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Post-publication Peer Reviews to:
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![[Read P3R]](/icons/misc/sectionDOWN.gif){kind=icon}
CONS meningitis: to be or not to be?
Do We have Enough Evidnce To Tap?: Response to Stoll etal
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Amit Upadhyay, Registrar Monash Medical Centre, Clayton, Charles Barfield, Deputy Director, Monash Medical Centre, Clayton
Send letter to journal:
anuamit7{at}rediffmail.com Amit Upadhyay, et al.
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We read with interest your article (1). We have the following comments to make 1. We were surprised to learn that the most common organism (29%) responsible for late onset meningitis in VLBW infants in the United States was Coagulase Negative Staphylococcus (CONS). In our experience, after excluding infants with intraventricular shunts or cerebral infarction, CONS has not been a significant cause of meningitis (2-4). Of 1281 cases of CONS sepsis, only 5 (0.4%) had meningitis (2). A report from England and Wales also found only 3 cases (1%) of meningitis due to CONS out of 144 cases of bacterial meningitis (5), while another small study from Oxford reported no cases of CONS meningitis(6). Laboratory based studies may over estimate the incidence of CONS meningitis. Gruskay et al described 10 babies with CONS meningitis, but they were likely to be contaminants, as all had normal CSF cell count and biochemistry (7). We note that data on other CSF parameters (cells, glucose, protein, and Gram stain) and other haematological parameters (full blood examination and C Reactive Protein etc) were not collected. We wonder if the absence of this supporting data may have led to the labelling of infants as having meningitis when in fact the CONS was a contaminant. So, we differ in authors' recommendation of considering LP in every baby with suspect late onset sepsis. In our unit, a LP is not a routine part of the investigation of late onset sepsis if CONS sepsis is proven unless there are clinical features suggestive of meningitis or laboratory tests indicate a non- reassuring response to antibiotic therapy. 2. We share the authors concern regarding under diagnosing meningitis. However, it would be interesting to know whether the risk of death and late neurodevelopmental sequelae were highest in the units with the lowest lumbar puncture evaluation rates. Presumably these units would have the highest incidence of under diagnosed meningitis and higher long- term neonatal morbidity when compared to the units with the highest lumbar puncture evaluation rates. References 1. Barbara J. Stoll, Nellie Hansen, Avroy A. Fanaroff, Linda L. Wright, Waldemar A. Carlo, Richard A. Ehrenkranz, et al. To Tap or Not to Tap: High Likelihood of Meningitis Without Sepsis Among Very Low Birth Weight Infants. Pediatrics 2004;113:1181-1186. 2. Isaacs D; Australasian Study Group For Neonatal Infections. A ten year, multicentre study of coagulase negative staphylococcal infections in Australasian neonatal units. Arch Dis Child Fetal Neonatal Ed. 2003;88:F89 -93. 3. Isaacs D, Barfield C, Clothier T, Darlow B, Diplock R, Ehrlich J, et al. Late-onset infections of infants in neonatal units. J Paediatr Child Health. 1996; 32:158-61. 4. Isaacs D, Barfield CP, Grimwood K, McPhee AJ, Minutillo C, Tudehope DI. Systemic bacterial and fungal infections in infants in Australian neonatal units. Australian Study Group for Neonatal Infections. Med J Aust 1995; 162: 198-201. 5. Holt DE, Halket S, de Louvois J, Harvey D. Neonatal meningitis in England and Wales: 10 years on. Arch Dis Child Fetal Neonatal Ed 2001; 84: F85-89. 6. Hristeva L, Booy R, Bowler I, Wilkinson AR. Prospective surveillance of neonatal meningitis. Arch Dis Child 1993; 69: 14-8. 7. Gruskay J, Harris MC, Costarino AT, Polin RA, Baumgart S. Neonatal Staphylococcus epidermidis meningitis with unremarkable CSF examination results. Am J Dis Child 1989; 143: 580-2. |
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Rafeeq Muhammed, senior house officer, paediatrics MBBS,MD, C.Harikumar, A.Tuladhar
Send letter to journal:
drrafeeq{at}rediffmail.com Rafeeq Muhammed, et al.
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We wish to raise a few concerns regarding the study reported by Stoll and colleagues. The authors could have provided the mortality and outcome details of those 44% of the infants with culture confirmed sepsis, on whom a lumbar puncture was not performed .If the outcome was poor in this group in comparison with the study population who had undergone lumbar puncture, we could have strongly argued for the need of lumbar puncture as an essential part of sepsis workup. ---In the study population, only 89 (6.5%) infants were positive for meningitis out of 1352 babies with culture positive sepsis. Only Forty five (6.5%) babies had meningitis out of 682 (637+45) infants, who were worked up for sepsis and their blood cultures were negative. This shows that even if we do lumbar puncture in all babies as a part of sepsis work up, we are going to pick up only an additional 6.5% of babies with meningitis. However the authors themselves state that there was no difference in the risk of death between infants who did and did not have a lumbar puncture. The fact that 45% of infants with meningitis (14 out of 31) died within seven days of CSF cultures shows the severity of the clinical presentation and that may be the common reason behind the deferral of lumbar puncture by the clinicians. ---We also found it surprising that 94 infants had contaminated CSF cultures, when considering the fact that lumbar puncture is one of the highly aseptic procedures we undertake in neonatal units. R.Muhammed, C.Harikumar, A.Tuladhar Department of Paediatrics University Hospital Of North Tees, Stockton on Tees. UK Correspondence to Dr R.Muhammed; drrafeeq@rediffmail.com Competing interests: none declared |
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