病毒性脑膜炎

如果患者病情非常严重、免疫力受损或此前已接受抗生素治疗，可经验性抗生素治疗，因为延迟使用抗生素与不良结果相关。

抗生素应覆盖 B 族链球菌、李斯特菌和大肠杆菌群。

如果婴儿在患病前曾经在医院接受看护，抗生素还应覆盖金黄色葡萄球菌（如果 MRSA 流行，使用万古霉素；如果怀疑为甲氧西林敏感的金黄色葡萄球菌感染，则使用氟氯西林或萘夫西林）。

诊断为病毒性脑膜炎后可以停止抗生素治疗。

关于经验性抗生素治疗的选择，应参考本地方案和指南。

如果患者病情非常严重、免疫力受损或此前已接受抗生素治疗，可经验性抗生素治疗，因为延迟使用抗生素与不良结果相关。

诊断为病毒性脑膜炎后可以停止抗生素治疗。

关于抗生素治疗的选择，应参考本地方案和指南。

针对经选择患者组全部患者的治疗推荐

尽管未证实在给予抗生素之前给予地塞米松辅助治疗能够显著降低细菌性脑膜炎患者的死亡率，但已证实此治疗可减少高收入国家患者的听力受损和神经系统后遗症。[41]de Gans J, van der Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002;347:1549-1556.http://www.nejm.org/doi/full/10.1056/NEJMoa021334#t=articlehttp://www.ncbi.nlm.nih.gov/pubmed/12432041?tool=bestpractice.com[42]van de Beek D, de Gans J, McIntyre P, et al. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis. 2004;4:139-143.http://www.ncbi.nlm.nih.gov/pubmed/14998499?tool=bestpractice.com[43]Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015;(9):CD004405.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004405.pub5/fullhttp://www.ncbi.nlm.nih.gov/pubmed/26362566?tool=bestpractice.com

如腰椎穿刺排除脑膜炎，或如果怀疑病毒性脑膜炎，可停用地塞米松。[41]de Gans J, van der Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002;347:1549-1556.http://www.nejm.org/doi/full/10.1056/NEJMoa021334#t=articlehttp://www.ncbi.nlm.nih.gov/pubmed/12432041?tool=bestpractice.com[42]van de Beek D, de Gans J, McIntyre P, et al. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis. 2004;4:139-143.http://www.ncbi.nlm.nih.gov/pubmed/14998499?tool=bestpractice.com[43]Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015;(9):CD004405.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004405.pub5/fullhttp://www.ncbi.nlm.nih.gov/pubmed/26362566?tool=bestpractice.com

通常建议对此前身体健康且无免疫抑制的所有成人和儿童使用地塞米松进行辅助治疗。[44]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al; EFNS Task Force. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008;15:649-659.http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com[45]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016;72:405-438.http://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com不应用于免疫功能受损或年龄＜3 个月的患者。[46]National Institute for Health and Care Excellence. Bacterial meningitis and meningococcal septicaemia: management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care. 2015. http://www.nice.org.uk/ (last accessed 24 September 2016).http://www.nice.org.uk/guidance/CG102

如果患者病情非常严重、免疫力受损或此前已接受抗生素治疗，可经验性抗生素治疗，因为延迟使用抗生素与不良结果相关。

因为老年人免疫力底下，建议联合使用万古霉素、头孢曲松和氨苄西林。

诊断为病毒性脑膜炎后可以停止抗生素治疗。

关于抗生素治疗的选择，应参考本地方案和指南。

针对经选择患者组全部患者的治疗推荐

尽管未证实在给予抗生素之前给予地塞米松辅助治疗能够显著降低细菌性脑膜炎患者的死亡率，但已证实此治疗可减少高收入国家患者的听力受损和神经系统后遗症。[41]de Gans J, van der Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002;347:1549-1556.http://www.nejm.org/doi/full/10.1056/NEJMoa021334#t=articlehttp://www.ncbi.nlm.nih.gov/pubmed/12432041?tool=bestpractice.com[42]van de Beek D, de Gans J, McIntyre P, et al. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis. 2004;4:139-143.http://www.ncbi.nlm.nih.gov/pubmed/14998499?tool=bestpractice.com[43]Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015;(9):CD004405.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004405.pub5/fullhttp://www.ncbi.nlm.nih.gov/pubmed/26362566?tool=bestpractice.com

