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Recommendations for empiric antimicrobial therapy for purulent meningitis based on patient age and specific predisposing condition*

Recommendations for empiric antimicrobial therapy for purulent meningitis based on patient age and specific predisposing condition*
Predisposing factor Common bacterial pathogens Antimicrobial therapy
Age
<1 month Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes Ampicillin plus cefotaxime; OR ampicillin plus an aminoglycoside
1 to 23 months Streptococcus pneumoniae, Neisseria meningitidis, S. agalactiae, Haemophilus influenzae, E. coli Vancomycin plus a third-generation cephalosporinΔ
2 to 50 years N. meningitidis, S. pneumoniae Vancomycin plus a third-generation cephalosporinΔ
>50 years S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gram-negative bacilli Vancomycin plus ampicillin plus a third-generation cephalosporinΔ
Head trauma
Basilar skull fracture S. pneumoniae, H. influenzae, group A beta-hemolytic streptococci Vancomycin plus a third-generation cephalosporinΔ
Penetrating trauma Staphylococcus aureus, coagulase-negative staphylococci (especially Staphylococcus epidermidis), aerobic gram-negative bacilli (including Pseudomonas aeruginosa) Vancomycin plus cefepime; OR vancomycin plus ceftazidime; OR vancomycin plus meropenem
Postneurosurgery Aerobic gram-negative bacilli (including P. aeruginosa), S. aureus, coagulase-negative staphylococci (especially S. epidermidis) Vancomycin plus cefepime; OR vancomycin plus ceftazidime; OR vancomycin plus meropenem
Immunocompromised state S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gram-negative bacilli (including P. aeruginosa) Vancomycin plus ampicillin plus cefepime; OR vancomycin plus meropenem§
* For recommended doses, refer to the UpToDate content on treatment of bacterial meningitis in children and adults.
¶ Ceftriaxone or cefotaxime.
Δ Some experts would add rifampin if dexamethasone is also given.
Add ampicillin if meningitis caused by Listeria monocytogenes is suspected.
§ Meropenem provides sufficient coverage for Listeria when used as part of an initial regimen. However, if Listeria is identified, the patient should generally be switched to a regimen that includes ampicillin. Refer to the UpToDate topic that discusses treatment of Listeria for a discussion of regimen selection.
Modified with permission from: Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267. Copyright © 2004 University of Chicago Press.
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