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Gram-negative bacillary meningitis: Treatment

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

INTRODUCTION

Gram-negative bacilli are an important cause of nosocomial meningitis, accounting for 33 percent of 197 episodes in the same report [1]. 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. Gram-negative bacilli remain an uncommon cause of community-acquired bacterial meningitis in adults, accounting for 3 to 11 percent of episodes [1-4].

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 [5,6]. The mortality rate among 40 adults with spontaneous gram-negative bacillary meningitis in a single center case series was 53 percent, which was almost 20 times higher than the mortality rate of spontaneous bacterial meningitis due to Neisseria meningitides in adults from the same hospital [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 [7]. Thus, timely identification of the infection and early commencement of therapy are vital.

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".)

GENERAL PRINCIPLES FOR TREATMENT

The treatment of gram-negative bacillary meningitis remains a therapeutic challenge. Despite appropriate therapy and an apparent clinical response, CSF cultures may remain positive for as long as 13 days after treatment is begun [8,9]. 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 [8]. 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) [7]. The longer the CSF remains positive in neonates, the greater the chance of neurologic deficits in the survivors [7,8].

                         

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