Patient Encounter 2 Part 1

BB is a 4-month-old infant who is brought to the ED with a 3-day history of excessive crying, irritability, and poor eating. His parents report a tympanic temperature of 38.2°C (100.8°F) measured at home. Vital signs and laboratory values include a rectal temperature of 39°C (102.2°F), respirations 44 per minute, and peripheral WBC of 13.8 x 103/mm3 (13.8 x 109/L), with 65% PMNs. Physical examination reveals only that BB is more irritable while being held than when allowed to lie still. The child has not initiated routine vaccine schedule since receiving HBV initial dose at birth.

What signs and symptoms consistent with meningitis are present in BB?

What clues to causative pathogen are present in BB?

What empiric antimicrobial regimen should be started?

High-dose penicillin G traditionally has been the drug of choice for the treatment of pneumococcal meningitis. However, due to increases in pneumococcal resistance, the preferred empirical treatment now includes a third-generation cephalosporin in

combination with vancomycin. All CSF isolates should be tested for penicillin and cephalosporin resistance by methods endorsed by the CLSI. Once in vitro sensitivity results are known, therapy may be tailored (Table 70-3). Patients with a history of type I penicillin allergy or cephalosporin allergy may be treated with vancomycin. Treatment should be continued for 10 to 14 days, after which no further maintenance therapy is required. Antimicrobial prophylaxis is not indicated for close contacts.

Administration of vaccines to high-risk individuals is a key strategy to reduce the risk of invasive pneumococcal disease. The 23-valent pneumococcal vaccine targets sero-types that account for over 90% of invasive disease in high-risk patients. However, the 23-valent vaccine does not produce a reliable immunologic response in children younger than 2 years of age, nor does it reduce pneumococcal carriage. The 7-valent pneumococcal protein-polysaccharide conjugate vaccine introduced in 2,000 targets the seven most common serotypes in children and provides protection (94%

reduction) against invasive pneumococcal disease (such as sepsis and meningitis) in

children younger than 5 years of age. Widespread administration of the 7-valent conjugate vaccine to children has also contributed to a 28% reduction in invasive pneumococcal disease in adults. Unlike the 23-valent vaccine, the 7-valent vaccine reduces carriage and transmission. S. pneumoniae remains the most common cause of bacterial meningitis in children, with nearly 50% of strains due to nonvaccine serotypes.8

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