4.03 - Central Nervous System Infections

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Meningitis

 
<50 years 
Immunocompetent 
S pneumo
N meningitides
H influenza

 
Ceftriaxone 2 gm IV q12H
   
Duration: 10 - 14 days 

Blood C&S and CSF examination ASAP.
In patient with focal neurological sign or immunosuppressed, performed CT brain before LP.
Take cultures before empiric antibiotic therapy (at least blood C&S if LP has to be delayed). 


Focal neurological sign or immunosupressed: 
Blood cultures, empiric therapy, CT then LP. 
 
>50 years 
S pneumo
Listeria
H influenza
N meningitides
Group B Strep

 
Ceftriaxone 2 gm IV q12H 
+ Ampicillin 2 gm IV q4H
 
 
Immunocompromised 
(including alcoholism / pregnant / debilitated): 
S pneumo
Listeria
Gram negative

 
Post Neurosurgery or Penetrating Head Injury 
S epidermidis
S aureus
P acnes
S pneumo


Facultative and aerobic gram negatives including:
    P aeruginosa 
    A baumanii 
(possible MDR)

 
Vancomycin 
25 - 30 mg/kg loading dose, then 15 - 20 mg/kg IV q8 - 12H 
+ Ceftazidime 2 gm IV q8H
 
 
Trauma With Basilar Skull Fracture 
S pneumoniae
H influenza
S pyogenes


 
Antibiotic is not required unless is infected. 
If evidence of infection: 
Vancomycin 25 - 30 mg/kg loading dose, then 15 - 20 mg/kg q12H 
+ Ceftazidime 2 gm IV q8H

 

Brain Abscess

 
Primary 
Unknown Source:
S aureus
Streptococci
Gram negative
Anaerobes

Sinusitis:
Streptococci (including S pneumonia) Anaerobes

Chronic Otitis Media:
Gram negatives
Streptococci
Anaerobes 

Post Surgical, Traumatic: 
Staphylococci
Enterobactericeae

Cyanotic Heart Disease: 
Streptococci (S viridians)

Immunocompromised: 
Nocardia
Toxoplasma gondii
Cryptococcus
Aspergillus 
Scedosporium

 
Metronidazole 500 mg IV q8H 
+ Ceftriaxone 2 gm IV q12H 
 
Benzylpenicillin 3 - 4 MU IV q4H 
+ Metronidazole 500 mg IV q8H
 
Duration: Treat until response seen by neuroimaging. 

Surgical Emergency: must drain. 
Treatment similar to brain abscess.
 
Post Surgical, Traumatic Brain Abscess

 
Vancomycin 15 - 20 mg/kg IV q12H 
+ Ceftazidime 2 gm IV q8H

 
Vancomycin 15 - 20 mg/kg IV q12H 
+ Meropenem 2 gm IV q8H
 
Duration: Treat until response seen by neuroimaging.

Subdural Empyema
 

 
Vancomycin 15 - 20 mg/kg IV q12H 
+ Ceftazidime 2 gm IV q8H

 
Vancomycin 15 - 20 mg/kg IV q12H 
+ Meropenem 2 gm IV q8H

Encephalitis

 
Herpes (HSV, rarely VZV, EBV, HHV-6 ) >50% cases

Other rare treatable causes:
MTB, Listeria, Cat-scratch disease, Mycoplasma

 
Acyclovir 500 mg IV q8H
   
Duration: 14 days.

Add Doxycycline PO if suspect rickettsii, mycoplasma.


