Central Nervous System Infections

Ceftriaxone 2g (child 50mg/kg) IV BID

PLUS

Dexamethasone 10mg (child 0.15mg/kg) IV QID for 4 days

If immunocompromised, over 50 years old, or neonate, to cover the possibility of Listeria, ADD:

Benzylpenicillin 4 million IU (2.4g) (child 100 000 IU (60mg)/kg) IV Q4H

Alternative:

If ceftriaxone is unavailable use:

Cefotaxime 2g (child 50mg/kg) IV QID

OR

Chloramphenicol 1g (child 25mg/kg) IV QID

OR

Meropenem 2g (child 40mg/kg) IV TID

If benzylpenicillin is unavailable and patient is at risk of Listeria use:

Ampicillin 2g (child 50mg/kg) IV Q4H

(No need to add additional listeria cover if meropenem is used)

Perform blood cultures on all patients prior to antibiotics. Lumbar puncture should be performed for CSF protein, glucose, microscopy, and culture, wherever possible, ideally prior to antibiotics, however treatment should not be delayed if there is difficulty obtaining CSF.

Raised intracranial pressure is generally a contraindication to performing lumbar puncture. Raised intracranial pressure may cause coma or focal neurological signs. Fundoscopy and CT (to rule out a space occupying lesion) can be performed prior to lumbar puncture, if there are concerns.

CNS tuberculosis is an important differential diagnosis. If patient has chronic meningitis symptoms with persisting headache or patient is immunocompromised, also consider cryptococcal meningitis. Request Cryptococcal antigen on CSF or blood if this is suspected.

See Neonatal Meningitis in Chapter 11: Paediatric Infections (Neonates, Infants and Children).

Meropenem 2g (child 40mg/kg) IV TID

PLUS

Vancomycin loading dose 25-30mg/kg IV, then dose according to Vancomycin dosing section.

Perform blood cultures on all patients, obtain CSF where possible. Direct antibiotics once culture results are available.

Induction:

Fluconazole 1200mg (child 12mg/kg) IV / PO OD

THEN

Consolidation:

Fluconazole 800mg (child 6-12mg/kg) PO OD.

THEN

Eradication:

Fluconazole 200mg - 400mg (child 6mg/kg) PO OD

In patients with Cryptococcomas:

Extend duration of induction to at least 6 weeks.
Following induction treat with fluconazole 400mg-800mg (child 6mg/kg) for 12 to 18 months.

In patients with HIV, who are asymptomatic, and have a negative CSF, but serum CrAg is positive:

Fluconazole 400mg (child 6 mg/kg) PO OD ART can be started without delay.

Continue until patient is on ART AND has a CD4 count >100 cells/microL for at least 3 months

Raised intracranial pressure (ICP):

Daily lumbar punctures should be performed to manage raised ICP due to Cryptococcal meningitis, until the patient is asymptomatic and CSF pressure is normal (<20cm).
In symptomatic patients with CSF pressure ≥50cm aim to reduce intracranial pressure by 50% of the opening pressure.

There is no role for acetazolamide, or mannitol to reduce intracranial pressure in cryptococcal meningitis.

There is no role for corticosteroids to reduce intracranial pressure in cryptococcal meningitis except in the setting of IRIS or cerebral oedema surrounding a cryptococcoma.

Duration:

Induction: At least 2 weeks. Extend if no clinical improvement, or if CSF sterilization not achieved (i.e. CSF cultures still grow cryptococcus at 2 weeks).

Consolidation: At least 8 weeks. Extend if slow clinical response, CSF sterilization not achieved by 2 weeks, or ART delayed by >10 weeks.

Eradication: At least 12 months.

In HIV delay commencement of antiretroviral therapy (ART) until 2-10 weeks after antifungal therapy has started.
After 12 months fluconazole can be stopped if the patient is on ART, with a CD4 count >100 and an undetectable viral load.

VZV encephalitis should be suspected if associated with a typical rash (see Zoster / Shingles in Skin and Soft Tissue Infections chapter).

Antimicrobial 

Comments and Duration of Therapy

Ceftriaxone 2g (child 50mg/kg) IV BID

PLUS

Metronidazole 500mg (child 12.5mg/kg) IV TID

If multiple abscesses or probable haematogenous spread ADD:

Cloxacillin 2g (child 50mg/kg) IV QID

OR

If increased risk of MRSA (recent prolonged or frequent hospital admission, prior colonization with MRSA).

Vancomycin IV, dose according to Vancomycin dosing section dosing section

For brain abscess after penetrating trauma or neurosurgery treat Meningitis following penetrating head trauma or neurosurgery (for duration follow Brain abscess and Subdural Empyema)

Surgical drainage is required. If present, infected sinus or ear should be drained and infected bone removed where possible. Send blood cultures, and tissue for culture and TB testing. Send Cryptococcal antigen. Change antibiotics according to culture results.

Seizures are frequent and prophylactic anticonvulsants should be given

In those who are immunocompromised consider other diagnoses including Toxoplasmosis, Cryptococcosis, Nocardiosis, and TB. Malignancy should also be considered if there is no improvement with empiric therapy.

Duration:

Treat for 6-8 weeks with a minimum of 2-4 weeks IV. If used, oral antibiotics should have good CNS penetration (e.g. Co-trimoxazole, fluoroquinolones). Do not use oral beta-lactams. IV treatment should be extended if surgical drainage cannot be performed.

Cloxacillin 2g (child 50mg/kg) IV QID

PLUS

In adults only: Ceftriaxone 2g IV BID

If increased risk of MRSA (recent prolonged or frequent hospital admission, prior colonization with MRSA) ADD:

Vancomycin, dose according to Vancomycin dosing section.

Take two sets of blood cultures prior to antibiotics.
Perform CT or MRI for diagnosis.
Change antibiotics according to culture results. If no microbiological diagnosis is obtained modify antibiotics according to the most likely cause of infection.

Duration:

Treat for at least 6 weeks, with a minimum of 2-4 weeks IV.

If antiparasitic treatment is indicated (see comments) USE:

Albendazole 7mg/kg (maximum dose 600mg) PO BID

PLUS

Dexamethasone 0.1mg/kg PO OD

OR

Prednisone 1mg/kg PO OD

(begin steroids one day before antiparasitic)

Patients should also be commenced on anti-epileptic treatment.

Diagnose based on consistent clinical picture and radiology (CT and/or MRI). Serologic testing is not currently available in Timor.
All patients should be evaluated for ocular cysticercosis by ophthalmology. Only treat patients with active lesions. Patients with calcified cysts and no active cysts do not benefit from treatment. Do not give antiparasitic therapy to patients with untreated hydrocephalus, ocular cysticercosis or high cyst burden disease with diffuse cerebral oedema, as inflammation around the degenerating cysts may worsen symptoms.

Oedema surrounding active lesions may cause raised intracranial pressure; this should be managed with corticosteroids.

Duration:

Treat for 10 days