Central nervous system

NHS Dumfries & Galloway Antimicrobial Handbook
NHS Dumfries and Galloway

Suspected meningococcal meningitis is a medical emergency and requires urgent resuscitation and antibiotics.
Collect blood cultures, CSF if possible, throat swab and EDTA blood for meningococcal / pneumococcal PCR, but do not delay giving antibiotics.
Start antimicrobial therapy <1 hour of presentation after lumbar puncture unless contraindicated.

Review previous microbiology results: If resistant target organisms previously isolated (e.g. MRSA, ESBL, known resistance to empirical antibiotic choices), discuss antibiotic choice with Paediatric and/or Microbiology Consultant.

User guide: for further advice regarding antimicrobial prescribing good practice, oral switch, penicillin allergy, dosing, and safety considerations: HERE

Bacterial meningitis

First line <6 weeks

IV cefOTAXime
and IV gentamicin 
and IV amoxicillin 

Steroids: not of proven benefit in this age group.

Stop amoxicillin if CSF culture does not show Listeria after 48 hours AND Listeria PCR is negative.

Add IV aciclovir if <1 month AND any one of:

    • ALT or AST >2x upper limit of normal
    • vesicles
    • seizures
    • CSF pleocytosis
    • suspected meningitis/encephalitis
    • recent maternal herpes simplex disease
    • postnatal contact with herpes simplex virus
    • Consider if: day 3-14 age with none of the above but no other obvious cause or not improving or unexplained maternal febrile illness peripartum to 14 days postpartum, especially if premature
    • Stop if alternative cause is found
First line 6 weeks - 3 months

IV cefOTAXime or IV cefTRIAXone

Steroids: not of proven benefit in this age group.

First line >3 months

IV cefOTAXime or IV cefTRIAXone

Steroids: add dexamethasone for 4 days if bacterial meningitis without purpura.

Penicillin allergy (severe)

Discuss with microbiology

If there is a delay in obtaining microbiology advice, refer to UK-PAS guidance: HERE

TOTAL duration
  • Full course of parenteral therapy.
  • Oral antibiotics are not appropriate treatment for a patient with suspected or confirmed meningitis.
  • Longer treatments may be required if brain abscess and/or other foci of infection are identified.
  • Specific situations:
    • Neisseria meningitidis: 5-7 days
    • Haemophilus influenzae: 7-10 days
    • Streptococcus pneumoniae: 10-14 days
    • Group B Streptococcus: at least 14 days
    • Gram negative bacilli: at least 14 days
    • Listeria monocytogenes: IV amoxicillin for 21 days AND IV gentamicin for 7 days
    • Suspected bacterial meningitis, but culture/PCR negative:
          • <3 months = 14 days
          • >3 months = 10 days
  • Seek advice advice from Paediatric Consultant and/or Microbiology Consultant
Comments
  • Public Health Notification
    Suspected or confirmed meningococcal disease and invasive Haemophilus influenzae type b require notification to Public Health Scotland, via the local Health Protection Team (HPT). Additionally, prophylaxis and contact tracing should be discussed.

Viral encephalitis

First line

IV aciclovir

Alternative:

Nil available

PO treatment not recommended.

TOTAL duration
  • On advice from Paediatric Consultant and/or Microbiology Consultant.

Editorial Information

Last reviewed: 20/02/2024

Next review date: 20/02/2026

Author(s): Dr Jon van Aartsen (Consultant Microbiologist), Dr Jed Bamber (Consultant Paediatrician).

Version: v1.0

Approved By: AMT (20.02.2024) and ADTC (28.02.2024)

Reviewer name(s): Dr Jed Bamber (Consultant Paediatrician), AMS Team.