The antibiotic and anti-inflammatory treatment of bacterial meningitis in adults: Do we have to change our strategies in an era of increasing antibiotic resistance?

Community acquired bacterial meningitis remains a feared infection because of its high morbidity and mortality. During the last decade, the incidence and the microbial resistance patterns of pathogens causing bacterial mening itis have changed considerably. A sharp increase in meningococcal disease h as been observed and meningitis caused by penicillin resistant Streptococcu s pneumoniae emerged as a matter of major concern. Since pneumococcal. resi stance in Belgium to third generation cephalosporins remains rare and low l evel, addition of vancomycin to the initial empirical therapy including thi rd generation cephalosporins is not yet necessary. However, the evolution o f the resistance patterns of invasive S. pneumoniae should be followed very carefully. The emergence of penicillin resistant pneumococci also raises c oncern about the safety of adjuvant anti-inflammatory therapy with dexameth asone. Although there is a growing evidence suggesting a decrease of neurol ogical complications after administration of adjuvant dexamethasone, this t herapy may lower the already borderline penetration through the blood-brain barrier of the currently used antibiotics. This may result in therapeutic failure. We therefore presently do not advocate the routine use of dexameth asone in the therapy of adult bacterial meningitis.