Literature needs to be evaluated as a whole. No one should be ready to "drop anything in the trash" because of one article. It is just as absurd to demote our clinical skills because someone believes that "the sensitivity and specificity is low." Nothing replaces a good H&P, quality experience, and strong clinical judgement. Not one lab, radiographic study or article.
On a side note, Gent is an excellent drug for synergy to kill gram + organisms such as GBS. In addition, there is less inducible resistance to aminoglycosides than to cephalosporins. As stated, monitoring levels are a real pain in the butt, though! SB
Scott A. Barron, MD, FAAP
Children's Emergency Center
Mercy Medical Center
Des Moines, IA 50314
> Date: Sat, 8 Aug 2009 21:51:26 -0500
> From: [log in to unmask]
> Subject: Re: question
> To: [log in to unmask]
> Thanks for reminding us of the study from Baylor. I do not agree with some
> of your comments:
> 1. You said...." RBCs should be considered part of a traumatic tap and
> their presence/absence should not be allowed to mislead decision making.
> Just one more thing you were taught in residency that has proven to be
> erroneous. Drop it in the trash heap." I am not ready to "drop it" based on
> 3 (Yes, three!) cases of CNS herpes out of a total cohort of 499 viral
> pathogens from one center. Recall that this teaching is based on the fact
> that some viruses can cause a hemorrhagic meningoencephalitis and HSV is one
> of the treatable causes of meningoencephalitis in the neonatal age group. It
> is not isolated RBCs' that we are referring to, but RBC's in conjunction
> with CSF pleiocytosis.
> 2. You said."The risk of acyclovir increases further if your PCR isn't
> back from the lab in 48 hrs. Ampicillin is very effective against Listeria.
> Acyclovir's benefit to the patient (not the malpractice lawyer) is more
> marginal. " I am not sure what you are suggesting here. The patient that
> Todd described had meningitis. Early CNS-herpes infection has to be in the
> differential diagnosis of this febrile neonate. We know that early treatment
> with Acyclovir makes all the difference in a disease with devastating
> neurologic sequelae. I would initiate & continue anti-viral therapy until
> HSV culture or PCR is available, and the neonate remains "well." I don't
> care how long the PCR takes because the risk benefit ratio would
> overwhelmingly favor overtreatment for bacterial and HSV meningitis in this
> age group.
> 3. You said." There is literature to support almost all neonatal HSV
> occurring before 3 weeks of age." While mostly true for disseminated & SEM
> disease, CNS herpes can occur from 4-55 days. I had the privilege of
> training with one of the foremost authorities on herpes infections, Dr. Rich
> Whitley @ UAB, and I would urge you to read his chapter on HSV infection in
> the neonatal period in Nelson's Textbook. You are hastily embracing &
> referencing a commentary by one so called "expert." I would urge caution
> here before discarding the possibility of HSV meningitis in this patient.
> 4. "For Group B strep, a more likely pathogen at 5 weeks of age, amp and
> gent remains the best combination." Yes, late onset GBS is the likely
> bacterial etiology for meningitis @ 5 wks. However, if this is proven GBS,
> gentamycin is not necessary. Ampicillin should suffice. The gent. is for
> coverage of enteric gram negatives/coliforms. Although, I do not believe
> that this is the best combination for expectant antimicrobial coverage. At
> our center, we prefer cefotaxime because it does not require monitoring of
> drug levels and is not associated with nephro- or oto-toxicity.
> Jay Pershad
> Le Bonheur
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