Cerebrospinal fluid (CSF)

(1) Continuous infusion or a discontinuous infusion with a minimum of four infusions (75 mg/kg/6 hours): The daily dose for the continuous infusion is initiated immediately after the administration of a loading dose of 50 mg/kg over one hour.

(2) Arguments for listeriosis:

• Pregnancy
• Patients over 50 years of age
• Immunosuppression (corticosteroid therapy, myeloma)
• Patients with alcoholism, cirrhosis, etc.; gastrectomy, progressive onset, rhombencephalitis, mixed CSF findings

In case of a severe penicillin allergy (anaphylactic shock or angioedema)

Consult an infectious disease specialist if possible. Otherwise:

• Gram-positive cocci (+): Vancomycin and rifampin (loading dose of 30 mg/kg over one hour, and then daily dose of 40-60 mg/kg/day to be adjusted to obtain residual plasma concentrations between 15 and 20 mg/L AND Rifampicin: 300 mg, twice daily)
• Gram-negative (-): Ciprofloxacin (800 mg – 1200 mg)
• Gram-positive bacilli (+) (Listeria): Trimethoprim-sulfamethoxazole (10-20 mg/kg (of the trimethoprim component) as 4 doses/day) 

If the direct examination (DE) is negative:

• Without arguments for Listeria: Vancomycin + Rifampin
• With arguments for Listeria: Vancomycin + Rifampin + Trimethoprim-sulfamethoxazole (6 to 9 vials of 80/400 mg per day IV, divided into 3 doses)

Dexamethasone IV 10 mg every 6 hours for 4 days. Administer before or concomitant with antibiotics (if missed: can be initiated up to 12 hours after the start of antibiotics). Indicated if positive direct examination (meningococcus or pneumococcus in adults,  and pneumococcus or Haemophilus in children) or negative direct examination but turbid CSF or signs of bacterial meningitis, or contraindication to lumbar puncture. 

Contraindicated

Immunosuppressed patients

Meningococcus

Mandatory urgent declaration

Additional droplet precautions (surgical mask) for meningococcus or suspected cases, which can be lifted 24 hours after the first injection of IV third-generation cephalosporins (3GC ceftriaxone or cefotaxime).

Antibiotic prophylaxis

• Rifampin 300 mg 2 capsules twice a day for 48 hours
• Ciprofloxacin 500 mg single dose
• Ceftriaxone 250 mg IV or IM applies to healthcare workers only if they performed mouth-to-mouth resuscitation, intubation, or unmasked aspiration

NOT in immunocompromised

Just before or at the same time as the first injection of antibiotics in case of:

A suspicion of bacterial meningitis without microbiological confirmation, but with an empirical antibiotic therapy decision taken in infants aged between 3 and 12 months.

This scenario is observed when:

• the indication for brain imaging delays the lumbar puncture (neurological contraindications to the lumbar puncture) 
• the lumbar puncture is contraindicated for non-neurological reasons
• turbid or even purulent CSF is observed at lumbar puncture
• a negative direct examination of CSF is observed at lumbar puncture, but other CSF and blood biological findings confirm the bacterial meningitis diagnosis

Initial microbiological diagnosis indicative of:

H. influenzae bacterial meningitis

Pneumococcal bacterial meningitis