Assure coverage for resistantStreptococcus pneumoniae with vancomycin if there is a concernfor meningitis
Assure coverage for resistantStreptococcus pneumoniae with vancomycin if there is a concernfor meningitis: Excerpt from Avoiding Common Pediatric Errors
Author:
Yolanda Lewis-Ragland, MD
What to Do - Interpret the Data
The first penicillin-resistant Streptococcus pneumoniae strain was isolated in
1967. Since then, however, there have been many reports of treatment failure
in patients with pneumococcal infections caused by strains resistant to penicillin and other antimicrobial agents such as chloramphenicol, macrolides,
trimethoprim-sulfamethoxazole, and cephalosporins. As a result, the
selection of antimicrobial agents for the treatment of infections caused
by these organisms has become increasingly difficult. In particular, the
emergence of pneumococci-resistant to broad-spectrum cephalosporins has
limited the antibiotic choices for the treatment of pneumococcal meningitis.
Meningitis Signs and Symptoms
Patients with central nervous system (CNS) infections, regardless of the
etiology (bacterial, viral, or other), generally present with similar clinical
features. The systemic signs of CNS infection include fever, malaise, and
impairment of essential organs (heart, lung, liver, or kidney function). For
older children and adults, the classic signs and symptoms suggesting CNS
infection include headache; stiff neck; fever or hypothermia; changes in
mental status, including hyperirritability evolving into lethargy and coma;
seizures; and focal sensory and motor deficits.
Infants and young children, however, may lack obvious signs of meningitis, and present with simple temperature instability rather than fever. Otherwise, lethargy, irritability, vomiting, and poor feeding are often signs of
CNS involvement in this group. Nuchal rigidity or a bulging fontanelle is
present in <50% of infants and young children with meningitis.
Risk Factors for Developing Meningitis
Conditions that predispose the patient to infection of the CNS should be
sought. One of the most common causes of meningitis is an infection of the
sinuses orother structuresinthehead orneck region thatresultsindirectextension of infection into the intracranial compartment. Open head injuries,
recent neurosurgical procedures, immunodeficiency, and the presence of a
mechanical shunt may likewise predispose individuals to intracranial infection.
Management of Bacterial Meningitis
The broad-spectrum cephalosporins, cefotaxime and ceftriaxone, have traditionally been used as standard therapy for bacterial meningitis in infants
and children. However, in the past decade, penicillin-and cephalosporin-
resistant pneumococcal meningitis has been reported. In fact, cultures of
cerebrospinal fluid (CSF) were positive for 3 to 14 days after the initiation
of therapy. Therefore, in an attempt to identify an effective therapy, several antibiotic regimens including vancomycin, chloramphenicol, rifampin,
erythromycin, and imipenem, alone and in combination were given to
patients to identify an ideal anti–pneumococcal meningitis regimen.
Researchers concluded that on the basis of data from the pneumococcal
meningitis models and limited clinical experience, it was impossible to make
a single recommendation for initial empiric treatment that would be suitable
forallpatientswithsuspectedorprovenpneumococcalmeningitis.However,
the following guidelines could be considered in managing such patients:
• Physicians should be aware of the S. pneumoniae susceptibility patterns
in their area and request their hospital laboratories to perform dilution
susceptibility tests on any pneumococcal isolates recovered from usually
sterile body sites.
• Because penicillin-resistant pneumococci have been identified in many
areas of the United States, initial empiric therapy for bacterial meningitis
should be based on the possibility that it is the etiology of the patient's
illness. The recommended therapy is therefore ceftriaxone or cefotaxime
and vancomycin (60 mg/kg/day divided in four doses), in addition to
dexamethasone.
• A repeat lumbar puncture in patients with pneumococcal meningitis to
document eradication of the pathogen should be performed 24 to 36 hours
after the start of therapy, primarily in patients in whom the organism is
cephalosporin resistant.
• Alteration of the initial antimicrobial regimen should be based on the
clinical response of the patient and on the results of the CSF culture and
susceptibility studies from the second lumbar puncture. In the event that
the patients' clinical condition has worsened or that the follow-up Gram-
stained smear or culture of CSF indicates failure to substantially reduce
or eradicate the organism, substitution of rifampin for vancomycin in the
therapeutic regimen is recommended.
• Patients without complications should be treated for a minimum of
10 days.
Suggested Readings
Heyderman RS, Klein NJ. Emergency management of meningitis. J R Soc Med. 2000;93:225–
229.
Phillips EJ, Simor AE. Postgraduate medicine: symposium: bacterial meningitis in children
and adults. Changes in community-acquired disease may affect patient care. Postgrad Med.
1998;103(3):102–117.
WiseKA,BedfordM,WadhwaSS,etal.MeningitiscausedbyStreptococcuspneumoniaeshowing
high level resistance to penicillin. Pathology. 1995;27(2):165–167.
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Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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