Published online May 1, 2006
PEDIATRICS Vol. 117 No. 5 May 2006, pp. 1688-1694 (doi:10.1542/peds.2005-2282)
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Early Vancomycin Therapy and Adverse Outcomes in Children With Pneumococcal Meningitis

Steven C. Buckingham, MDa, Jonathan A. McCullers, MDb, Jorge Luján-Zilbermann, MDc, Katherine M. Knapp, MDb, Karen L. Orman, MDd and B. Keith English, MDa

a Department of Pediatrics, University of Tennessee Health Science Center and Children's Foundation Research Center at Le Bonheur Children's Medical Center, Memphis, Tennessee
b Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
c Department of Pediatrics, University of South Florida, Tampa, Florida
d Department of Pediatrics, Kosair Children's Hospital, Louisville, Kentucky

BACKGROUND. Experts recommend that children with suspected pneumococcal meningitis should empirically receive combination therapy with vancomycin plus either ceftriaxone or cefotaxime. The relationship between timing of the first dose of vancomycin relative to other antibiotics and outcome in these children, however, has not been addressed.

METHODS. Medical records of children with pneumococcal meningitis at a single institution from 1991–2001 were retrospectively reviewed. Vancomycin start time was defined as the number of hours from initiation of cefotaxime or ceftriaxone therapy until the administration of vancomycin therapy. Outcome variables were death, sensorineural hearing loss, and other neurologic deficits at discharge. Associations between independent variables and outcome variables were assessed in univariate and multiple logistic regression analyses.

RESULTS. Of 114 subjects, 109 received empiric vancomycin therapy in combination with cefotaxime or ceftriaxone. Ten subjects (9%) died, whereas 37 (55%) of 67 survivors who underwent audiometry had documented hearing loss, and 14 (13%) of 104 survivors were discharged with other neurologic deficits. Subjects with hearing loss had a significantly shorter median vancomycin start time than did those with normal hearing (<1 vs 4 hours). Vancomycin start time was not significantly associated with death or other neurologic deficits in univariate or multivariate analyses. Multiple logistic regression revealed that hearing loss was independently associated with vancomycin start time <2 hours, blood leukocyte count <15000/µL, and cerebrospinal fluid glucose concentration <30 mg/dL.

CONCLUSIONS. Early empiric vancomycin therapy was not clinically beneficial in children with pneumococcal meningitis but was associated with a substantially increased risk of hearing loss. It may be prudent to consider delaying the first dose of vancomycin therapy until ≥2 hours after the first dose of parenteral cephalosporin in children beginning therapy for suspected or confirmed pneumococcal meningitis.

Key Words: Streptococcus pneumoniae • vancomycin • meningitis • dexamethasone • hearing loss

Abbreviations: CSF—cerebrospinal fluid

Accepted Nov 3, 2005.


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Reducing the Risk of Neurologic Sequelae in Meningitis
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