Remarks ■ There were no included trials. ■ The GDG emphasized that this recommendation is for therapy with ampicillin, cefotaxime or ceftriaxone combined with gentamicin. However, the GDG emphasized that ampicillin should be given in addition to thirdgeneration cephalosporins and gentamicin (i.e. triple therapy) if Listeria monocytogenes is suspected. ■ The GDG made these recommendations for empiric first-choice treatment of suspected meningitis in infants where the causative organism is unknown. ■ The GDG recommended that cerebrospinal fluid (CSF) cultures and antimicrobial sensitivity testing should be used to inform therapy for infants with suspected meningitis wherever possible. However, the GDG recognized that CSF specimens may not be available and that microscopy and culture-testing facilities may be limited in LMICs. ■ The GDG recognized that ceftriaxone has been associated with bilirubin binding and jaundice in young infants but considered that data were limited. ■ The GDG recognized that regimens without gentamicin are used in some settings, such as third-generation cephalosporin monotherapy or third-generation cephalosporins plus ampicillin. They also recognized that there are toxicities associated with short- and long-term gentamicin use, there are difficulties in measuring gentamicin levels, and that observational studies report that gentamicin may have poor penetration into CSF. However, the GDG also considered that gentamicin penetration may be enhanced by inflamed meninges and that gentamicin is widely used for treatment of suspected meningitis in both HIC and LMIC settings. The GDG also emphasized that gentamicin levels should be measured wherever possible. ■ The GDG emphasized that the antibiotics must be given by the parenteral (IM or IV) route for suspected meningitis. ■ The GDG emphasized that care with antibiotic dosing is needed. The GDG recognized that there were limited data on antibiotic dosing. The GDG suggested that the following doses of antibiotics should be used: ampicillin IM/IV 50 mg/kg every 12 hours in the first week of life and every 8 hours after the first week of life for at total of at least three weeks, or cefotaxime IM/IV 50 mg/kg every 12 hours in the first week of life and every 6 hours after the first week of life for a total of at least three weeks, or ceftriaxone IM/IV 100 mg/kg once a day (whether starting in the first week of life or later) for a total of at least three weeks, plus gentamicin IM/IV 5 mg/kg once a day in the first week of life and 7.5 mg/kg once a day after the first week of life for a total of at least three weeks (see alsoTable 3.1 later in this chapter). ■ The GDG considered that antibiotic duration should be for at least three weeks, and continued for longer if the infant is not improving. The GDG emphasized the importance of adjusting empiric antibiotic therapy during the course of the illness, as is routinely done in many hospitals. This includes targeting individual antibiotic therapy regimens based on microbiological test results and stopping antibiotic therapy based on validated, clinical and laboratory risk stratification algorithms. ■ The GDG made a strong recommendation despite the lack of trials as they felt strongly about the importance of providing clear guidance for the management of infants with meningitis. The GDG were able to use their knowledge and experience in best practice clinical management in managing meningitis in young infants to make this recommendation by consensus.