Ceftriaxone 2g IV q12h

PLUS

Ampicillin 2g IV q4h

(if suspecting listeriosis, please see comments) 

Cefotaxime 2g IV q6h

PLUS

Ampicillin 2g IV q4h

(if suspecting listeriosis, please see comments)

*If allergic to Cephalosporin, consider meropenem 2g IV q8h

Antibiotics should not be delayed if lumbar puncture is delayed by radiological investigation.

If no organism is isolated from CSF C&S but LP is suggestive of bacterial meningitis and the patient is responding, continue antibiotics for 10-14 days.

Dexamethasone 10mg IV q6h is recommended 15 to 20 minutes before or at the time of first dose of antibiotics. Continue for 4 days if the Gram stain and/or cultures are consistent with S. pneumoniae. Discontinue if not Streptococcus pneumonia or if bacterial meningitis is subsequently thought not to be present.

Incidence of listeriosis increases in people > 50 years of age, immunosuppressed and pregnancy. Consider empirical cover with IV ampicillin especially if the course of disease is indolent or there is epidemiological risk (refer section 1.4 - Listeriosis).

Duration: 10-14 days

Ceftriaxone 2g IV q12h

Cefotaxime 2g IV q6h

If organism is susceptible and patient is allergic to cephalosporins:

Ciprofloxacin 400mg IV q8h

Duration: 7-10 days

Penicillin resistant and cephalosporin resistant strains (MIC to Cephalosporin ≥ 2 mcg/ml):

 Refer ID physician

Penicillin resistant strain

(MIC to Penicillin ≥ 0.12 mcg/ml)

Cefotaxime 2g IV q6h

All attempts should be made to ascertain the MIC of isolated pneumococcus. Ceftriaxone or cefotaxime should be de-escalated to benzylpenicillin once the MIC result has been confirmed.

Duration: 10-14 days

*Refer to Appendix 1 for vancomycin loading dose.

Benzylpenicillin 4MU IV q4h (if MIC to Penicillin ≤ 0.06 mcg/ml)

If MIC to penicillin is > 0.06 mcg/ml use:

Ceftriaxone 2g IV q12h

OR

Cefotaxime 2g IV q6h 

If organism is susceptible and patient is allergic to cephalosporins:

Ciprofloxacin 400mg IV q8h

Duration: 5-7 days

Children/Adolescent < 15 years:

Refer to Paediatric Non-Surgical Chemoprophylaxis (Meningococcal Exposure) Section

Ceftriaxone 250mg IM as single dose (especially in pregnancy and lactating mothers)

OR

Azithromycin 500mg PO as single dose

Close contacts are defined as those individuals who have had contact for > 8 hours and within 1 meter of the index case. Individuals who were in contact with oropharyngeal secretions of the index case in the last 7 days before onset of symptoms up to 24 hours after appropriate antibiotics should also receive chemoprophylaxis.

For index case who received only benzylpenicillin as therapy, chemoprophylaxis should also be given upon discharge to eliminate nasopharyngeal carriage. 

Ampicillin 2g IV q4h

OR

Benzylpenicillin 4MU IV q4h, MAY ADD *Gentamicin 5mg/kg/day IV in 3 divided doses

Trimethoprim/sulfamethoxazole 10 to 20mg/kg/day [based on the TMP component] IV/PO q6-12h

OR

Meropenem 2g IV q8h 

Duration of treatment is 3 weeks depending on clinical response. May be longer in an immunocompromised host.

*Current evidence supporting combination therapy with gentamicin is weak but it can be considered for severe infections for synergistic effect.

Otogenic source:

Ceftazidime 2g IV q8h 

OR

Ceftriaxone 2g IV q12h

PLUS

Metronidazole 500mg IV q8h

--

Duration to be determined by clinical response (usually 4-8 weeks with IV therapy for 2 weeks minimum depending on whether surgical drainage done, clinical and radiological response).

De-escalate antibiotics based on culture result and sensitivity.

Cloxacillin 2g IV q6h

PLUS

Ceftriaxone 2g IV q12h

OR

Cefotaxime 2g IV q4-6h

--

Source control is strongly recommended.

It is important to attempt to obtain specimen to guide antimicrobial therapy.

Continue therapy for at least 6 weeks, with a minimum of 2 weeks IV therapy. Duration to be determined by clinical response, whether surgical drainage done, clinical and radiological response.

Add on Vancomycin if suspecting MRSA infection or patient is deteriorating.

Acyclovir 10mg/kg IV q8h

--

Use Ideal Body Weight in obese class 1 and 2 patients (BMI 30-39.9kg/m2).

Use Adjusted Body Weight for class 3 obesity patients (BMI>40kg/m2).

Duration: 14-21 days

Induction Therapy:

Amphotericin B deoxycholate 0.7-1.0mg/kg/day IV q24h

PLUS

5-Flucytosine 100mg/kg/day PO q6h

Consolidation Therapy:

Fluconazole 400-800mg PO q24h

Maintenance Therapy:

Fluconazole 200mg PO q24h

Induction Therapy:

Amphotericin B deoxycholate 0.7-1.0mg/kg/day IV q24h

PLUS

Fluconazole 800-1200mg PO q24h

OR

Fluconazole 1200mg PO q24h

PLUS

5-Flucytosine 100mg/kg/day PO q6h

Consolidation Therapy:

Fluconazole 800mg PO q24h

Maintenance Therapy:

Fluconazole 200mg PO q24h

Lipid formulations of amphotericin may be used in cases of severe nephrotoxicity.

Repeat lumbar puncture at end of 2 weeks of induction therapy.

Duration of induction therapy:

4-6 weeks (consider 6 weeks if patient has neurological complications and positive CSF culture at 2 weeks).

Duration of consolidation phase:

8 weeks

Use fluconazole 800mg/day if induction phase is less than 4 weeks/ induction phase did not use flucytosine or amphotericin B.

Duration of maintenance Phase:

12 months (longer therapy may be needed to achieve eradication).

Prompt baseline lumbar puncture is strongly encouraged. If pressures are elevated, regular LP is recommended. Consider insertion of EVD/ VP shunting if persistent high CSF pressures. Use of mannitol/ steroids and acetazolamide are not recommended in managing pressures.

In non-HIV/non-transplant patients, consider intermittent LP to look for relapse of cryptococcal infection during consolidation/ maintenance phase (relapse/persistent rate).

If C&S is not available:

Ceftazidime 2g IV q8h

MAY ADD 

*Vancomycin 25-30mg/kg loading dose then 15-20mg/kg IV q8-12h; not to exceed 2g per dose

Meropenem 2g IV q8h

MAY ADD

*Vancomycin 25-30mg/kg loading dose then 15-20mg/kg IV q8-12h; not to exceed 2g per dose

De-escalate antibiotics to targeted therapy when the culture results are available. 

*Vancomycin trough level should be 10-14µmol/L or 15-20mcg/L

*Refer to Appendix 1 for vancomycin loading dose.