3.03 - Central Nervous System Infections [updated]

A) Adults

For all patients with confirmed pneumococcal and meningococcal meningitis, consider vaccinations post recovery.  

For all patients with proven or suspected CSF leak, consider pneumococcal vaccinations with PCV13. For further information regarding pneumococcal vaccination schedule please click HERE. (https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf)

Disease / Etiology

Preferred

Alternative

Comments

Meningitis
 
<50 years 
Immunocompetent 
S pneumoniae
N meningitides
H influenza

  
Ceftriaxone 2 gm IV q12H		    
Duration: 10 - 14 days 

Blood C&S and CSF examination ASAP.

Performed CT brain before LP for patients with:

- History of CNS diseases (mass lesion, CVA)

- New onset seizure

            -  Papilloedema

            -  Altered consciousness

            -  Focal neurology deficit


Take cultures before empiric antibiotic therapy (at least blood C&S if LP has to be delayed). 

Do not wait for CT scan or LP results to start therapy.

 

Take cultures before empiric antibiotic therapy (at least blood C&S)

 

Duration is typically 10 - 14 days depending on organism:

Streptococcus pneumonia- 10-14 days

Neisseria meningitides- 7 days

Haemophilus influenza- 7 days

Listeria- 21 days

Gram negative bacilli- 21 days

 

Note: For patients on Vancomycin, to aim for serum trough levels of 15-20mg/L
 
>50 years 
S pneumoniae
Listeria
H influenza
N meningitides
Group B Streptococcus

  
Ceftriaxone 2 gm IV q12H 
+ Ampicillin 2 gm IV q4H		  
 
Immunocompromised 
(including alcoholism / pregnant / debilitated): 
S pneumoniae
Listeria
Gram negative
 
Post Neurosurgery or Penetrating Head Injury 
S epidermidis
S aureus
P acnes
S pneumoniae

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

  
Vancomycin 
25 - 30 mg/kg (max 2 gm) 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

 Ceftriaxone 2 gm IV q12H  
Metronidazole 500 mg IV q8H 


Ceftazidime 2gm IV q8H

+

Metronidazole 500mg IV q8H

 

Vancomycin 25 - 30 mg/kg loading dose, then 15 - 20 mg/kg q12H 

+

Ceftazidime 2 gm IV q8H



Ceftriaxone 2g IV q12H



Refer ID


  
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.

For  primary Brain Abscess with unknown source,

Add on IV Vancomycin if Staph aureus is suspected
 
Post, Traumatic Brain Abscess
Staphylococci
Enterobactericeae		  
Vancomycin 25 - 30 mg/kg (max 2 gm) loading dose, 15 - 20 mg/kg IV q8 - 12H 
+ Ceftazidime 2 gm IV q8H

  
Vancomycin 25 - 30 mg/kg (max 2 gm) loading dose, 15 - 20 mg/kg IV q8 - 12H 
+ Ceftriaxone 2 gm IV q12H

  
Duration: Treat until response seen by neuroimaging.

Post Surgical, Brain Abscess 

  
Vancomycin 25 - 30 mg/kg (max 2 gm) loading dose, 15 - 20 mg/kg IV q8 - 12H
+ Ceftazidime 2 gm IV q8H

  
Vancomycin 25 - 30 mg/kg (max 2 gm) loading dose, 15 - 20 mg/kg IV q12H
+ Cefepime 2 gm IV q8H

Subdural Empyema 

  
Vancomycin 25 - 30 mg/kg (max 2 gm) loading dose, 15 - 20 mg/kg IV q8 - 12H
+ Ceftazidime 2 gm IV q8H

  
Vancomycin 25 - 30 mg/kg (max 2 gm) loading dose, 15 - 20 mg/kg IV q8 - 12H 
+ Cefepime 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 10mg/kg IV q8H * 		   

Duration: 14 days.

Add Doxycycline PO 100 mg q12H if suspect rickettsii, mycoplasma.

