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Kevin,

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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