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Correspondence  |   April 2007
Therapy in Postpuncture Meningitis
Author Affiliations & Notes
  • Diederik van de Beek, M.D., Ph.D.
    *
  • *Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. or
Article Information
Correspondence
Correspondence   |   April 2007
Therapy in Postpuncture Meningitis
Anesthesiology 4 2007, Vol.106, 876-877. doi:10.1097/01.anes.0000264756.24264.b3
Anesthesiology 4 2007, Vol.106, 876-877. doi:10.1097/01.anes.0000264756.24264.b3
To the Editor:—
We read with great interest the comprehensive overview by Baer1 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.2 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.2 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.3,4 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.2,5 Alternatively, one can use cefepime, which also has greater in vitro  activity than the third-generation cephalosporins.2,5 
In addition, Baer recommends the use of adjunctive dexamethasone in patients with PDPM.1 In a recent European randomized clinical trial, adjunctive dexamethasone therapy reduced mortality from 15% to 7%.6 Of the total of 301 included patients in this trial, 9 (3%) had meningitis due to viridans streptococci, and were partly described previously.7 One of the 5 patients included in the placebo group died, versus  1 of the 4 in the dexamethasone group. Both patients died of S. milleri  meningitis; others had meningitis due to S. salivarius  (n = 4), S. sanguis  (n = 2), and S. oralis  (n = 1) (van de Beek, unpublished, October 2006). In a recent quantitative review of the effect of adjunctive dexamethasone in adults with community-acquired bacterial meningitis that included the results of five clinical trials, treatment with dexamethasone was associated with a significant reduction in mortality and neurologic sequelae.8 On basis of these data, dexamethasone is advised for patients with suspected or proven community-acquired bacterial meningitis and should be continued for 4 days, regardless of microbial cause.5 However, PDPM has a different pathophysiology, and cerebrospinal fluid cultures yielded specific distribution of causative species, as compared with patients with community-acquired bacterial meningitis.1,9 Therefore, adjunctive dexamethasone is not recommended in the subgroup of patients with PDPM.
*Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. or
References
Baer ET: Post–dural puncture bacterial meningitis. Anesthesiology 2006; 105:381–93Baer, ET
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