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The emergence of resistant pneumococcal meningitis--implications for empiric therapy
P McMaster1, P McIntyre, R Gilmour
1Department of Immunology and Infectious Diseases, The Children's Hospital at Westmead, PO Box 3515, Parramatta, NSW 2124, Australia.
Background:
Following the emergence of penicillin and cephalosporin resistant pneumococcal meningitis in the United States, inclusion of vancomycin in empiric therapy for all suspected bacterial meningitis was recommended by the American Academy of Pediatrics. Few data are available to evaluate this policy.
Aims:
To examine the management and clinical course in relation to antibiotic therapy of a large unselected cohort of children with pneumococcal meningitis in a geographic area where antibiotic resistance has recently increased.
Methods:
Retrospective review of all cases of pneumococcal meningitis in a defined population (Sydney, Australia), 1994-99.
Results:
A total of 104 cases without predisposing illnesses were identified; timing of lumbar puncture (LP) was known in 103. Resistance to penicillin increased from 0 to 20% over the study period. Only 57 (55%) had an early LP (prior to parenteral antibiotics); 55 (96%) had organisms on Gram stain. Severe disease (intensive care admission or death) increased significantly from 57 cases with early LP (28%) to 33 with delayed LP (42%) to 13 with no LP (62%). Evidence of pneumococcal infection was available within 24 hours in 85% of those with delayed or no LP. Outcome was not related to empiric vancomycin use, which increased from 5% prior to 1998 to 48% in 1999.
Conclusion:
LP is frequently delayed in pneumococcal meningitis. Based on disease severity, empiric vancomycin is most justified when LP is deferred. If an early LP is done, vancomycin can be withheld if Gram positive diplococci are not seen.
Insights
Delayed lumbar puncture in pneumococcal meningitis increases disease severity. Empiric vancomycin is most justified for delayed lumbar punctures, but can be withheld if Gram-positive diplococci are not seen on early lumbar puncture.
Area of Science:
- Pediatric Infectious Diseases
- Bacterial Meningitis Pathogenesis
- Antibiotic Resistance Epidemiology
Background:
- Penicillin and cephalosporin resistance in pneumococcal meningitis prompted vancomycin recommendations.
- Limited data exist to evaluate the efficacy of this empiric vancomycin policy.
Purpose of the Study:
- To assess management and clinical outcomes of pneumococcal meningitis in children.
- To correlate outcomes with antibiotic therapy in an area of increasing antibiotic resistance.
Main Methods:
- Retrospective review of 104 pediatric pneumococcal meningitis cases in Sydney, Australia (1994-1999).
- Analysis of lumbar puncture timing, antibiotic use, and disease severity.
- Evaluation of penicillin resistance trends.
Main Results:
- Penicillin resistance increased from 0% to 20% during the study period.
- Early lumbar puncture (prior to antibiotics) occurred in only 55% of cases.
- Delayed or no lumbar puncture was associated with significantly increased severe disease (42%-62%) compared to early lumbar puncture (28%).
- Empiric vancomycin use did not correlate with patient outcomes.
Conclusions:
- Lumbar puncture is frequently delayed in pediatric pneumococcal meningitis.
- Empiric vancomycin is most indicated when lumbar puncture is deferred due to increased disease severity.
- Vancomycin may be withheld if Gram-positive diplococci are absent on early lumbar puncture results.