A 52-year-old man presents with fever, neck stiffness, and confusion of 1 day duration. CSF shows 4,000 neutrophils per mm3, protein 300 mg/dL, glucose 25 mg/dL. Gram stain shows gram-positive diplococci. Which regimen should be started immediately?
- A Ceftriaxone plus vancomycin plus dexamethasone ✓
- B Penicillin G alone
- C Ceftriaxone plus ampicillin
- D Meropenem plus acyclovir
Correct answer: A. Ceftriaxone plus vancomycin plus dexamethasone
Explanation
Gram-positive diplococci suggest pneumococcus, the commonest cause of community-acquired bacterial meningitis in adults. Standard empiric therapy combines ceftriaxone with vancomycin to cover penicillin-resistant pneumococci, plus adjunctive dexamethasone given before or with the first antibiotic dose to reduce mortality and neurological sequelae. Ampicillin is added for listerial coverage in neonates, the elderly, or immunocompromised patients, not routinely at age 52.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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