Initialtherapy

Initial therapy should be sufficient to kill all pathogens, which are likely to be:

All ages over 5 years

For Neisseria meningitidis and Streptococcus pneumoniae benzylpenicillin 2-4 g 4—6-hourly should be given, followed, in the case of Neisseria meningitidis, by rifampicin for 2 days prior to discharge from hospital (to eradicate persisting organisms). Some prefer to use cefotaxime 2-3 g 6-8-hourly in all cases until the results of susceptibility tests are known, and this may be the generally preferred choice if penicillin resistance in pneumococci and meningococci rises in prevalence. Optimal therapy for penicillin-resistant pneumococcal meningitis may comprise cefotaxime 2-3 g 6-8-hourly plus vancomycin 1 g 12-hourly plus rifampicin 600 gm 12-hourly.

Children under 5 years

Neisseria meningitidis is now commonest and Haemophilus influenzae, formerly a frequent pathogen, is much less often isolated (as a result of immunisation programmes). Streptococcus pneumoniae is also less commonly found than in older patients.

Give a cephalosporin, e.g. cefotaxime. When Haemophilus influenzae is isolated give rifampicin for 4 days before discharge from hospital to clear naso-pharyngeal carriage.

Neonates

For Escherichia coli: give cefotaxime or ceftazidime perhaps with gentamicin. For Group B streptococci: give benzylpenicillin plus gentamicin. Consult a specialist text for details of doses for neonates.

Ampicillin must be added if Listeria monocytogenes is suspected.

Dexamethasone given i.v. and early appears to reduce long-term neurological sequelae, especially sensorineural deafness, in infants and children. There is not, however, general agreement about the use of dexamethasone for meningitis in adults.

Chloramphenicol remains a good alternative for 'blind' therapy in patients giving a history of ß-lactam anaphylaxis.

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