B) Paediatrics

Disease / Etiology

Preferred

Alternative

Comments

Meningitis


< 1 month:
Group B Streptococcus
E coli

Gram negative organisms
Listeria (Rare)

GBS strongly suspected:
Benzylpenicillin
100,000 units/kg IV
q12H (< 7 days of life);
q6-8H (> 7 days of life)
+ Gentamicin

If Listeria suspected: 
Ampicillin 100 mg/kg IV
q12H (< 7 days old); 
q8H (7 - 21 days old);
q6H (> 21 days old)
+ Gentamicin for 21 days
(Consider stopping Gentamicin after 7 days)

Non-GBS meningitis:
Cefotaxime 50 mg/kg
(max 2 gm) IV
q12H (< 7 days of life);
q6 - 8H (> 7 days of life) + Gentamicin


Benzylpenicillin
100,000 units/kg IV
q12H (< 7 days of life);
q6 - 8H (> 7 days of life)
+
Cefotaxime
50 mg/kg (max 2 gm) IV
q12H (<7 days of life);
q6-8H (> 7 days of life)

 


Duration: Minimum 14 days.

Gentamicin
1 week - 10 years old:
8 mg/kg IV q24H for Day 1 then 6 mg/kg IV q24H;
> 10 years old:
7 mg/kg IV q24H for Day 1 then 5 mg/kg IV q24H

For H. influenzae type b give Rifampicin for 4 days before hospital discharge to those under 10 years of age or to those in contact with vulnerable household contacts.
Duration of treatment depends on organisms:
S pneumo : 10 - 14 days
N meningitides : 7 days
H influenza : 7 - 10 days

For Strep pneumonia which has high MIC for Penicillin (> 2 ug/mL in meningitis) add Vancomycin 20 mg/kg IV q8H (> 28 days old) to Ceftriaxone

1 - 3 months:
Organism from either age group

> 3 months:
S pneumonia
H influenza
N meningitidis


Head trauma
Staphylococci


Ceftriaxone 50 mg/kg
(max 2 gm) IV q12H
OR
Cefotaxime 50 mg/kg
(max 2 gm) IV q4 - 6H

 

Brain Abscess


Primary 

Streptococci
Anaerobic Gram Negative Bacilli
Enterobacteriaceae
Staph aureus
Mixed Flora













 

 

 

 


3rd Generation Cephalosporin
Ceftriaxone 50 mg/kg
(max 2 gm) IV q12H
OR
Cefotaxime 50 mg/kg
(max 2 gm) IV
q12H (< 7 days of life);
q6 - 8H (7 - 28 days of life); q4 - 6H (> 28 days of life)
OR
Ceftazidime 50 mg/kg IV q12H (< 7 days of life);
q6 - 8H (>7 days of life)
(if Pseudomonas suspected)
+
Metronidazole 15 mg/kg IV single dose followed by 7.5 mg/kg IV q8H
±
Vancomycin 25 mg/kg IV STAT, then 15 mg/kg IV q6H (MRSE, MRSA)

 


Consider adding Amikacin / Gentamicin in neonates.

Duration: 4 - 6 weeks (after surgical intervention), 
6 - 8 weeks if conservative treatment .

For children with head trauma, anti-staphylococcal coverage is recommended.


Post Surgical, Traumatic Brain Abscess 
Staph
Pseudomonas
Gram negatives
S pneumoniae


Vancomycin 15 mg/kg IV q6H
+
Ceftazidime 50 mg/kg IV q12H (< 7 days of life);
q6 - 8H (> 7 days of life)

 

Encephalitis

 


Aciclovir
<3 months old:
20 mg/kg IV q8H;
3 months - 12 years old:
500 mg/m2 IV q8H;
> 12 years old:
10 mg/kg IV q8H

 


Duration: for at least 21 days in encephalitis - confirm cerebrospinal fluid negative for herpes simplex virus before stopping treatment.

Ventriculitis / Meningitis Following Ventriculoperitoneal Shunts


Staph epidermidis
Staph aureus
Gram negative
Acinetobacterbaumanii

Vancomycin 15 mg/kg IV q6H
+
Ceftriaxone 50 mg/kg IV q12H


Vancomycin 15 mg/kg IV q6H
+
Meropenem 40 mg/kg IV q8H

Occasional convulsions with meropenem.
In some situation, direct intraventricular instillation of targeted antimicrobial is needed in ventriculitis. Consult ID.