1. Central nervous system infections
Bacterial Meningitis G00.9
Management algorithm for patients with suspected bacterial meningitis
Yes
No
Yes
Yes
No Yes
Guidelines for treatment of acute bacterial meningitis
ICD-10 CODE
Suspicion of bacterial meningitis
Immunocompromised, history of selected CNS diseases,papilledema,or selected focal
neurological deficit(need of a CT Brain) or delay in performance of diagnostic lumbar
puncture
Blood culture and lumbar puncture STAT
Dexamethasone + empirical anti- microbial
therapy
CSF findings of bacterial meningitis
Positive CSF Gram stain
Dexamethasone +
targeted antimicrobial
therapy
Dexamethasone +
empiric antimicrobial
therapy
Blood culture STAT
Dexamethasone + empirical antimicrobial
therapy
Negative CT scan of the head
Perform lumbar puncture

3. Start empirical therapy, and then examine CSF within 30 minutes. If focal neurological deficit is
present, give empiric Rx, do head CT, then do LP.
Anatomic sites
Diagnosis
Aetiological
agents
Suggested regimes Alternate regimes Comments
Empiric therapy-CSF Gram stain is negative
Age:50 years or less
S. pneumonia,
N. meningitidis,
H.influenzae
Ceftriaxone 2 g IV q 12h
or cefotaxime 2 g q4-6h IV
x 10-14 days
Dexamethasone 10mg IV
q 6h x 4 days.Give with or
just before 1st dose of
antibiotics.
Meropenem 2g IV q8h
+ x 10-14 days
Dexamethasone 10mg
IV q 6h x 4 days.Give
with or justbefore 1st
dose of antibiotics.
Penicillin allergy :
Chloramphenicol
50mg/kg/d IV div q6h
+ TMP/SMX 15-
20mg/kg/d div.Q6h +
vancomycin 500-
750mg q6h IVx 10-14
days
Age: > 50 years or
immunocompromised
S. pneumoniae,
Listeria,Gram-
negative bacilli
Ampicillin 2gmq4h IV +
ceftriaxone2 gm q 12h or
cefotaxime2gm q 6h +
vancomycin 500 750mg q
6h IV + 4 days
dexamethasone 0.15
mg/kg q6h IV
Meropenem 2g IV q8h
+ x 10-14 days
dexamethasone 0.15
mg/kg IV q 6h x 4days
Peni ci l lin al l ergy
: vancomycin 500-
750 mg q 6h IV +
TMP/SMX 15-20
mg/kg/d div q 6-
8h IV

4. Anatomic sites
Diagnosis
Aetiological
agents
Suggested
regimes
Alternate
regimes
Comments
Post-neuro s u r g e r y
or post-head trauma
S. neumoniae,
S. aureus,
P. aeruginosa
coliforms
Vanco 1g q 6-12h
IV (until known not
MRSA)+ ceftazidime 2
gm q 8h IV
Meropenem 1gm
q8h IV+ vanco 1g q
6h IV (until known
not MRSA)
Vanco is not optimal for
S. pneumonia once
identified q u i c k l y s
w i t c h t o
ceftriaxone/cefotaxime
Specific therapy-Positive CSF Gram-stain or culture
Gram-positive diplococci S. pneumoniae
Ceftriaxone 2 g IV q
12h or cefotaxime 2 g
IV q 6h x 10-14 days +
Dexamethasone 10mg
IV q 6h x 4 days.
Meropenem 2g IV
q8h +
Dexamethasone10mg
IV q 6h x 4 days.
Gram-negative diplococci N. meningitis Pen G 4 MU q4h IV x
7days +
Dexamethasone10mg
IV q 6h x 4 days.
Ceftriaxone 2 g IV q
12h or cefotaxime 2
g q4-6h IV +
Dexamethasone10mg
IV q 6h x 4 days.
P e n a l l e r g y :
chloramphenicol
50mg/kg ( u p t o 1 g )
q 6h +
Dexamethasone10mg
IV q 6h x 4 days.
Gram-positive b a c i l l i
o r coccobacilli
Listeria
monocytogenes
Ampicillin2g IV q4h x
21 days+ gentamicin
2mg/kg loading dose
than 1.7mg/kg q8h
TMP/SMX 15-
20mg/kg/d div. q6h x
21days
Gram-negative bacilli H. influenzae,
P. aeruginosa,
coliforms
Ceftazidime 2g IV q8h x
21days+ gentamicin
2mg/kg loading dose
than 1.7mg/kg q8h
Meropenem 2g q8hIV
x 21days
Non-Typhoid Salmonellas (common in HIV infection) Ceftriaxone 2g q 12 h IV+ Ciprofloxacin 750mgq 12h IV x 3
weeks
Meningovascular syphilis Penicillin G20mu/d IV in 4 divided doses x 10 days.
Penicillin allergy:Ceftriaxone2g every 12 hours x 10
days/Consider desensitization.

