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ARTICLES:
Steven C. Buckingham, Jonathan A. McCullers, Jorge Luján-Zilbermann, Katherine M. Knapp, Karen L. Orman, and B. Keith English
Early Vancomycin Therapy and Adverse Outcomes in Children With Pneumococcal Meningitis
Pediatrics 2006; 117: 1688-1694 [Abstract] [Full text] [PDF]
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P3Rs published:

[Read P3R] Reducing the Risk of Neurologic Sequelae in Meningitis
Steve Piecuch, MD, MPH   (28 July 2006)

Reducing the Risk of Neurologic Sequelae in Meningitis 28 July 2006
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Steve Piecuch, MD, MPH,
Clinical Associate Professor of Pediatrics
SUNY-Downstate Medical Center

Send letter to journal:
Re: Reducing the Risk of Neurologic Sequelae in Meningitis

stevepiecuch{at}aol.com Steve Piecuch, MD, MPH

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