Central Nervous System Infections

EMPIRIC TREAMENT OF CENTRAL NERVOUS SYSTEM INFECTIONS Clinical Setting Bacterial meningitis Community-acquired Likely P...

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EMPIRIC TREAMENT OF CENTRAL NERVOUS SYSTEM INFECTIONS Clinical Setting Bacterial meningitis Community-acquired

Likely Pathogens S. pneumoniae, N. meningitidis, H. influenzae type b, b L. monocytogenes

a

Empiric Therapy First line: ceftriaxone + b,c vancomycin ± ampicillin Alternatives: moxifloxacin + b,c vancomycin ± ampicillin d

Consider adjunctive dexamethasone in the following scenarios: » Children >6 weeks of age with suspected or proven H. influenzae type b meningitis » Adults with suspected or proven S. pneumoniae meningitis

Bacterial meningitis Hospital-acquired (post-neurosurgical, CSF shunt) Recommend formal ID consultation for additional management, including diagnostics and treatment

Brain abscess

Viral encephalitis Immunocompetent hosts

Aerobic gram-negative bacilli (including P. aeruginosa), S. aureus (including MRSA), coagulase-negative staphylococci, Propionibacterium acnes

If CSF shunt present, all infected components should be removed. First line: cefepime + vancomycin

Streptococci, anaerobes, S. aureus (including MRSA)

First line: ceftriaxone + metronidazole ± vancomycin

Herpes simplex virus, varicella-zoster virus Other viruses

Usual Duration H. influenzae & N. e meningitidis : 7 days e S. pneumoniae : 10-14 days e L. monocytogenes : at least 21 days Dexamethasone should be continued for no more than 2-4 days.

21 days If shunt present, duration of therapy likely dependent upon removal of shunt and sterilization of CSF cultures

Alternatives: f Meropenem + vancomycin

Alternatives: Meropenem ± vancomycin Moxifloxacin + metronidazole ± vancomycin Aztreonam + metronidazole + vancomycin IV acyclovir Supportive care

4-8 weeks Duration of therapy dependent upon response to treatment (clinically and radiographically), receipt of surgical interventions, causative pathogen, and abscess characteristics (number of lesions, initial size, and location)

14-21 days Not applicable

Antiviral therapy not recommended

Viral encephalitis Immunocompromised hosts

Herpes simplex virus, varicella-zoster virus Cytomegalovirus

IV acyclovir

14-21 days

IV ganciclovir + foscarnet

Consider empiric coverage for the following depending on clinical scenario

Human herpesvirus 6 HIV Other viruses (including West Nile virus, EpsteinBarr virus, JC virus)

IV ganciclovir or foscarnet HAART therapy Supportive care

21 days, then maintenance therapy e 21 days Indefinitely Not applicable

Enteroviruses, arboviruses Cryptococcus neoformans

Supportive care

Recommend formal ID consultation for additional management, including diagnostics and treatment

Viral meningitis Fungal meningitis Consider empiric coverage for the following depending on clinical scenario

Recommend formal ID consultation for additional management, including diagnostics and treatment

Coccidioides species Blastomyces species, Histoplasma capsulatum Aspergillus species

Antiviral therapy not recommended

Not applicable

Antiviral therapy not recommended

Induction: liposomal amphotericin B + flucytosine Consolidation: fluconazole First line: fluconazole Alternative: itraconazole Liposomal amphotericin B followed by itraconazole Voriconazole or liposomal amphotericin B

Recommend formal ID consultation to determine duration of therapy

a

Antibiotic therapy should be tailored based on susceptibility results Consider coverage for Listeria monocytogenes if any of the following: neonates (<1 month old), age >50 years, pregnancy, liver disease, alcoholism, malignancy, and defects in cell-mediated immunity (e.g. glucocorticoids, transplantation). c For severe penicillin allergies, consider TMP-SMX for coverage for Listeria monocytogenes. d Adjunctive dexamethasone therapy should be initiated before or with the first dose of antibiotics. Adjunctive dexamethasone should not be given to patients who have already received antibiotics as this is not likely to improve outcomes. e No strong evidence for durations of therapy. Duration of therapy may need to be individualized based on clinical response. f Consider ciprofloxacin or aztreonam as an alternative if severe penicillin allergy (e.g. anaphylaxis) b

References 1. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39: 1267-84. 2. Tunkel AR, Glaser CA, Bloch KC, et al. The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2008; 47: 303-27. Revised: 5/21/2015