Empirical Antimicrobial Therapy

After expeditious workup (i.e., evaluation of risk factors, clinical signs and symptoms, and laboratory data) and diagnosis, prompt and aggressive antimicrobial therapy is initiated. Appropriate empirical treatment is of the utmost importance in patients with suspected CNS infections. In most patients, a diagnostic LP will be performed before beginning antibiotics, but this never should delay initiation of antimicrobials. Antibiotic pretreatment may alter the CSF profile and complicate interpretation. Empirical therapy should be directed at the most likely pathogen(s) for a specific patient, taking into account age, risk factors for infection (including underlying disease and immune dysfunction, vaccine history, and recent exposures), CSF Gram stain results, CSF antibiotic penetration, and local antimicrobial resistance patterns. Results of the CSF Gram stain may be used to help narrow empirical therapy for bacterial meningitis. In the absence of a positive Gram stain, empirical therapy should be continued for at least 48 to 72 hours, when meningitis may, in most cases, be ruled out by CSF findings inconsistent with bacterial meningitis, negative CSF culture, and negative PCR evaluations. A repeat LP may be useful in the absence of other findings. Table 70-1 outlines recommendations for empirical antibiotic therapy for bacterial meningitis by most likely pathogen(s) and patient risk factors.

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