Therapy in postpuncture meningitis.

摘要

To the Editor:-We read with great interest the comprehensive overview by Baer regarding post-dural puncture (bacterial) meningitis (PDPM). However, some questions can be raised regarding treatment recommendations for patients with PDPM. The recommendation for empiric treatment that is made in this article follows Infectious Diseases Society of America guidelines for Streptococcus pneumoniae meningitis. In these guidelines, use of vancomycin plus the third-generation cephalosporins ceftriaxone or cefotaxime is recommended with the addition of ampicillin in patients older than 50 yr. Of the 179 reviewed cases in this article, indeed, almost half had meningitis due to viridans streptococci; however, relatively high rates of Staphylococcus aureus (9 patients, 5%). Pseudomonas aeruginosa (8 patients, 4%), and Enterococcus faecalis (3 patients, 2%) were also found.1 This specific distribution of species stresses that PDPM should be regarded as a specific category of patients that most resembles the "standard" category of patients with recent neurosurgery. In this category, recent guidelines recommend vancomycin plus ceftazidime. Ceftazidime, and not ceftriaxone or cefotaxime, has shown efficacy in several studies of patients with Pseudomonas meningitis. Alternatively, one can use cefepime. which also has greater in vitro activity than the third-generation cephalosporins.