Infectious Diseases II

surrounding intraventricular antibiotics administration and the lack of head-to-head comparisons

with intravenous antimicrobials, the administration of systemic antimicrobials should be continued

in conjunction with intraventricular antibiotics.

Definitive antibiotic therapy can be determined according to finalized cultures and susceptibility results.

In general, definitive therapy should entail choosing the therapy with the most appropriate spectrum of

activity and an adequate penetration into the CSF. Therapy should be continued for at least 7 days in all

patients with meningitis. S. pneumoniae, coagulase-negative staphylococci, S. aureus, gram-negative

bacilli, and Cutibacterium acnes (previously known as Propionibacterium acnes) should be treated for

10–14 days and Listeria monocytogenes for at least 21 days. CSF should be negative for S. aureus for at

least 10 days before shunt replacement.

Empiric Therapy

Patient Group

Common Pathogens

Recommended Empiric Therapy

Community-Acquired Pathogens

18–50 yr

N. meningitidis, S. pneumoniae

Vancomycin + third-generation

cephalosporin (e.g., ceftriaxone)

> 50 yr or any age

with predisposing

conditiona

N. meningitidis, S. pneumoniae,

L. monocytogenes, H. influenzae, aerobic GNB

(e.g., E. coli)

Vancomycin + third-generation

cephalosporin (e.g., ceftriaxone) +

ampicillin

Health care–associated or nosocomial

Basilar skull fracture

(communication with

sinuses or oropharynx)

S. pneumoniae; H. influenzae;

group A β-hemolytic streptococci

Vancomycin + third-generation

cephalosporin (e.g., ceftriaxone)

Penetrating trauma

S. aureus, CoNS, aerobic enteric (e.g., E. coli)

and non–lactose-fermenting (e.g., P. aeruginosa)

gram-negative bacilli

Vancomycin + cefepime or

ceftazidime or meropenem

Post-neurosurgery

Aerobic enteric (e.g., E. coli) and non–lactose-

fermenting (e.g., P. aeruginosa) gram-negative

bacilli, S. aureus, CoNS

Vancomycin + cefepime or

ceftazidime or meropenem

CSF shunt

Aerobic enteric (e.g., E. coli) and non–lactose-

fermenting (e.g., P. aeruginosa) gram-negative

bacilli, S. aureus, Propionibacterium acnes

Vancomycin + cefepime or

ceftazidime or meropenem

aAltered immune status, alcoholism

CoNS = coagulase-negative staphylococci; GNB = gram-negative bacteria.