3-YEAR MULTICENTER SURVEILLANCE OF PNEUMOCOCCAL MENINGITIS IN CHILDREN - CLINICAL CHARACTERISTICS, AND OUTCOME RELATED TO PENICILLIN SUSCEPTIBILITY AND DEXAMETHASONE USE

Objectives. To evaluate the antibiotic susceptibility of Streptococcus pneumoniae isolates obtained from the blood and cerebrospinal fluid o f children with meningitis. To describe and compare the clinical and m icrobiological characteristics, treatment, and outcome of children wit h meningitis caused by S. pneumoniae based on antimicrobial susceptibi lity of isolates and the administration of dexamethasone. Design and P atients. Children with pneumococcal meningitis were identified from am ong a group of patients with systemic infections caused by S pneumonia e who were enrolled prospectively in the United States Pediatric Multi center Pneumococcal Surveillance Study at eight children's hospitals i n the United States. From September 1, 1993 to August 31, 1996, 180 ch ildren with 181 episodes of pneumococcal meningitis were identified an d data were collected by retrospective chart review. Outcome. Clinical and laboratory characteristics were assessed. All pneumococcal isolat es were serotyped and antibiotic susceptibilities for penicillin and c eftriaxone were determined. Clinical presentation, hospital course, an d outcome parameters at discharge were compared between children infec ted with penicillin-susceptible isolates and those with nonsusceptible isolates and for children who did and did not receive dexamethasone. Results. Fourteen (7.7%) of 180 children died; none of the fatalities were because of a documented failure of treatment caused by a resistan t strain. Only 1 child, who had mastoiditis and a lymphangioma, experi enced a bacteriologic failure with a penicillin-resistant (minimum inh ibitory concentration = 2 mu g/mL) organism. Of the 166 surviving chil dren, 41 (25%) developed neurologic sequelae (motor deficits) and 48 ( 32%) of 151 children had unilateral (n = 26) or bilateral (n = 22) mod erate to severe hearing loss at discharge. Overall, 12.7% and 6.6% of the pneumococcal isolates were intermediate and resistant to penicilli n and 4.4% and 2.8% were intermediate and resistant to ceftriaxone, re spectively. Clinical presentation, cerebrospinal fluid indices on admi ssion, and hospital course, morbidity, and mortality rates were simila r for patients infected with penicillin- or ceftriaxone-susceptible ve rsus nonsusceptible organisms. However, the relatively small numbers o f nonsusceptible isolates and the inclusion of vancomycin in the treat ment regimen for the majority of the patients limit the power of this study to detect significant differences in outcome between patients in fected with susceptible and nonsusceptible isolates. Nonetheless, our results show that the nonsusceptible organisms do not seem to be intri nsically more virulent. Forty children (22%) received dexamethasone (g reater than or equal to 8 doses) initiated before or within 1 hour aft er the first dose of antibiotics. The incidence of any moderate or sev ere 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 wa s significantly higher in the dexamethasone group (55% vs 33%). Howeve r, children in the dexamethasone group more frequently required intuba tion 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, seve rity 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. Children with pneumococcal meningitis caused by penicilli n- or ceftriaxone-nonsusceptible organisms and those infected by susce ptible strains had similar clinical presentation and outcome. The use of dexamethasone was not associated with a beneficial effect in this r etrospective and nonrandomized study. Only a well-designed, prospectiv e, randomized, placebo-controlled study, conducted in centers where op timal supportive care can be provided, will determine the potential be nefit, if any, of dexamethasone in patients with pneumococcal meningit is.