Recurrent Meningitis

Recurrent meningitis can have both infectious and noninfec-tious causes. A CSF leak accounts for approximately 75% of cases of recurrent meningitis. Clinically, it presents more like aseptic meningitis. A careful history may detect a drug exposure, structural lesion, or associated systemic disorder. To be truly recurrent, the CSF must confirm pleocytosis. Between episodes, the CSF must also be documented to return to normal. The interval between recurrences can be months to years. Unless the source is bacterial, the course of recurrent meningitis is usually self-limited, and spontaneous recovery is generally the rule. Optimal treatment is aimed at the underlying cause.

Table 42-13 Specific Antibiotic Treatments for Known Pathogens

Pathogen

Primary Therapy

Alternative*

Group B streptococcus

Penicillin G or ampicillin

Vancomycin or third-generation cephalosporin

Streptococcus pneumoniae (MIC <0.1)

Third-generation cephalosporin

Meropenem penicillin

S. pneumoniae (MIC >0.1)

Vancomycin plus third-generation cephalosporin"

Substitute rifampin for vancomycin; or meropenem; or vancomycin as monotherapy if highly allergic to other alternatives

Haemophilus influenzae (ß-lactamase negative)

Ampicillin

Third-generation cephalosporin or chloramphenicol or aztreonam

H. influenzae (ß-lactamase positive)

Third-generation cephalosporin

Chloramphenicol or aztreonam or fluoroquinolones*

Listeria monocytogenes

Ampicillin plus gentamicin

TMP-SMX

Neisseria meningitidis

Penicillin G or ampicillin

Third-generation cephalosporin

Enterobacteriaceae

Third-generation cephalosporin plus aminoglycoside

TMP-SMX or aztreonam or fluoroquinolones or antipseudomonal penicillin5 (or ampicillin) plus aminoglycoside

Pseudomonas aeruginosa

Ceftazidime plus aminoglycoside

Aminoglycoside plus aztreonam or aminoglycoside plus antipseudomonal penicillin§

Staphylococcus aureus (methicillin sensitive)

Antistaphylococcal penicillin11 ± rifampin

Vancomycin plus rifampin or TMP-SMX plus rifampin

S. aureus (methicillin resistant)

Vancomycin plus rifampin

Staphylococcus epidermidis

Vancomycin plus rifampin

"If patient is highly allergic or intolerant of primary therapy. Ceftriaxone or cefotaxime. ¿Ciprofloxacin or levofloxacin. §Piperacillin, mezlocillin, or ticarcillin. 11Nafcillin, oxacillin, or methicillin.

MIC, Minimum inhibitory concentration; TMP-SMX, trimethoprim-sulfamethoxazole.

Table 42-14 Common Pathogens of Bacterial Meningitis and Empiric Treatment Based on Age

Age

Common Pathogens

Treatment*

Duration (days)

0-1 mo

Group B streptococcus Listeria monocytogenes Escherichia coli Streptococcus pneumoniae

Ampicillin plus third-generation cephalosporin or ampicillin plus aminoglycoside

14-21 14-21 21

10-14

1-3 mo

Group B streptococcus, E. coli, L. monocytogenes S. pneumoniae

Neisseria meningitidis, Haemophilus influenzae

Ampicillin plus third-generation cephalosporin

14-21 10-14 7-10

3 mo-18 yr

H. influenzae, N. meningitidis S. pneumoniae

Third-generation cephalosporin or meropenem or chloramphenicol

7-10 10-14

18-50 yr

H. influenzae, N. meningitidis S. pneumoniae

Third-generation cephalosporin or meropenem or ampicillin plus chloramphenicol

7-10 10-14

>50 yr

S. pneumoniae L. monocytogenes

Gram-negative bacilli (other than H. influenzae)

Ampicillin plus third-generation cephalosporin or ampicillin plus fluoroquinolone* or meropenem

10-14 14-21 21

"Add vancomycin in areas where there is greater than 2% incidence of highly drug-resistant S. pneumoniae. Ceftriaxone or cefotaxime. ¿Ciprofloxacin or levofloxacin.

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