5. Prophylaxis for Neisseria meningitides
Organism susceptibility Regimes
Neisseria meningitides
Exposure to closecontactis required.Organismspread by
respiratory droplets, not aerosols (high risk if close
contract for at least 4 h during week before illness e.g.
housemates, day care contracts, cellmates) or exposure
to pt's nasopharyngeal secretions (intubations, mouth-
to- mouth resuscitation, nasotracheal suctioning)
Ciprofloxacin 500mg PO stator RIF600mg q12h PO x 4
doses (children >1 month age 10mg/kg q12h PO x 4
doses)or ceftriaxone 250 mg IMstat

6. Fungal Meningitis ICD 10 CODE G02.1
Fungal meningitis
Anatomic sites
Diagnosis
Aetiological
agents
Suggested regimes Alternate regimes Comments
Cryptococcal
meningitis
C. neoformans Amphotericin B 1
mg/kg/day IV
+Fuconazole 800 mg per
day x 14 days followed
by fluconazole
400mg q24h PO x 10 weeks
followed by 2° prophylaxis:
fluconazole 200 mg q24h PO
F l u c o n a z o l e
400mg PO q12h x 6-
10 weeks followed
by 2° prophylaxis:
fluconazole 200 mg
q24h
Immune
reconstitution
c r y p t o c o c c a l
meningitis:
consider adding
steroids
Candida chronic
meningitis-rare
Candida spp Fluconazole 400mg IVI/PO
q24h x6months

7. T B Meningitis in adults
ICD 10 CODE A17.0
Pathogen Initial therapy Continuation phase Comments
M. Tuberculosis
INH+RIF+ETB+PZA for
2 months (see dosage
forTBtreatmentinSouth
AfricanNational
Tuberculosis Guidelines)
INH+RIFfor7- months
For patients unable totakeoral
treatmentasaresultof severe
disease use parentral
antibiotics(INH, RIF,
aminoglycosides,
fluoroquinolones)
Dexamethasone 10 mg
e/12h IV orPO tapered
over 6 weeks
Viral Meningoencephalitis
ICD 10 CODE A87
Anatomic sites
Diagnosis
agents Suggested regimes
Herpes
Encephalitis
CMV encephalitis
HSV
Cytomegalovirus
Acyclovir10mg/kgIV
q8h x14-21 days
Ganciclovir5mg/kgIV
q12h x 3-6 wks

8. BrainAbscess
ICD 10 CODE G06.0
Brain abscess
Anatomic sites
Diagnosis
Aetiological agents Suggested regimes Alternate regimes Comments
Primary or
contiguous
source & subdural
empyema
S t r e p t oc oc c i ,
Anaerobes-bac t e
r o i d e s ,
Enterobacteriaceae
S. aureus
Ceftriaxone 2g IV q12h/
c e f otax i me 2 g IV q
4 h+ me troni da zol e
500mg IV 6h
PenG 20-24 mU IV
qd+metro500mg
IV
In conj unction
w i th n e u r o s u r g i
c a l management,
empyemamustbe
drained. Durationof rx
is unclear until
response byCTscan
Post traumatic Enterobacteriacea
S. aureus
Cloxacillin2gIV q4h +
Ceftriaxone2gIV q12h
Vancomycin 1g IV
q12h if MRSA su
spe ct e d +
ceftriaxone 2gIV
q12h
Nocardiosis
Nocardiaasteroids
& N.brasiliensis
T M P / S M X ( c o -
trimoxazole) 15mg/kg/d
of TMP& 75 mg/kg/dof
SMX IV or PO div.in2-4
doses.After 3-4 wks ↓
dose to
10mg/kg/dof TMP
Imipenem 500mg
IV q6h +
amikacin7.5mg/kg
IV q12hx
3-4 wks& thenPO
regimenor
minocycline 200mg
q12h IV until
clinical
improvement,then
POuntil cured.
Durationof rx
generally3m o n t h
s f o r
immunocompetent
host&
6 m o n t h s f o r
immunocompromised
C e r e b r a l
toxoplasmosisin
AIDS patients
Toxoplasmagondi TMP/SMX10/50 mg/kg/d
POor IV div. q12h x 4 wks
t he n s up pr e s si on
TMP/SMX-DS1 table PO
q24h.
Pyrimethamine
(pyr) 200mg
POx 1then100mg
POq24h
+ clindamycin
600mg PO/IV q6h +
folinicacid10-
15mg/d PO
Primary prophyla
xis TMP/SMX-DS1 tab
x PO q24h, or
TMP/SMX-SS1 table
POq24h