Duration of Therapy

The frequency of CSF (cerebriospinal fluid) examinations depends on the clinical

course, but a repeated examination should be done in 24 to 48 hours if there has not been
satisfactory improvement or if the causative microorganism is a more resistant gram-negative
bacillus or a highly penicillin-resistant (or cephalosporin-resistant) S. pneumoniae, especially in
patients who are receiving adjunctive dexamethasone therapy. Routine “end-of-treatment” CSF
examination is unnecessary in most patients with the common types of community-acquired
bacterial meningitis. Meningococci are rapidly eliminated from the circulation and CSF with
appropriate antimicrobial therapy, which should be continued for 4 to 7 days after the patient
becomes afebrile. If the patient has responded well, a follow-up lumbar puncture is not
necessary. H. influenzae meningitis should be treated for 7 to 10 days. Follow-up CSF
examination may be omitted in patients who have responded with rapid clinical resolution of the
meningitis. In pneumococcal meningitis, antimicrobial treatment should be continued for 10 to
14 days, and follow-up examination of the CSF should be performed, particularly when the
patient has coexistent mastoiditis. More prolonged therapy is indicated with concomitant
parameningeal infection. Meningitis caused by L. monocytogenes should be treated for 21 days.
Treatment of gram-negative bacillary meningitis with parenteral antimicrobials is prolonged,
usually for a minimum of 3 weeks (particularly in patients with a recent neurosurgical procedure)
to prevent relapse. Repeated examinations of the CSF are necessary both during and at the
conclusion of treatment to determine whether bacteriologic cure has been achieved. When
treating meningitis resulting from vancomycin-resistant Enterococcus faecium with linezolid, an
antibiotic that is bacteriostatic, approximately 4 weeks of therapy is indicated.

Other Aspects of Treatment

Adjunctive Corticosteroids

In children, the routine use of dexamethasone administered intravenously (either 0.15 mg/kg
every 6 hours for 4 days or 0.4 mg/kg every 12 hours for 2 days) either at the time of or 10 to 20
minutes before initiating antimicrobial therapy (third-generation cephalosporin) has no effect on
mortality but reduces the incidence of neurologic sequelae (primarily bilateral sensorineural
hearing loss). However, the benefits are seen predominantly in H. influenzae type b meningitis,
the incidence of which has been sharply reduced by the use of protein-conjugate vaccines. In a
randomized double-blind study in adults with community-acquired bacterial meningitis,
adjunctive dexamethasone therapy (10 mg every 6 hours intravenously for 4 days) significantly
reduced the proportion of patients with an unfavorable neurologic outcome from 25 to 15% or a
fatal outcome from 15 to 7%.[2] Adverse events were not increased in those receiving
dexamethasone. Notably, the risk of gastrointestinal bleeding was not increased in the
dexamethasone-treated group. Dexamethasone's beneficial effect was most evident in the
subgroup of patients with pneumococcal meningitis, in whom unfavorable outcomes were
reduced from 52 to 26% and deaths from 34 to 14%. In this trial, adjuvant dexamethasone was
not beneficial in patients with meningococcal meningitis, but the number of patients in this
subgroup was small. Based on these data, adjunctive dexamethasone (0.15 mg/kg every 6 hours
for 2 to 4 days, with the initial dose 10 to 20 minutes before or simultaneously with the initial
dose of antimicrobial therapy) is recommended in adults with suspected or demonstrated
pneumococcal meningitis. Continuation of dexamethasone requires demonstration of gram-
positive diplococci on the CSF Gram stain or positive blood or CSF cultures for S. pneumoniae.
When vancomycin is used in treatment of meningitis resulting from highly cephalosporin-
resistant S. pneumoniae, as is recommended in the United States, the addition of rifampin should
be considered because dexamethasone may reduce the CSF concentration of vancomycin (see
Table 437-3 ).