A 45-year-old female is diagnosed as a case of pneumococcal meningitis. Her blood samples were sent for culture sensitivity. In the mean time best drug to start as an empirical treatment is:
Ans. d. Vancomycin + ceftriaxone (Ref: Harrison 19/e p889, 18/e p3416)Antimicrobial therapy of pneumococcal meningitis is initiated with a cephalosporin (ceftriaxone, cefotaxime, or cefepime) and vancomycin."Antimicrobial therapy of pneumococcal meningitis is initiated with a cephalosporin (ceftriaxone, cefotaxime, or cefepime) and vancomycin. For S. pneumoniae meningitis, an isolate of S. pneumoniae is considered to be susceptible to penicillin with a minimal inhibitory concentration (MIC) <0.06 mg/mL, to have intermediate resistance when the MIC is 0.1 -1.0 mg/mL, and to be highly resistant when the MIC >1.0 mg/mL. Isolates of S. pneumoniae that have cephalosporin MICs <_0.5 mg/mL are considered sensitive to the cephalosporins (cefotaxime, ceftriaxone, cefepime). Those with MICs of 1 mg/mL are considered to have intermediate resistance, and those with MICs >_2 mg/mL are considered resistant. For meningitis due to pneumococci, with cefotaxime or ceftriaxone MICs <0.5 mg/mL, treatment with cefotaxime or ceftriaxone is usually adequate. For MIC >1 mg/mL, vancomycin is the antibiotic of choice; Rifampin can be added to vancomycin for its synergistic effect but is inadequate as monotherapy because resistance develops rapidly when it is used alone."- Harrison 18/e p3416"A 2-week course of intravenous antimicrobial therapy is recommended for pneumococcal meningitis."- Harrison 18/e p3416"Patients with penicillin- and cephalosporin-resistant strains of S. pneumoniae who do not respond to intravenous vancomycin atone may benefit from the addition of intraventricular vancomycin. The intraventricular route of administration is preferred over the intrathecal route because adequate concentrations of vancomycin in the cerebral ventricles are not always achieved with intrathecal administration."- Harrison 18/e p3416Antimicrobial Therapy of CNS Bacterial Infections Based on PathogensOrganismAntibioticNeisseria meningitidesPenicillin-sensitive* Penicillin G or ampicillinQPenicillin-resistant* Ceftriaxone or cefotaximeQStreptococcus pneumoniaePenicillin-sensitive* Penicillin GQPenicillin-intermediate* Ceftriaxone or cefotaxime or cefepimeQPenicillin-resistant* (Ceftriaxone or cefotaxime or cefepime) + vancomycinQGram-negative bacilli (except Pseudomonas spp.)* Ceftriaxone or cefotaximeQPseudomonas aeruginosa* Ceftazidime or cefepime or meropenemQStaphylococci spp.Methicillin-sensitive* NafcillinQMethicillin-resistant* VancomycinQListeria monocytogenes* Ampicillin + gentamicinQHaemophilus influenzae* Ceftriaxone or cefotaxime or cefepimeQStreptococcus agalactiae* Penicillin G or ampicillinQBacteroides fragilis* MetronidazoleQFusobacterium spp.* MetronidazoleQ
Penicillin G
Doxycycline
Streptomycin
Vancomycin + ceftriaxone
C.N.S.