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Central Nervous System

Central Nervous System

ALL suspected cases of meningitis MUST be discussed with Consultant Microbiologist at first opportunity(during working hours)and reported to Public Health England. Meningococcal sepsis and H influenzae require prophylaxis of contacts
Microbiological specimens

  • CSF
  • Blood culture
  • Throat swab for meningococci
  • Urine for pneumococcal antigen
  • EDTA blood for meningococci PCR

Serology viruses / cryptococcus [HIV / Immunocompromised] as appropriate

The choice of agent should take into account the patient's risk for C. difficile infection

 

Meningitis: initial blind therapy

Meningococcal meningitis suspected and accompanied with purpuric non-blanching rash or signs of meningitis

Common Pathogen(s)
Streptococcus pneumoniae;
Neisseria meningitides;
Haemophilus influenzae;
Listeria monocytogenes.

Antibiotic - 1st line
Ceftriaxone 2g q12h IV.
Add in:
Amoxicillin 2g q6h IV if high risk for Listeria e.g. immunocompromised, >55 years, pregnant or history of alcohol abuse.

or

Co-trimoxazole 1.44g IV 12 hourly if high risk for Listeria as above


2nd Line
If history of anaphylaxis to penicillin or serious penicillin allergy – meropenem 2g q8h IV (but approximately 8-11% cross allergy with penicillin - discuss with microbiologist)

 Or chloramphenicol may be used if history of immediate hypersensitivity reaction to penicillin or cephalosporins. Choramphenicol IV 25mg/kg q6h (providing high doses reduced as clinically indicated) (plasma concentration monitoring required in elderly and hepatic impairment)

Add in:
Co-trimoxazole 1.44g IV 12 hourly if high risk for Listeria. (when using  chloramphenicol)

Comment
Notifiable disease

 

Meningitis: meningococci

Duration of therapy 7 days

Common Pathogen(s)
Meningococci

Antibiotic - 1st line
Benzylpenicillin 2.4g q4h IV.

2nd Line
Ceftriaxone 2g q12h IV.

 

Meningitis: pneumococci

Duration of therapy 14 days

Common Pathogen(s)
Pneumococci

Antibiotic - 1st line
Benzylpenicillin 2.4g q4h IV.
If Penicillin resistant Pneumococcus or Hx of foreign travel: Contact Microbiologist .

2nd Line
Ceftriaxone 2g IV q12h

Comment

Dexamethasone 10mg q6h PO for 4 days started with first dose of antibiotics.

 

Meningitis: Haemophilus influenzae

Duration of therapy 10days

Common Pathogen(s)
Haemophilus influenzae.

Antibiotic - 1st line
Ceftriaxone 2g q12h IV

Comment
Dexamethasone 10mg q6h PO for 4 days started with or just before the first dose of antibiotics

 

Meningitis: Listeria

Duration of therapy 21 days

Common Pathogen(s)
Listeria.

Antibiotic - 1st line

Amoxicillin 2g q4h IV
plus
Gentamicin [stop gentamicin after 7-days].(click here for full gentamicin policy)
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70year or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.

5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/min  or
3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.

If patient is obese ie. 20% over ideal body weight - use adjusted body weight

2nd Line
Co-trimoxazole 1.44g q12h IV.

Comment
Gentamicin*: 5mg/ kg  but for elderly patients or with moderate/severe renal impairment(CrCl <30ml/min),may require 3mg/ kg or shorter duration treatment.

Consider this as a possible cause if history of alcohol abuse

 

Brain abscess/
Subdural empyema/
Penetrating craniocerebral injuries

Discuss duration of therapy with Neurosurgery/Microbiology
Common Pathogen(s)

Antibiotic - 1st line
Ceftriaxone 2g q12h IV
plus
Metronidazole 500mg q8h IV (400mg q8h PO)


2nd Line
Discuss with Consultant Microbiologist.

Comment
Refer to Neurosurgery.

 

Encephalitis

Duration of therapy: 14-21 days, guided by clinical response

Common Pathogen(s)
Herpes simplex;
Varicella zoster.

Antibiotic - 1st line
Aciclovir 10mg/kg q8h IV.
All treatment must be IV.

Comment
If Herpes simplex positive cases:
If treating for 14days only - repeat lumbar puncture around day 14 and if PCR negative – can stop treatment or if PCR positive – continue for another 14days
Or treat for 21days and no further lumbar puncture is required.