The emergence of resistant pneumococcal meningitisimplications for empiric
therapy
P McMaster1, P McIntyre1,
R Gilmour1, L Gilbert3, A
Kakakios1 and C Mellis2
1 Department of Immunology and Infectious
Diseases, The Childrens Hospital at Westmead, PO Box 3515, Parramatta, NSW
2124, Australia 2 Department of Paediatrics and Child Health, University of Sydney,
Australia 3 Institute of Clinical Pathology and Medical Research, Westmead
Hospital, PO Box 533, Wentworthville, NSW 2145, Australia
Correspondence to:
A/Prof P McIntyre, National Centre for Immunisation Research and Surveillance of
Vaccine Preventable Diseases, Royal Alexandra Hospital for Children and
University of Sydney, Westmead, Sydney, NSW 2145, Australia; peterm@wch.edu.au
Background: Following the emergence of penicillin and
cephalosporinresistant pneumococcal meningitis in the United States,
inclusionof vancomycin in empiric therapy for all suspected
bacterialmeningitis 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 relationto 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 meningitisin a defined population (Sydney, Australia), 199499.
Results: A total of 104 cases without predisposing illnesseswere identified; timing of lumbar puncture (LP) was known in
103. Resistance to penicillin increased from 0 to 20% over thestudy
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 significantlyfrom 57
cases with early LP (28%) to 33 with delayed LP (42%)to 13 with no
LP (62%). Evidence of pneumococcal infection wasavailable within 24
hours in 85% of those with delayed or noLP. Outcome was not related
to empiric vancomycin use, whichincreased 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 canbe
withheld if Gram positive diplococci are not seen.
Abbreviations: AAP, American Academy of Pediatrics; CSF,
cerebrospinal fluid; LP, lumbar puncture; TGC, third generation cephalosporin;
WBC, white blood cell; WCC, white cell count
This article has been cited by other articles:
F A I Riordan and A J Cant When to do a lumbar puncture
Arch. Dis. Child., September 1, 2002; 87(3): 235 - 237.
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