如腰椎穿刺排除脑膜炎，或如果怀疑病毒性脑膜炎，可停用地塞米松。[41]de Gans J, van der Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002;347:1549-1556.http://www.nejm.org/doi/full/10.1056/NEJMoa021334#t=articlehttp://www.ncbi.nlm.nih.gov/pubmed/12432041?tool=bestpractice.com[42]van de Beek D, de Gans J, McIntyre P, et al. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis. 2004;4:139-143.http://www.ncbi.nlm.nih.gov/pubmed/14998499?tool=bestpractice.com[43]Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015;(9):CD004405.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004405.pub5/fullhttp://www.ncbi.nlm.nih.gov/pubmed/26362566?tool=bestpractice.com

通常建议对此前身体健康且无免疫抑制的所有成人和儿童使用地塞米松进行辅助治疗。[44]Chaudhuri A, Martinez-Martin P, Kennedy PG, et al; EFNS Task Force. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008;15:649-659.http://www.ncbi.nlm.nih.gov/pubmed/18582342?tool=bestpractice.com[45]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016;72:405-438.http://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com不应用于免疫功能受损或年龄＜3 个月的患者。[46]National Institute for Health and Care Excellence. Bacterial meningitis and meningococcal septicaemia: management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care. 2015. http://www.nice.org.uk/ (last accessed 24 September 2016).http://www.nice.org.uk/guidance/CG102

治疗包括充分水合、针对发热使用解热药、针对呕吐使用止吐剂和针对头痛使用镇痛药。

报告提示阿昔洛韦可降低单纯疱疹引起的脑膜炎症状的严重程度并缩短病程。证据 C阿昔洛韦作为单纯疱疹性脑膜炎的有效治疗方法：低质量证据对阿昔洛韦与安慰剂在单纯疱疹的治疗进行了对比。轶事性的证据表明，阿昔洛韦可以改善症状。[47]Bergstrom T, Alestig K. Treatment of primary and recurrent herpes simplex virus type 2 induced meningitis with acyclovir. Scand J Infect Dis. 1990;22:239-240.http://www.ncbi.nlm.nih.gov/pubmed/2162558?tool=bestpractice.com低质量的观察性（队列）研究或者受试者＜200名且方法学存在缺陷的随机对照临床试验（RCT）。但尚未在安慰剂对照前瞻性试验中证实。[47]Bergstrom T, Alestig K. Treatment of primary and recurrent herpes simplex virus type 2 induced meningitis with acyclovir. Scand J Infect Dis. 1990;22:239-240.http://www.ncbi.nlm.nih.gov/pubmed/2162558?tool=bestpractice.com

膦甲酸可用于对阿昔洛韦耐药的严重单纯疱疹感染。

疗程：7-10 日。

对于巨细胞病毒，使用更昔洛韦或缬更昔洛韦作为一线治疗药物。

二线和三线药物分别包括膦甲酸和西多福韦。

疗程：7 至 10 日（西多福韦除外）。

复发性良性淋巴细胞性脑膜炎（又称 Mollaret 脑膜炎）是一种罕见疾病，由病毒感染引起。2 型单纯疱疹是最常见的致病原。

HSV-2 脑膜炎约 20% 会复发。[15]Bergstrom T, Vahlne A, Alestig K, et al. Primary and recurrent herpes simplex virus type 2-induced meningitis. J Infect Dis. 1990;162:322-330.http://www.ncbi.nlm.nih.gov/pubmed/2165105?tool=bestpractice.com抗病毒药物预防已在一些患者用于抑制复发。[48]Shalabi M, Whitley RJ. Recurrent benign lymphocytic meningitis. clinical infectious diseases. Clin Infect Dis. 2006;43:1194-1197.http://www.journals.uchicago.edu/doi/full/10.1086/508281http://www.ncbi.nlm.nih.gov/pubmed/17029141?tool=bestpractice.com然而，近期证据表明，在预防 HSV-2 型脑膜炎复发方面，用口服抗病毒药进行次级预防并无益处。[49]Aurelius E, Franzen-Röhl E, Glimåker M, et al. Long-term valacyclovir suppressive treatment after herpes simplex virus type 2 meningitis: a double-blind, randomized controlled trial. Clin Infect Dis. 2012;54:1304-1313.http://www.ncbi.nlm.nih.gov/pubmed/22460966?tool=bestpractice.com如果进行抗病毒药物治疗，治疗应在 1 年后停止，因为 Mollaret 脑膜炎往往会消退。治疗的决策者应为专科医生。