CNS INFECTION GUIDANCE in ADULTS

• Guidance applies to non pregnant adult patients only • All doses assume normal renal and hepatic function • TREATMENT SHOULD ALWAYS BE ADJUSTED ACCORDING TO MICROBIOLOGY SENSITIVITY RESULTS

INFECTION PATHOGEN EMPIRICAL TREATMENT COMMENTS BACTERIAL MENINGITIS – pneumococcus Follow flow chart for initial early management Duration: (Consider outpatient IV therapy if patient has COMMUNITY ACQUIRED and treatment then: had ≥5 days treatment, afebrile and clinically improving)

meningococcus Ceftriaxone IV 2g bd No organism identified but clinical condition

(Penicillin allergy: Chloramphenicol IV 25mg/kg qds) consistent with bacterial meningitis: 10 days if Ref: British Infection + patient has clinically recovered. Request ID consult Association Early Management Haemophilus influenzae Dexamethasone IV 10mg qds for 4 days only via email: [email protected] Flow chart 2016 (3ml of 3.3mg/ml dexamethsone base injection) Organism identified: • started with or just before first dose of antibiotics. British Infection Association occasionally other gram meningococcus: 5 days ceftriaxone (if patient not • If antibiotics have already been commenced Guideline on diagnosis and negative bacteria recovered by 5 days extend course to 7 days initially dexamethasone should be initiated up until 12 hours management of acute and review) + stop dexamethasone meningitis and meningococcal after the first dose of antibiotics. • If pneumococcal meningitis is confirmed or thought sepsis in immunocompetent pneumococcus: 10 days ceftriaxone (if pati ent taking adults 2016 Listeria spp probable, continue dexamethsone for 4 days. longer to respond extend course up to 14 days) + 4 if ≥60 years • If another cause of meningitis is confirmed or days dexamethasone OR thought probable, the dexamethasone should be immunocompromised stopped. pencillin/cephalosporin resistant pneumococcus: 14 (including alcohol days ceftriaxone + vancomycin (vancomycin dependency and If listeria cover required (see pathogen box) then add to monotherapy not recommended due to concerns re diabetes) above: CSF penetration) + 4 days dexamethasone

Amoxicillin IV 2g 4 hourly Listeria spp at least 21 days of amoxicillin (Penicillin allergy: Co-trimoxazole IV 120mg/kg divided + stop dexamethasone into 4 doses/day) Haemophilus influenzae 10 days of ceftriaxone If recent travel (within last 6 months) to country with high + stop dexamethasone rates of pencillin resistant pneumococci then add: Vancomycin IV (aim for predose level 15-20mg/L) or other gram negative bacteria: 21 days of antibiotic Rifampicin IV/PO 600mg bd regime agreed with ID/Micro + stop dexamethasone

Countries with high rates of pneumococcal resistance:

Canada Pakistan Mexico Greece Locally it is agreed that where any meningitis guidance China Poland Italy Turkey states ampicillin IV 2g that amoxicillin IV 2g can be Croatia Spain USA substituted. NHS Tayside does not keep ampicillin. TREATMENT SHOULD ALWAYS BE ADJUSTED ACCORDING TO MICROBIOLOGY SENSITIVITY RESULTS

INFECTION PATHOGEN EMPIRICAL TREATMENT COMMENTS VENTRICULITIS AND pseudomonas IV ceftazidime 2g 8 hourly Always seek specialist Micro/ID advice for MENINGITIS - + rationalising antimicrobials and duration. SHUNT ASSOCIATED + other gram negative IV vancomycin OR POST OPERATIVE bacteria (aim for predose level 15-20mg/L) Shunt may require to be removed.

Staph. epidermidis Intraventricular* vancomycin (20mg daily Staph. aureus clamped for 1 hour) may be considered if patient Ref: IDSA Guidance 2017 Propionibacterium sp (if known anaphylaxis to penicillin or cephalosporin IV ciprofloxacin 400mg tds + IV vancomycin) has an EVD in place or responds poorly to Ref: Intraventricular systemic therapy alone (must be prepared in antimicrobial therapy pharmacy aseptic unit). No level monitoring required. MENINGITIS - pneumococcus IV ceftriaxone 2g 12 hourly Often upper respiratory tract pathogens POST TRAUMA Haemophilus influenzae + streptococci IV metronidazole 500mg tds Always seek specialist advice anaerobes BRAIN ABCESS streptococci IV ceftriaxone 2g 12 hourly Add IV flucloxacillin 2g qds if staphylococcal Bacteroides spp + infection suspected IV metronidazole 500mg 8 hourly IV vancomycin if penicillin allergic or MRSA proven or suspected (aim for predose level 15-20mg/L) Duration: minimum 4 weeks VIRAL ENCEPHALITIS Herpes simplex (HSV) IV aciclovir 10mg/kg 8 hourly Perform CT Scan prior to lumbar puncture if Other viruses Adjust dose in renal impairment see SPC clinical contraindication to immediate LP For obese patients use ideal body weight (see ref p352) Ref: BIA Guidance 2012 14 days (21 days if immunocompromised) then Offer HIV testing in patients with encephalitis where repeat LP. If HSV PCR remains positive then HSV1 PCR is negative continue treatment and weekly PCR until negative.

IV treatment only recommended VIRAL MENINGITIS enteroviruses Initial early management and treatment as for Aseptic/lymphocytic meningitis is an indication for HIV Herpes simplex (HSV) community acquired bacterial meningitis. testing. Ref: British Infection Varicella zoster (VZV) HSV2 is usually a sexually transmitted infection Association Gui deli ne on paramyxovirus (mumps) Stop antibacterials, antivirals and steroid treatment consider need for testing for other STIs including HIV. diagnosis and management of if enteroviral or mumps meningitis is diagnosed and acute meningitis and manage symptomatically. Continuation of meningococcal sepsis in antivirals for HSV/VZV should be discussed with ID. immunocompetent adults 2016

Approved by: Antimicrobial Management Group Date: March 2016 Updated: Sept 2018 Review: Sept 2021