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Tuberculous Meningitis - Treatment
Last reviewed: 06.07.2025
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Treatment of tuberculous meningitis
Various combinations of anti-tuberculosis drugs are used. During the first 2 months and until antibiotic sensitivity is detected, 4 drugs are prescribed (first stage of treatment): isoniazid, rifampicin, pyrazinamide, and ethambutol or streptomycin. The regimen is adjusted after drug sensitivity is determined. After 2-3 months of treatment (second stage of treatment), they often switch to 2 drugs (usually isoniazid and rifampicin). The minimum duration of treatment is usually 6-12 months. Several drug combinations are used.
- Isoniazid 5-10 mg/kg, streptomycin 0.75-1 g/day during the first 2 months. With constant monitoring of the toxic effect on the VIII pair of cranial nerves - ethambutol 15-30 mg/kg per day. When using this triad, the severity of intoxication is relatively low, but the bactericidal effect is not always sufficient.
- To enhance the bactericidal effect of isoniazid, rifampicin is added together with streptomycin and ethambutol at 600 mg once a day.
- In order to maximize the bactericidal effect, pyrazinamide is used in a daily dose of 20-35 mg/kg in combination with isoniazid and rifampicin. However, when these drugs are combined, the risk of hepatotoxic action increases significantly.
The following combination of drugs is also used: para-aminosalicylic acid up to 12 g/day (0.2 g per 1 kg of body weight in divided doses 20-30 minutes after meals, washed down with alkaline water), streptomycin and phthivazid at a daily dose of 40-50 mg/kg (0.5 g 3-4 times a day).
The first 60 days of the disease are of crucial importance in treatment. In the early stages of the disease (within 1-2 months), it is advisable to use glucocorticoids orally to prevent adhesive pachymeningitis and related complications.
Inpatient treatment should be long-term (about 6 months), combined with general health measures, enhanced nutrition and subsequent stay in a specialized sanatorium. Then, for several months, the patient continues to take isoniazid. The total duration of treatment is 12-18 months.
Pyridoxine (25-50 mg/day), thioctic acid, and multivitamins are used to prevent neuropathies. Patients must be monitored to prevent drug intoxication in the form of liver damage, peripheral neuropathies, including damage to the optic nerves, and to prevent complications in the form of cicatricial adhesive process and open hydrocephalus.
Forecast
Before the use of anti-tuberculosis drugs, meningitis ended in death on the 20th-25th day of the disease. Currently, with timely and long-term treatment, a favorable outcome occurs in 90-95% of patients. With late diagnosis (after the 18th-20th day of the disease), the prognosis is poor. Sometimes relapses and complications occur in the form of epileptic seizures, hydrocephalus, neuroendocrine disorders.
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