*(will require renal adjustment in the presence of renal impairment)
 Healthcare associated Ventriculitis/ Meningitis









 Vancomycin 25 - 30 mg/kg (max 2 gm) loading dose, 15 - 20 mg/kg IV q8 - 12H

+

Ceftazidime 2 gm IV q8H		 Vancomycin 25 - 30 mg/kg (max 2 gm) loading dose, 15 - 20 mg/kg IV q8 - 12H

+

Cefepime 2 gm IV q8H		 Ensure that CSF and blood cultures are sent.

If initial cultures are negative, and suspicion is high, to contact lab to incubate for up to 10 days

If a shunt is present, and infected, removal is essential.

When to re-implant shunt:

CoNs/P.acnes with no CSF abnormality and negative cultures after 48 hours of externalisation –third day after removal

CoNS/P.acnes with CSF abnormality and repeat negative cultures- after at least 7 days of antimicrobial therapy

If repeat culture positive, continue antibiotics- re-implant after 7-10 days of negative culture

Staph aureus or gram negative bacilli- 10 days after CSF culture negative


B) Paediatrics


Disease / Etiology

Preferred

Alternative

Comments

Meningitis


< 1 month:
Group B Streptococcus
E coli
Listeria (Rare)


Benzylpenicillin
100,000 units/kg/dose IV
q8H (< 7 days of life);
q6H (> 7 days of life)

+

Cefotaxime
50 mg/kg/dose (max 2 gm) IV
q12H (<7 days of life);
q6H (> 7 days of life)


If Listeria suspected: 
Ampicillin 50 mg/kg/dose IV
q12H (< 7 days old); 
q8H (7 - 21 days old);
q6H (> 21 days old)
+                   

Gentamicin 5 mg/kg/dose IV q24H
for 21 days
(Consider stopping Gentamicin after 7 days)




Duration of treatment depends on organisms:
S pneumoniae : 14 days
N meningitides : 7 days
H influenzae : 10 days

Listeria: 21 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 pneumoniae
H influenza
N meningitidis



Ceftriaxone 50 mg/kg/dose
(max 2 gm) IV q12H


OR


Cefotaxime 50 mg/kg/dose
(max 2 gm) IV q6H

 

Brain Abscess


Primary 
Streptococci
Anaerobic Gram Negative Bacilli
Enterobacteriaceae
Staph aureus
Mixed Flora











 

 

Cloxacillin 50mg/kg/dose IV q6H

+

Cefotaxime 50 mg/kg/dose
(max 2 gm) IV
q12H (< 7 days of life);
q6H (>7 days of life)

+

Metronidazole 15 mg/kg/dose IV single dose followed by 7.5 mg/kg/dose IV q8H

 

Ceftazidime 50 mg/kg/dose IV q8H (if Pseudomonas suspected)

OR


Ceftriaxone 50 mg/kg/dose
(max 2 gm) IV q12H



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 pneumonia

Cloxacillin 50mg/kg/dose IV q6H

+

Ceftriaxone 50mg/kg/dose IV q12H

Vancomycin 15 mg/kg/dose IV q6-8H (MRSE, MRSA)

+

 

Ceftazidime 50 mg/kg/dose IV q8H (If pseudomonas suspected)

Encephalitis

 


Aciclovir
>3 months old:
10mg/kg/dose 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
Acinetobacter baumanii


Vancomycin 15 mg/kg/dose IV q6-8H

+

Ceftazidime 50 mg/kg/dose IV q8H


Vancomycin 15 mg/kg/dose IV q6-8H

 

+


Cefepime 50mg/kg/dose q8H

 

OR

 

Meropenem 40 mg/kg/dose IV q8H


For MSSA, downgrade Vancomycin to Cloxacillin IV 50mg/kg/dose q6H

 

Occasional convulsions with Meropenem.


In some situation, direct Intraventricular instillation of targeted antimicrobial is needed in Ventriculitis. Consult ID.