A 23-year-old previously healthy female develops sudden high fever, headache, photophobia, and petechial purpura on the trunk. Lumbar puncture demonstrates cloudy CSF with opening pressure 280 mm H2O, WBC 4,200/uL (92% neutrophils), protein 240 mg/dL, and glucose 18 mg/dL (serum glucose 100 mg/dL). What is the immediate empirical antimicrobial and adjunctive regimen?

Answer and explanation

Correct answer: C. Intravenous ceftriaxone, vancomycin, and dexamethasone

  1. Step 1: Markedly elevated neutrophils, elevated opening pressure, high protein, and CSF-to-serum glucose ratio < 0.40 confirm acute bacterial meningitis (likely Neisseria meningitidis or Streptococcus pneumoniae).
  2. Step 2: Standard empirical therapy in adults under 50 is third-generation cephalosporin (ceftriaxone) plus vancomycin (covering resistant pneumococci).
  3. Step 3: Dexamethasone administered with or just prior to the first dose of antibiotics significantly reduces hearing loss and neurological sequelae in pneumococcal meningitis.
Answer
Intravenous ceftriaxone, vancomycin, and dexamethasone.
Why not the others: Acyclovir treats viral HSV encephalitis; ampicillin is added only for age > 50 or immunocompromise (Listeria); antifungal therapy is for fungal meningitis.

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