To evaluate the
antibiotic susceptibility of Streptococcus pneumoniae isolates obtained from the blood and cerebrospinal fluid of children with
meningitis. To describe and compare the clinical and microbiological characteristics, treatment, and outcome of children with
meningitis caused by S pneumoniae based on antimicrobial susceptibility of isolates and the administration of
dexamethasone.
DESIGN AND PATIENTS: Children with
pneumococcal meningitis were identified from among a group of patients with systemic
infections caused by S pneumoniae who were enrolled prospectively in the United States Pediatric Multicenter Pneumococcal Surveillance Study at eight children's hospitals in the United States. From September 1, 1993 to August 31, 1996, 180 children with 181 episodes of
pneumococcal meningitis were identified and data were collected by retrospective chart review.
OUTCOME: Fourteen (7.7%) of 180 children died; none of the fatalities were because of a documented failure of treatment caused by a resistant strain. Only 1 child, who had
mastoiditis and a
lymphangioma, experienced a bacteriologic failure with a
penicillin-resistant (minimum inhibitory concentration = 2 microgram/mL) organism. Of the 166 surviving children, 41 (25%) developed neurologic sequelae (motor deficits) and 48 (32%) of 151 children had unilateral (n = 26) or bilateral (n = 22) moderate to severe
hearing loss at discharge. Overall, 12.7% and 6.6% of the pneumococcal isolates were intermediate and resistant to
penicillin and 4.4% and 2.8% were intermediate and resistant to
ceftriaxone, respectively. Clinical presentation, cerebrospinal fluid indices on admission, and hospital course, morbidity, and mortality rates were similar for patients infected with
penicillin- or
ceftriaxone-susceptible versus nonsusceptible organisms. However, the relatively small numbers of nonsusceptible isolates and the inclusion of
vancomycin in the treatment regimen for the majority of the patients limit the power of this study to detect significant differences in outcome between patients infected with susceptible and nonsusceptible isolates. Nonetheless, our results show that the nonsusceptible organisms do not seem to be intrinsically more virulent. Forty children (22%) received
dexamethasone (>/=8 doses) initiated before or within 1 hour after the first dose of
antibiotics. The incidence of any moderate or severe
hearing loss was significantly higher in the
dexamethasone group (46%) compared with children not receiving any
dexamethasone (23%). The incidence of any
neurologic deficits, including
hearing loss, also was significantly higher in the
dexamethasone group (55% vs 33%). However, children in the
dexamethasone group more frequently required intubation and
mechanical ventilation and had lower initial concentration of
glucose in the cerebrospinal fluid than children who did not receive any
dexamethasone. When we controlled for the confounding factor, severity of illness (intubation), the incidence of any
deafness and of any neurologic sequelae, including
deafness, were no longer significantly different between children who did or did not receive
dexamethasone.
CONCLUSIONS: