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GuidelinesEML (Adult Hospital STG)

Infectious and Parasitic Conditions

Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2019 Edition

Please click on the link below to access the most up-to-date version of this guideline. The content on this page is currently being updated to align with the latest publication. Always check the version number at the bottom of the screen to confirm which version you are using.

Click here to access the Adult Hospital Level Chapter 14: Neurological Disorders with Supporting NEMLC Report-2020-4-Review-Version-3.0-22-November-2025

Meningitis

Tuberculosis meningitis (TBM)

Cryptococcal meningitis

Viral meningoencephalitis

Meningovascular syphilis (neurosyphilis)

Brain abscess

Antimicrobial use in patients with head injuries

Neurocysticercosis

MENINGITIS

A32.1† + (G01*)/A39.0† + (G01*)/G00.0-3/G00.8-9/G03.0-2/G03.8-9

N. meningitidis, H. influenzae Type B and listeriosis are notifiable medical conditions.

DIAGNOSIS

  • Computed tomography should be done before lumbar puncture in patients with:
    • focal neurological signs,
    • new seizures,
    • papilloedema, or
    • reduced level of consciousness.
  • In cases where lumbar puncture is delayed or cannot be done (e.g. uncontrolled significant bleeding tendency), commence empiric antibiotic therapy after taking samples for blood cultures. 
  • Attempt the lumbar puncture later, if possible.

GENERAL MEASURES

  • Observe patient closely with regular monitoring of vital signs and neurological state.
  • Pay close attention to hydration status.
  • Nurse patients in a quiet, semi-dark surrounding.
  • Repeated lumbar punctures are of no benefit in uncomplicated bacterial meningitis.
  • Prompt initiation of antibiotic therapy is associated with improved outcomes in patients with bacterial meningitis.

MEDICINE TREATMENT

All patients require sufficient analgesia:

  • Paracetamol, oral, 500 mg–1 g, 4–6 hourly as required (to a maximum of 4 g in 24 hours).
    • Maximum dose: 15 mg/kg/dose.

AND/OR

  • NSAID, e.g.:
  • Ibuprofen, oral, 400 mg then 8 hourly with meals, if needed.

Severe pain:

  • Tramadol, oral, 50-100 mg 4-6 hourly.
    • May be increased to a maximum daily dose of 400 mg.

Antibiotic therapy

Empiric therapy for bacterial meningitis, until sensitivity results are available:

  • Ceftriaxone, IV, 2 g 12 hourly for 10 days.

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Adjunctive corticosteroids are not recommended as trials in low-middle income countries have not demonstrated benefit.

Meningococcal meningitis A39.0 + (G01*)

For confirmed meningococcal disease only:

  • Benzylpenicillin (penicillin G), IV, 20–24 MU daily in 4–6 divided doses for one week.

AND

Eradicate nasopharyngeal carriage with a single dose of ciprofloxacin 500 mg after completing course of benzylpenicillin. This is not required if the patient was treated with an initial pre-referral dose of ceftriaxone.

  • Ciprofloxacin, oral, 500 mg immediately as a single dose.

Severe penicillin allergy: (Z88.0)

  • Meropenem, IV, 2g 8 hourly for 7 days. 

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Prophylaxis of contacts:

Only for close household contacts and for healthcare workers who resuscitate patients before they received appropriate treatment.

  • Ciprofloxacin, oral, 500 mg immediately as a single dose.

Pneumococcal meningitis G00.1

Conditions causing cerebrospinal fluid (CSF) leaks increase the risk for this type of infection, e.g. skull fractures, congenital defects, neurosurgery.
If sensitive to penicillin: 

  • Benzylpenicillin (penicillin G), IV, 20–24 MU daily in 4–6 divided doses for 10 days.

If resistant to penicillin: 

  • Ceftriaxone, IV, 2 g 12 hourly for at least 10 days.

Severe penicillin allergy: (Z88.0)

  • Meropenem, IV, 2 g 8 hourly for 10 days.

Note

Consult a microbiologist/infectious diseases specialist.

Haemophilus influenzae G00.0

  • Ceftriaxone, IV, 2 g 12 hourly for 10 days.

Severe penicillin allergy: (Z88.0)

  • Meropenem, IV, 2 g 8 hourly for 10 days.

Note

Consult a microbiologist/infectious diseases specialist.

Listeria monocytogenes meningitis A32.1

  • Ampicillin, IV, 3 g 6 hourly for 21 days. 

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AND

Severe penicillin allergy: Z88.0

  • Consult a specialist.

