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[Pneumococcal meningitis in children: should probabilistic antibiotherapy of infectious meningitis be modified?]
A Le Masne1, J L Gaillard, F Lacaille
1Service de pédiatrie générale, hôpital Necker-Enfants-Malades, Paris, France.
Background:
Since a significant proportion of Streptococcus pneumoniae strains is now resistant to penicillin and sometimes to third-generation cephalosporin, it is necessary to reevaluate the initial therapy of bacterial meningitis proposed before identification of the organism and its susceptibility pattern.
Population:
From 1 January 1992 to 31 March 1994, nine children with acute S pneumoniae meningitis were treated with ceftriaxone plus aminoglycoside as conventional initial therapy. Eight children were less than 1 year-old (five from 3 to 6 months). Five S pneumoniae strains were penicillin-resistant; four had a ceftriaxone minimal inhibitory concentration (MIC) of 0.047 to 0.094 mg/L and one of 1.5 mg/L. Ceftriaxone was given intravenously at doses of 50 mg/kg twice a day to patients less than 12 months old and 100 mg/kg once a day to patients older than 12 months. Intravenous amikacin (7.5 mg/kg twice daily) or netilmicin (3 mg/kg twice daily) were administered in combination. Dexomethasone was given to all children as adjunctive therapy. Follow-up lumbar puncture was performed after 24 to 36 hours of treatment.
Results:
For each of the nine patients, cerebrospinal fluid was sterile with normal glucose level. After 2 or 4 days, initial therapy had been modified according to antibiogram and MIC. Monotherapy with ceftriaxone was continued in five children. Rifampicin was associated with initial bitherapy in one case. In two other patients, initial empiric therapy was stopped and changed to chloramphenicol.
Conclusion:
No case of bacteriological failure was noted in our patients but evolution of epidemiology and emergence of decreased penicillin sensibility in S pneumoniae strains (55% in our study) suggests that a third antibiotic (vancocin or rifampicin) should be associated with the standard first-line drug when S pneumoniae is suspected.
Insights
Initial therapy for Streptococcus pneumoniae meningitis in children, including ceftriaxone and aminoglycoside, showed no bacteriological failure. However, rising penicillin resistance suggests adding a third antibiotic like vancomycin or rifampicin for suspected S. pneumoniae cases.
Area of Science:
- Pediatric Infectious Diseases
- Bacteriology
- Clinical Pharmacology
Context:
- Increasing penicillin and cephalosporin resistance in Streptococcus pneumoniae necessitates reevaluation of empirical meningitis treatment.
- Acute bacterial meningitis requires prompt and effective initial antibiotic therapy.
Purpose:
- To assess the efficacy of initial ceftriaxone plus aminoglycoside therapy for acute Streptococcus pneumoniae meningitis in children.
- To evaluate treatment modifications based on susceptibility patterns.
Summary:
- Nine children with S. pneumoniae meningitis received ceftriaxone and aminoglycoside. Five strains showed penicillin resistance, and four had reduced ceftriaxone susceptibility.
- All patients achieved sterile cerebrospinal fluid. Initial therapy was adjusted in three cases; five continued ceftriaxone monotherapy.
- No bacteriological failure occurred, but 55% of S. pneumoniae strains exhibited decreased penicillin sensitivity.
Impact:
- Supports the need for empirical antibiotic regimens that account for emerging antimicrobial resistance in S. pneumoniae.
- Highlights the importance of susceptibility testing and potential addition of vancomycin or rifampicin for suspected S. pneumoniae meningitis.