Max 2000 mg/dose · Max 8000 mg/day · Duration: 14–21 days · Meningitis dose 200 mg/kg/day IV q6h — interval may be q8h–q12h in preterm neonates by GA/PNA; follow NICU protocol (Red Book, Nelson's)
• All suspected neonatal/young-infant bacterial meningitis requires hospitalization in NICU/pediatric inpatient unit with close neurologic and hemodynamic monitoring — do not manage as outpatient (AAP Red Book, WHO newborn infection guidance).
• Obtain blood culture and LP with CSF studies (cell count, glucose, protein, Gram stain, culture, PCR where available) before antibiotics when feasible — do not delay empiric therapy >30–60 min in unstable infants or when LP cannot be performed promptly (AAP, NICE NG240).
• CT before LP when: new focal neurologic signs, new-onset seizures, GCS <10 or declining consciousness, papilledema, immunocompromise, or prior CNS disease/shunt — if CT delays antibiotics, give doses first and perform LP when safe (NICE, AAP).
• Ampicillin is mandatory in this age group for Listeria coverage — do not use ceftriaxone/cefotaxime monotherapy in neonates/infants <3 months or immunocompromised hosts (AAP Red Book, ESPID).
• Dexamethasone adjunct: limited neonatal data — not routine; consider specialist consultation for Hib or pneumococcal meningitis in infants >6 weeks if given with or immediately before first antibiotic dose (0.15 mg/kg q6h × 4 days); avoid if already on antibiotics >12 h (AAP, IDSA principles).
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Cefotaxime • i.v. • 50–50 mg/kg/dose • 3×/day
Max 2000 mg/dose · Max 12000 mg/day · Duration: 14–21 days · Neonates: 50 mg/kg q8h (150 mg/kg/day); infants 1–3 months may use q6h (200 mg/kg/day) — preferred third-generation cephalosporin in neonates over ceftriaxone (bilirubin displacement risk)
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Ampicillin • i.v. • 50–50 mg/kg/dose • 4×/day
Max 2000 mg/dose · Max 8000 mg/day · Duration: 14–21 days · WHO alternative when third-generation cephalosporin unavailable — inferior CNS penetration vs cefotaxime; switch when cefotaxime accessible
• Ampicillin + gentamicin: WHO/resource-limited settings when cefotaxime is unavailable — covers GBS and Gram-negatives but inferior meningeal penetration vs cefotaxime; switch to cefotaxime when accessible.
• Add vancomycin when MRSA concern, healthcare-associated infection, or severe disease with high local MRSA prevalence — not routine in uncomplicated community neonatal meningitis (AAP Red Book).
• Immunocompromised infants (including congenital immunodeficiency, chemotherapy, transplant): maintain ampicillin for Listeria even if age >3 months; broaden per ID consult.
• Meropenem (20–40 mg/kg/dose q8h): severe infection, ESBL Gram-negatives, or beta-lactam allergy with concern for Gram-negatives — specialist-guided; pair with ampicillin if Listeria risk (ESPID, IDSA principles).
• Ceftriaxone generally avoided in neonates with hyperbilirubinemia/jaundice — prefer cefotaxime in this age group (AAP Red Book, Nelson's).
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Gentamicin • i.v./i.m. • 5–5 mg/kg/dose • 1×/day
Max 80 mg/dose · Duration: 14–21 days · Extended-interval aminoglycoside by GA/PNA — monitor levels; cefotaxime preferred over gentamicin for meningitis when available (WHO Pocket Book, Red Book)
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Clinical notes
• LP and cultures before antibiotics when feasible without clinically meaningful delay — obtain blood culture, CSF cell count/differential, glucose, protein, Gram stain, culture, and meningococcal/pneumococcal PCR if available; if LP deferred (instability, coagulopathy, local infection), treat empirically and obtain CSF when safe.
• CT before LP indications: new focal neurologic deficit, new-onset seizure, decreased consciousness (GCS <10 or declining), papilledema, immunocompromise, or history of CNS disease/shunt — antibiotics should not be withheld solely for imaging.
• ICU/NICU admission: all neonates and young infants with suspected bacterial meningitis require inpatient care with neurologic checks, fluid/electrolyte management, seizure monitoring, and serial clinical assessment; shock, altered mental status, or respiratory compromise needs ICU.
• Duration by pathogen (after identification): N. meningitidis 7 days; H. influenzae 7–10 days; S. pneumoniae 10–14 days; GBS 14–21 days; Listeria 21 days; enteric Gram-negatives 21 days — adjust for slow clinical/CSF response (AAP Red Book, ESPID).
• Hearing follow-up: audiology assessment for all survivors — schedule before discharge or within 4 weeks; highest risk with pneumococcal and Hib meningitis. N. meningitidis household/close contacts: chemoprophylaxis with rifampin (<1 month: 5 mg/kg q12h × 2 days; ≥1 month: 10 mg/kg q12h × 2 days, max 600 mg/dose) or age-appropriate alternative per local protocol (AAP Red Book, NICE NG240).
• AAP Red Book — Bacterial meningitis (neonatal and infant empiric therapy, duration, prophylaxis) (2024)
• WHO Pocket Book of Hospital Care for Children — Severe bacterial infection and meningitis (2022)
• NICE NG240 — Meningitis (bacterial) and meningococcal disease (2023)
