Management of Invasive Streptococcus pneumoniae Meningitis

Empiric Antibiotic Therapy

In adults < 60 years, start ceftriaxone 2 g IV every 12 h or cefotaxime 2 g IV every 6 h as first‑line therapy for suspected bacterial meningitis. 1
Add vancomycin 15–20 mg/kg IV every 12 h or rifampicin 600 mg IV/PO every 12 h when penicillin‑resistant pneumococci are suspected (e.g., recent travel to high‑resistance regions). 1
For patients with a documented β‑lactam allergy, use chloramphenicol 25 mg/kg IV every 6 h as an alternative. 1
In adults ≥ 60 years, combine the above β‑lactam regimen with amoxicillin 2 g IV every 4 h to ensure coverage of Listeria monocytogenes. 1

Penicillin‑sensitive isolates (MIC ≤ 0.06 mg/L): continue ceftriaxone 2 g IV q12 h or cefotaxime 2 g IV q6 h; benzylpenicillin 2.4 g IV q4 h is an acceptable alternative. 1
Penicillin‑resistant but cephalosporin‑sensitive isolates (MIC > 0.06 mg/L, cephalosporin MIC ≤ 0.5 mg/L): maintain ceftriaxone 2 g IV q12 h or cefotaxime 2 g IV q6 h; no additional agents required. 1
Dual‑resistant isolates (penicillin + cephalosporin MIC > 0.5 mg/L): give ceftriaxone 2 g IV q12 h or cefotaxime 2 g IV q6 h plus vancomycin 15–20 mg/kg IV q12 h (target trough 15–20 µg/mL) and rifampicin 600 mg IV/PO q12 h. 1

Treat for 10 days total if the patient has clinically recovered by day 10. 1
Extend to 14 days total if recovery is not achieved by day 10. 1
For any infection caused by penicillin‑ or cephalosporin‑resistant strains, prescribe 14 days total regardless of clinical response. 1

Administer dexamethasone 10 mg IV every 6 h for 4 days, beginning with (or immediately before) the first antibiotic dose. 1
Discontinue dexamethasone by day 4–7; prolonged courses beyond this window provide no additional benefit. 2
Early dexamethasone (given before or with the first antibiotic) reduces mortality and neurological sequelae in pneumococcal meningitis. 1

Obtain repeat CT or MRI (MRI preferred) when any of the following occur:
- Glasgow Coma Scale decline ≥ 2 points,
- New focal neurological deficit,
- New or worsening seizure activity,
- Persistent fever beyond 7–10 days of appropriate therapy,
- Clinical deterioration suggesting complications (e.g., abscess, hydrocephalus, ventriculitis). 2
Routine repeat lumbar puncture is not indicated in clinically stable patients; perform only if deterioration suggests treatment failure or secondary intracranial infection. 2

Admit to ICU if the patient has a Glasgow Coma Scale ≤ 12 or a drop of ≥ 2 points, or if they experience seizures requiring ongoing management. 2
Patients with stable neurological status (GCS 15) may be managed on a regular ward with neurological checks every 4–6 hours. 2

For household contacts of meningococcal meningitis, offer a single dose of ciprofloxacin 500 mg PO, or ceftriaxone 250 mg IM, or rifampicin 600 mg PO every 12 h for 2 days. 3
No prophylaxis is recommended for contacts of patients with pneumococcal meningitis. 3

Do not stop antibiotics at day 10 if the patient has not fully recovered; extend therapy to 14 days. 1
Do not add vancomycin empirically unless there is confirmed or strongly suspected cephalosporin resistance, to avoid unnecessary toxicity. 2
Do not perform routine repeat lumbar punctures solely to monitor CSF parameters, as this does not improve outcomes and adds discomfort. 2
Do not use therapeutic hypothermia or routine adjuncts such as mannitol, acetaminophen, antiepileptic drugs, or hypertonic saline without specific indications. 3