REFERRAL

  • For neuro-imaging: patients not responding or worsening in condition, i.e. decrease in consciousness and cranial nerve palsies, despite appropriate therapy. This is especially urgent in patients with tuberculous meningitis, who may develop hydrocephalus and require an urgent shunting procedure.
  • Patients with shunts.

TUBERCULOSIS MENINGITIS (TBM)

A17.0 + (G01*)

DIAGNOSIS

  • CSF findings are extremely variable.
  • Generally, lymphocytes predominate, however, polymorphs predominate initially in about a third of patients.
  • Protein is usually > 1 g/L and glucose is usually low.
  • In cases where the differential diagnosis between bacterial and tuberculous meningitis is in doubt, lumbar puncture should be repeated 2–3 days later while still on ceftriaxone.
  • If the aetiology is bacterial, considerable improvement in CSF findings may be expected, but with untreated tuberculous meningitis, the cell counts and protein levels will be the same or higher as the original CSF findings; and the glucose level will be the same or lower.

MEDICINE TREATMENT

Treat with standard combination tuberculosis therapy according to National protocol and extend duration of therapy to 9 months (2 months intensive phase, 7 months continuation phase). See  Tuberculosis, Pulmonary.

In HIV-uninfected individuals:

Corticosteroid use may be of benefit in reducing neurological deficit in patients with grade II to III disease (focal neurological disease, depressed levels of consciousness, or a Glasgow Coma Scale of 14 or less).

  • Dexamethasone, IV, dosing as follows:
Weeks Dosing regimen
Initial dose 0.3-0.4 mg/kg/day for 2 weeks.
Week 3 0.2 mg/kg daily.
Week 4 0.1 mg/kg daily.
Week 5 to 8 4 mg/day, tapering daily dose by 1 mg each week.

OR

  • Corticosteroids (intermediate-acting) e.g.:
    LoE:IIalvii
  • Prednisone, oral, 60 mg daily for 2 weeks.
    LoE:IVblviii

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In people with HIV:

Note

There is uncertainty whether the use of corticosteroids is beneficial in PLWH with TBM. 

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CRYPTOCOCCAL MENINGITIS

GENERAL MEASURES

People living with HIV (see Cryptococcosis)

  • In PWH the aim is to suppress the infection until immune restoration occurs with antiretroviral therapy.

HIV-uninfected patients

  • In HIV-uninfected patients the aim is to cure the infection.

CRYPTOCOCCAL MENINGITIS, HIV-INFECTED

See Cryptococcosis

CRYPTOCOCCAL MENINGITIS, HIV-UNINFECTED

B45.1 + (G02.1*)

MEDICINE TREATMENT

Initial therapy:

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  • Amphotericin B, IV, 1 mg/kg daily. 
    • Ensure adequate hydration to minimise nephrotoxicity. (See Prescribing Information for Specific Medicines for preventing, monitoring and management of toxicity).
    • Duration of initial IV therapy:
      - Treat intravenously for 4 weeks, provided that there are no neurological complications and follow up CSF culture at 2 weeks is negative.
      - In patients with neurological complications or persistent positive culture: increase the initial phase of therapy to 6 weeks in consultation with a specialist.

AND

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  • Fluconazole, oral, 800 mg daily for 2 weeks, followed by 400 mg daily for 2 months.

Maintenance therapy:

  • Fluconazole, oral, 200 mg daily for a minimum of 1 year.

Follow all patients closely for relapses.

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Therapeutic lumbar puncture: 

This should be considered as the intracranial pressure is often elevated with a communicating hydrocephalus.

VIRAL MENINGOENCEPHALITIS

A86/B00.4† + (G05.1*)

DESCRIPTION

  • Patients present with headache, neck stiffness, and encephalitic symptoms which may include fever, personality or behavioural changes, hallucinations and seizures. 
  • Lumbar puncture typically shows mildly elevated protein, normal glucose and mild pleocytosis (< 500), mainly lymphocytes (early on polymorphs may predominate). 
  • Treatment for herpes simplex encephalitis should be commenced in all patients until this has been excluded (see below).

MEDICINE TREATMENT

Analgesia:

  • Paracetamol, oral, 500 mg–1 g, 4–6 hourly as required (to a maximum of 4 g in 24 hours).
    • Maximum dose: 15 mg/kg/dose.

AND/OR

  • NSAID, e.g.:
    • Ibuprofen, oral, 400 mg immediately then 8 hourly with meals, if needed.

