3.03 - Central Nervous System Infections

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

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.