over 60 kg: 2 x 600 mg/day for 2 days, eradication rate: 72-90%) or the single administration of ciprofloxacin (from 18 years: once 500 mg p. o., eradication rate (number of cases in which therapy causes the complete elimination of a pathogen): 90-95%), if necessary ceftriaxone 2-12 years: 125 mg i.m., from 12 years: 250 mg i.m. in an ED, eradication rate: 97%.
  • In pregnant women, the administration of rifampicin and gyrase inhibitors is contraindicated (prohibited)! They receive for prophylaxis (prevention) if necessary ceftriaxone.In pregnant women, the administration of rifampicin and gyrase inhibitors is contraindicated! They receive for prophylaxis if necessary ceftriaxone (250 mg once i.m.).

Haemophilus infuenzae infection

  • In case of close contact with a person who has Hib infection, rifampicin (dosage: from 1 month: 20 mg/kg/day (maximum 600 mg), in 1 ED for 4 days; adults: 600 mg p. o. in 1 ED for 4 days) should be taken as prophylaxis.
  • In pregnant women, ceftriaxone (antibiotic) is prescribed instead of rifampicin.