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OR

Herpes simplex encephalitis

Clinical features are fever, change in behaviour and seizures, which may be either focal or generalised. Evidence of mucocutaneous involvement is usually not present. Lumbar puncture shows the above features of viral meningoencephalitis. Evidence of encephalitis involving medial temporal lobe region on MRI/CT neuro-imaging or on EEG is strongly supportive of the diagnosis and positive HSV PCR test on CSF is diagnostic.

  • Aciclovir, IV, 10 mg/kg 8 hourly for 14 days (21 days in immunocompromised patients).
    • Start therapy as early as possible, i.e. before results are available.
    • A negative herpes PCR usually excludes the diagnosis unless the specimen was taken within 72 hours of onset of symptoms, when false negatives have been described. 

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Treat seizures appropriately, see Epilepsy. 

All suspected cases of herpes encephalitis should be discussed with a specialist.

REFERRAL

  • For neuro-imaging: patients not responding or worsening in condition, i.e. decrease in consciousness and cranial nerve palsies, despite appropriate therapy.
  • Patients with shunts.

MENINGOVASCULAR SYPHILIS (NEUROSYPHILIS)

A52.1 + (G01*)

DIAGNOSIS

  • Lumbar puncture typically shows lymphocytosis with mildly elevated protein and low/normal glucose.
  • Serum syphilis serology: a negative TPHA or TPA excludes the diagnosis; RPR may be negative in some cases.
  • CSF syphilis serology: a CSF VDRL positive result is highly specific for neurosyphilis, but may be negative in approximately 50%. A negative CSF FTA-ABS excludes the diagnosis of neurosyphilis.

MEDICINE TREATMENT

  • Benzylpenicillin (penicillin G), IV, 20 MU daily in 4–6 divided doses for 10 days.

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A serum RPR response (4-fold decline in titre) after 6 months is predictive of treatment success for neurosyphilis.

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Severe penicillin allergy: (Z88.0)

  • Refer for consideration of desensitisation and subsequent treatment with benzylpenicillin at a referral centre.

BRAIN ABSCESS

G06.0

DIAGNOSIS

  • Patient may present with focal neurological signs and signs of infection.
  • Neurological signs may not always be prominent.
  • Neuro-imaging usually confirms diagnosis.
  • Patients may have concomitant infection of ears, paranasal sinuses or lower respiratory tract.

MEDICINE TREATMENT

Empiric antibiotic therapy

  • Ceftriaxone, IV, 2 g 12 hourly.

AND

  • Metronidazole, oral, 400 mg 8 hourly or IV, 500 mg 8 hourly.

Adjust according to antimicrobial sensitivity after surgical drainage.

REFERRAL

  • All, as patients require urgent neurosurgery opinion and treatment.

ANTIMICROBIAL USE IN PATIENTS WITH HEAD INJURIES

S02.10-11/S06.11/S06.21/S06.31/S06.41/S06.51/S06.61/S06.71/S06.81/S06.91/ S09.9

MEDICINE TREATMENT

Basal skull fractures

  • Antibiotic prophylaxis is not indicated.

Penetrating brain injuries

Antibiotics are given for therapy.

  • Ceftriaxone, IV, 2 g 12 hourly for 7 days.

LoE:IVb

NEUROCYSTICERCOSIS

B69.0 + (G99.8*)

DIAGNOSIS

  • Patients may present with seizures and/or focal neurological deficit.
  • Typical cystic lesions are seen on neuroimaging.
  • Old, calcified lesions are inactive and do not require treatment.

GENERAL MEASURES

  • Health education.
  • Surgery for treatable ventricular blockage or spinal or intraocular cysts.

MEDICINE TREATMENT

For active or viable cysts only:

  • Albendazole, oral, 12 hourly for 8 days.
    • ≥ 60 kg: 400 mg.
    • < 60 kg: 7.5 mg/kg to a maximum of 800 mg daily.

Note:

Do not use in pregnancy due to teratogenicity.

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AND

  • Corticosteroids (intermediate-acting) e.g.:
    • Prednisone, oral, 60 mg daily for 8 days.

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  • Anticonvulsants, if required. See Epilepsy. 

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REFERRAL

  • Uncontrolled seizures despite antiparasitic and anticonvulsant therapy.

Click here to access the pdf.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-4_Version 2.0_6 June 2025

Chapter 14 Neurological Disorders_14.8 Infectious and Parasitic Conditions

Drugs mentioned

ICD-10 codes

NeoHealth® ID 20031 · updated 4/30/2026