Published online February 1, 2007
PEDIATRICS Vol. 119 No. 2 February 2007, pp. 416-417 (doi:10.1542/peds.2006-3334)
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LETTER TO THE EDITOR

Could Hearing Loss Be Related to Delay in Administration of Other Antibiotics Rather Than Early Use of Vancomycin?: In Reply

Steven C. Buckingham, MD
B. Keith English, MD
Department of Pediatrics
Children's Foundation Research Center at Le Bonheur Children's Medical Center
University of Tennessee Health Science Center
Memphis, TN 38103

Jonathan A. McCullers, MD
Katherine M. Knapp, MD
Department of Infectious Diseases
St Jude Children's Research Hospital
Memphis, TN 38103

Jorge Luján-Zilbermann, MD
Department of Pediatrics
University of South Florida
Tampa, FL 33606

Karen L. Orman, MD
Department of Pediatrics
Kosair Children's Hospital
Louisville, KY 40202

In our study on adverse outcomes of pneumococcal meningitis,1 we observed that hearing loss was significantly more frequent (in both univariate and multivariate analyses) among children who received their first dose of vancomycin either before or <2 hours after their first dose of cefotaxime or ceftriaxone than among those who received vancomycin later. Lee et al suggest that this association might be explained by delayed administration of cephalosporins rather than the early administration of vancomycin. We appreciate their interest in our article and the opportunity to explain why we believe their hypothesis does not explain our findings. First, children in our study received parenteral cephalosporins promptly; 75% did so within 1 hour, and 90% within 2 hours, of performance of the diagnostic lumbar puncture. Second, the timing of cephalosporin administration was not associated with hearing loss in univariate or multivariate analyses; the median time from lumbar puncture to first cephalosporin dose was <1 hour in children both with and without hearing loss. Third, only 5 children received vancomycin before their first dose of cefotaxime or ceftriaxone, and the maximum interval between these doses was 2.5 hours (median: 10 minutes). Finally, the proportions of children with hearing loss were similar among children who received early empiric vancomycin therapy regardless of whether vancomycin or a cephalosporin was the first parenteral antibiotic administered (4 of 5 vs 14 of 18; P > .99).

The assumption underlying the suggested hypothesis of Lee et al is that early initiation of antibiotic therapy improves the probability of a good outcome in patients with bacterial meningitis. Although this assertion is intuitively appealing, it is not well supported by the results of published studies; extant data do not suggest that a delay of even several hours is associated with an increased risk of hearing loss or other sequelae.2–4

We believe that cefotaxime or ceftriaxone should be administered promptly to children with suspected or confirmed bacterial meningitis. The question is, given that prompt initiation of therapy does not ensure a good outcome, what else should be done? The results of our study indicate that the early addition of vancomycin to the empiric antibiotic regimen might not be the answer. Alternative strategies that address the dual ends of sterilizing the cerebrospinal fluid while also minimizing inflammatory damage to host tissues must be investigated.

REFERENCES

  1. Buckingham SC, McCullers JA, Luján-Zilbermann J, Knapp KM, Orman KL, English BK. Early vancomycin therapy and adverse outcomes in children with pneumococcal meningitis. Pediatrics. 2006;117 :1688 –1694[Abstract/Free Full Text]
  2. Radetsky M. Duration of symptoms and outcome in bacterial meningitis: an analysis of causation and the implications of a delay in diagnosis. Pediatr Infect Dis J. 1992;11 :694 –698; discussion 698–701[ISI][Medline]
  3. Kallio MJ, Kilpi T, Anttila M, Peltola H. The effect of a recent previous visit to a physician on outcome after childhood bacterial meningitis. JAMA. 1994;272 :787 –791[Abstract]
  4. McIntyre PB, Macintyre CR, Gilmour R, Wang H. A population based study of the impact of corticosteroid therapy and delayed diagnosis on the outcome of childhood pneumococcal meningitis. Arch Dis Child. 2005;90 :391 –396[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics




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