Buckingham and colleagues conducted a very thorough retrospective
review of a relatively large group of patients with pneumococcal
meningitis. They found that those patients who received vancomycin within
two hours of their initial dose of ceftriaxone had an increased risk of
hearing loss. They concluded that it may be prudent to delay the first
dose of vancomycin until at least two hours after the initial dose of
ceftriaxone.
The authors point out that the increased incidence of hearing loss
seen in those who received vancomycin within two hours of ceftriaxone may
have been the result of an enhanced inflammatory response due to rapid
bacterial lysis. They further make the point that no apparent advantage to
the early use of vancomycin was found.
There is no question that an excessive inflammatory response can
cause serious harm to the patient. At the same time, an approach that
seeks to limit the inflammatory response by less effective bacterial
killing may also have adverse consequences. I would suggest that the
finding that there was no advantage to the early use of vancomycin is
interesting but of limited significance. This was a retrospective review
and not a controlled study of the timing of the vancomycin dose. In
addition, early vancomycin would only be expected to be advantageous in a
relatively small group of patients, those with a highly resistant
organism.
As the authors point out in their discussion, steroids have been
shown to be useful in reducing inflammation-induced neurologic injury in
patients with meningitis. However, the use of steroids in patients with
meningitis is not routine in many centers. I would respectfully question
the authors' recommendation to delay the initial vancomycin dose and
suggest that a more appropriate response to their findings might be a
strong recommendation to routinely administer steroids prior to or as soon
as possible after beginning antibiotic therapy in patients with suspected
bacterial meningitis.
Conflict of Interest:
None declared
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