Chapter 25. Central Nervous System Infections
The emergency physician is unable to obtain CSF after multiple attempts. Based on clinical findings, the team believes that the 13-day-old former 35-week gestational age baby may have meningitis. What is the best empiric therapy to begin in this baby before sending her to a pediatric hospital?
a. Ampicillin and gentamicin
b. Ceftriaxone and gentamicin
c. Vancomycin and cefotaxime
d. Ampicillin and ceftriaxone
Answer a is correct. Ampicillin provides appropriate empiric coverage for L. monocytogenes and S. agalactiae (may cover some aerobic Gram-negative bacilli as well). Gentamicin provides appropriate empiric coverage against aerobic Gram-negative bacilli (and some synergy with ampicillin against Gram-positives, like L. monocytogenes). Ampicillin and cefotaxime would also be an appropriate regimen.
Answer b is incorrect. While gentamicin is appropriate, this regimen is missing first-line empiric coverage for L. monocytogenes (ie, ampicillin). Also, ceftriaxone is not a first-line agent for bacterial meningitis in neonates (≤28 days) due to risk of adverse events, for example, biliary sludging, kernicterus, and potentially life-threatening precipitation with calcium-containing products.
Answer c is incorrect. While cefotaxime is appropriate, this regimen is missing empiric coverage for L. monocytogenes (ie, ampicillin). Also, vancomycin is broader empiric Gram-positive coverage than is generally needed for neonates.
Answer d is incorrect. While ampicillin is appropriate, cefotaxime is the preferred third-generation cephalosporin in neonates. Ceftriaxone is not a first-line agent for bacterial meningitis in neonates (≤28 days) due to risk of adverse events, for example, biliary sludging, kernicterus, and precipitation potentially life-threatening with calcium-containing products.
When the 13-day-old former 35-week gestational age baby is examined at the pediatric hospital, she is also noted to have some lesions. The team has just sent cultures of the lesions as well as HSV PCR of the CSF. Which of the following is an appropriate pharmacologic approach in this patient?
a. Wait for the cultures and PCR results to come back, then modify therapy if needed.
b. Change antibiotic therapy to ceftriaxone and vancomycin.
c. Add IV acyclovir to the current antibiotic regimen.
d. Add oral voriconazole therapy to the current antibiotic regimen.
Answer c is correct. IV acyclovir should be added as soon as possible as empiric therapy for HSV encephalitis while awaiting the results of diagnostic studies. The earlier the treatment is started, the lower the risk of death or serious sequelae.
Answer a is incorrect. Culture and PCR results may take hours to days to return. ...