CENTRAL NERVOUS SYSTEM INFECTIONS

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Empirical treatment

Common organisms:

Streptococcus pneumoniae

Neisseria meningitidis

Haemophilus influenzae

Other organisms:

Gram-negative rods

Ceftriaxone 2gm IV q12h

OR

Cefotaxime 2gm IV q6h

PLUS*

*Ampicillin 2gm IV q4h

Alternative for immunocompromised: Meropenem 2gm IV q8h

Antibiotic should not be delayed awaiting investigations.

Duration: 10-14 days

Dexamethasone 0.4mg/ kg/dose 15 to 20 minutes before or at the same time as first dose of antibiotics. Continue q12h for 4 days if the Gram stain and/or cultures are consistent with Streptococcus pneumoniae.

*Consider empirical coverage with Ampicillin for Listeriosis in people >60 years of age, alcoholic, immunosuppressed and pregnant.

Causative Organism isolated:

Streptococcus pneumoniae

Penicillin-susceptible strains

Benzylpenicillin 4MU IV q4h

Ceftriaxone or Cefotaxime should be de-escalated to Benzylpenicillin once the MIC result has been confirmed.

Duration: 10-14 days

Penicillin resistant strains

Ceftriaxone 2gm IV q12h

OR

Cefotaxime 2gm IV q6h

Penicillin resistant strains

Cefepime 2gm IV q8h

OR

Meropenem 2gm IV q8h

Cephalosporin resistant strains Vancomycin 25-30mg/kg loading dose then 15-20mg/kg IV q812h; not to exceed 2gm per dose

OR

Rifampicin 600mg IPO q12h

PLUS

Ceftriaxone 2gm IV q12h

OR

Cefotaxime 2gm IV q6h

Neisseria meningitidis

Benzylpenicillin 4MU IV q4h

If resistant to Penicillin

Ceftriaxone 2gm IV q12h

OR

Cefotaxime 2gm IV q6h

Duration 5-7 days

If treated with Benzylpenicillin, chemoprophylaxis given at discharge to eliminate nasopharyngeal carriage.

Neisseria meningitidis Prophylaxis for household and close contacts*

Age > 15 years:

Ciprofloxacin 500mg PO as single dose

OR

Rifampicin 600mg PO q12h for 2 days (4 doses) [not recommended in pregnancy]

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

OR

Azithromycin 500mg PO as single dose

*Contact for > 8 hours and within 1 meter of the index case and contact with oropharyngeal secretions in the last 7 days before onset of symptoms up to 24 hours after appropriate antibiotics.

Listeriosis

Ampicillin 2gm IV q4h

OR

Benzylpenicillin 4MU IV q4h

PLUS*

Gentamicin 5mg/kg/day IV in 3 divided doses

Trimethoprim-sulfamethoxazole  10 to 20mg/kg/day (TMP component) IV q6-12h

OR

Meropenem 2gm IV q8h

Duration - 3 weeks or longer (in immunocompromised host) depending on clinical response.            

Gentamicin is given until symptoms improve (minimum of 1 week).

Haemophilus influenzae

Ceftriaxone 2gm IV q12h

OR

Cefotaxime 2gm IV q6h

Cefepime 2gm IV q8h

If organism is susceptible and patient is allergic to cephalosporins:

Ciprofloxacin 400mg IV q8h

Duration: 7-10 days.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Tuberculous meningitis

Mycobacterium tuberculosis

 2HRZE + (7-10)HRE

Isoniazid (H)-5mg/kg

Rifampicin (R)- 10mg/kg

Ethambutol (E)- 15mg/kg

Pyrazinamide (Z)- 25mg/ kg

Pyridoxine 10-50mg PO q24h needs to be prescribed together with Isoniazid

Infection in HIV patients: Similar to HIV-uninfected adults.

Consider drug interactions

Daily dosing is recommended as per DOTS.

(Follow National Tuberculosis Guidelines)

Add dexamethasone

0.3-0.4mg/kg/day for 2 weeks, then 0.2mg/ kg/day for week 3, then 0.1mg/kg/day for week 4 and taper gradually and stop by 8 weeks.

Duration - usually 12 months.

Cryptococcal meningitis 

Cryptococcus neoformans

(In immunocompetent)

Induction Therapy:

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

PLUS

5-Flucytosine 100-150mg/ kg/day PO q6h

OR

Fluconazole 800-1200mg PO q24h

Induction Therapy: Fluconazole 1200mg PO q24h

PLUS

5-Flucytosine 100-150mg/ kg/day PO q6h

Duration of induction therapy: 4-6 weeks

Duration of consolidation therapy: 8 weeks

Duration of maintenance therapy: up to 12 months

Consolidation Therapy:

Fluconazole 400-800mg PO q24h

Maintenance Therapy:

Fluconazole 200mg PO q24h

Viral Encephalitis Herpes simplex

Varicella zoster

Acyclovir 10mg/kg* IV q8h

*dosing based on ideal body weight and not measured weight in obese.

Duration: 14-21 days

Brain Abscess/Subdural Empyema

Common organisms:

Streptococci

Staphylococci

Gram-negative bacilli

Anaerobes

Brain abscess/subdural empyema suspected arising from an oral source:

Ampicillin 2g q4-6h

OR

Ceftriaxone 2g IV q12h

PLUS

Metronidazole 500mg IV q8h

Duration - 4-8 weeks (IV 2 weeks minimum)

*Add Cloxacillin if suspected hematogenous spread, post-neurosurgery or post penetrating injury. In post-neurosurgery or trauma, consider cover for Pseudomonas.

Brain abscess/subdural empyema suspected arising from sinus or otogenic source:

Ceftriaxone 2gm IV q12h

OR

Cefotaxime 2gm IV q4-6h

PLUS

Metronidazole 500mg IV q8h

Brain abscess/subdural empyema arising from hematogenous spread or penetrating trauma (community acquired):

Ceftriaxone 2gm IV q12h

OR

Cefotaxime 2gm IV q4-6h

PLUS*

Cloxacillin 2gm IV q4h

PLUS

Metronidazole 500mg IV q8h

Brain abscess arising from hematogenous spread (hospital acquired) or post- neurosurgery:

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

PLUS

Ceftazidime 2gm IV q8h

OR

Cefepime 2gm IV q8h

OR

Meropenem 2 g IV q8h

Spinal Epidural Abscess

Common organisms:

Streptococci

Staphylococci

Gram-negative bacilli

Cloxacillin 2gm IV q4h

OR*

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

PLUS

Gentamicin 4-7mg/kg/day IV in 3 divided doses

OR

**Ceftriaxone 2gm IV q12h

OR

**Cefotaxime 2gm IV q4-6h

Duration: 2-6 weeks (IV 2 weeks minimum)

* Vancomycin if suspecting MRSA or allergy to Cloxacillin.

**3rd Generation Cephalosporin if Gentamicin is contraindicated.

Healthcare-associated ventriculitis and Meningitis

If C&S is not available:

Ceftazidime 2gm IV q8h

PLUS*

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

Meropenem 2gm IV q8h

PLUS*

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

*Vancomycin if MRSA suspected.

Cranial Trauma

Open fracture and Penetrating injuries

Amoxicillin-clavulanate 1.2gm IV q8h

Cefuroxime 1.5gm IV q8H

PLUS

Metronidazole 500mg IV q8H

Duration: 5-7 days

Penetrating craniocerebral injuries

Ceftriaxone 2gm IV q12h

PLUS

Metronidazole 400mg PO q8h

Duration: For 2 weeks initially and then review with microbiology