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Gram-negative bacillary meningitis: Treatment

N Deborah Friedman, MPH, MBBS, FRACP, MD
Daniel J Sexton, MD
Section Editor
Stephen B Calderwood, MD
Deputy Editor
Allyson Bloom, MD


Gram-negative bacilli are an important cause of nosocomial meningitis. Major risk factors for nosocomial meningitis include neurosurgery or head trauma within the past month, presence of a neurosurgical device, and a cerebrospinal fluid (CSF) leak. While Gram-negative bacilli remain an uncommon cause of community-acquired bacterial meningitis in adults, the frequency of cases arising from the community has increased substantially, from 3 percent of cases in older studies to over 75 percent of episodes in one newer study [1-4]. Acinetobacter baumannii is now the most common Gram-negative bacterium causing Gram-negative bacillary meningitis in the neurosurgical setting in parts of Europe, followed by Klebsiella pneumoniae [5,6].

Gram-negative bacillary meningitis is often fatal with reported mortality rates of 40 to 80 percent in adults and children, and complications are common in patients who survive [7,8]. As an example, the mortality rates among adults with both spontaneous and post-neurosurgical gram-negative bacillary meningitis in two studies were 53 and 57 percent [4,9]. These mortality rates were almost 20 times higher than the mortality rate of spontaneous bacterial meningitis due to Neisseria meningitides in adults, as reported in one of those same studies [4]. In another study conducted over a 21-year period, 61 percent of infants who survived gram-negative meningitis had developmental disabilities and neurologic sequelae [10].

The treatment of gram-negative bacillary meningitis will be reviewed here. The epidemiology, clinical manifestations, and diagnosis of this infection are discussed separately. (See "Gram-negative bacillary meningitis: Epidemiology, clinical features, and diagnosis".)

Additional discussion of the management of meningitis in children and adults is found elsewhere. (See "Bacterial meningitis in the neonate: Treatment and outcome" and "Bacterial meningitis in children older than one month: Treatment and prognosis" and "Initial therapy and prognosis of bacterial meningitis in adults" and "Treatment of bacterial meningitis caused by specific pathogens in adults".)


The treatment of gram-negative bacillary meningitis is difficult. Despite appropriate therapy and an apparent clinical response, cerebrospinal fluid (CSF) cultures may remain positive for as long as 13 days after treatment is begun [11,12]. The average duration of therapy needed to sterilize the CSF is two to four days in adults and 2.8 to 8.2 days in neonates [11]. In a series of 98 neonates and infants, positive results were obtained on CSF cultures for one to 18 days after the commencement of antibiotic therapy (mean 2.9 days) [10]. The longer the CSF remains positive in neonates, the greater the chance of neurologic deficits in the survivors [10,11].

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Literature review current through: Nov 2017. | This topic last updated: Sep 08, 2017.
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