65-year-old male with a past medical history of diabetes and hypertension who presented with medics to the hospital with complaints of headache, photophobia, and neck pain. Patient on arrival appears to be confused. Vitals are significant for patient with a rectal temp of 101.4. Patient is sent immediately for head CT which is normal. While awaiting lumbar puncture, patient is to be started on empiric antibiotics. What is the best choice from below? 

A. Vancomycin + Ceftriaxone

B. Vancomycin + Ceftriaxone + Dexamethasone

C. Acyclovir + Ceftriaxone

D. Vancomycin + Ceftriaxone + Ampicillin + Dexamethasone 

E. Vancomycin + Ceftriaxone + Ampicillin 

D. Empirically steroids need to be given to prevent complications that can be caused by pneumococcal meningitis along with ampicillin in this case due to age and risk factor of diabetes requiring coverage for Listeria. 

_{*Empiric Vancomycin is added to regimen for concern for penicillin resistant strep pneumonia.* If HSV or VZV is of concern empiric acyclovir should be started. *Dexamethasone should empirically be started on all patients prior to antibiotics in whom there is a concern for pneumococcal meningitis}

_{*CoNS- Coagulase negative staph aureus}

References

Farkas, Josh etal.“Meningitis and Encephalitis.” IBCC. Jan 2, 2017. <https://emcrit.org/ibcc/meningitis/>. 9/19/19.

Tunkel, Allan et al. “Clinical Features and Diagnosis of Acute Bacterial Meningitis in Adults.” August 2018. <www.uptodate.com>. 9/19/19.

Tunkel, Allan et al. “ Initial Therapy and Prognosis of Bacterial Meningitis in Adults.” August 2019. <www.uptodate.com>. 9/19/19.