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Infection

Meningitis Possible therapeutic alternatives
Empiric therapy (Age < 50 years) Common pathogens
(Cefotaxime 2 grams IVPB q4h or Ceftriaxone 2 grams IVPB q12h)
+
dexamethasone
(0.4mg/kg q12h or 0.15 mg/kg IV q6h  x 2 days given 30 minutes prior to antibiotics)
+
Vancomycin
1 gram  ivpb q12h (patient-specific dosing required - target trough 15-20 mcg/ml)   

May also add Rifampin 600mg po qd or 300mg po bid.

Alternative:
meropenem 2 gram IV q8h

Vancomycin 1 gram  ivpb q12h (patient-specific dosing required - target trough 15-20 mcg/ml)  

Dexamethasone (0.15 mg/kg IV q6h  x 2 to 4 days given 30 minutes prior to antibiotics)

Meropenem - Renal dosing

Creatinine Clearance

(mL/min)

Dose (dependent on type of infection) Dosing Interval
> 50 Recommended dose (2 g meningitis) Every 8 hours
> 25-50 Recommended dose Every 12 hours
10-25 One-half recommended dose Every 12 hours
< 10 One-half recommended dose Every 24 hours
If severe penicillin allergy:
Chloramphenicol 1g IV q6h(12.5 mg/kg IV q6h (max. 4 gm/day)
+
Vancomycin
1 gram  ivpb q12h (patient-specific dosing required - target trough 15-20 mcg/ml)    
+/-
Rifampin
.
Age > 50 years or alcoholism or other debilitating disease. Common pathogens
Ampicillin 2g IV q4h

Vancomycin 1 gram  ivpb q12h (patient-specific dosing required - target trough 15-20 mcg/ml)  

[Cefotaxime 2g IV q4-6h or Ceftriaxone 2g IV q12-24h ]
+
Dexamethasone (0.15 mg/kg IV q6h  x 2 to 4 days given 30 minutes prior to antibiotics)
Alternative:
meropenem 2 gram IV q8h

Vancomycin 1 gram  ivpb q12h (patient-specific dosing required - target trough 15-20 mcg/ml)  

Dexamethasone (0.15 mg/kg IV q6h  x 2 to 4 days given 30 minutes prior to antibiotics)

Meropenem - Renal dosing

Creatinine Clearance

(mL/min)

Dose (dependent on type of infection) Dosing Interval
> 50 Recommended dose (2 g meningitis) Every 8 hours
> 25-50 Recommended dose Every 12 hours
10-25 One-half recommended dose Every 12 hours
< 10 One-half recommended dose Every 24 hours
If severe penicillin allergy:
Vancomycin 1 gram  ivpb q12h (patient-specific dosing required - target trough 15-20 mcg/ml)  
+   
Bactrim 15-20 mg/kg/day in 4 divided doses pending culture results. or  
[Chloramphenicol 1g IV q6h(12.5 mg/kg IV q6h (max. 4 gm/day)

Vancomycin
1 gram  ivpb q12h (patient-specific dosing required - target trough 15-20 mcg/ml)  
+/-   
rifampin
300mg PO or IV bid]
Trauma or post neurosurgery Common pathogens
Vancomycin 1 gram IVPB q6-12h +
Ceftazidime 2 grams IVPB q8h. 

// If gram negative bacilli are suspected add Gentamycin IVPB +/- intrathecally.

Impaired cellular immunity Common pathogens
Ampicillin 2 grams IVPB q4h +
Ceftazidime 2 grams IVPB q8h. 
If severe penicillin allergy:
Bactrim 15-20mg/kg/day in 4 divided doses. May add Gentamicin
If Listeria present: cephalosporins are not effective.
N.meningitidis confirmed  
Penicillin G  4 million units IVPB q4h. 
If severe penicillin allergy:
Chloramphenicol 1g IV q6h (12.5 mg/kg IV q6h (max. 4 gm/day)

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