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AAP establishes treatment recommendations for invasive pneumococcal infections

American Family Physician, June, 1997

Because resistance of invasive pneumococcal strains to penicillin cefotaxime and ceftriaxone has increased during recent years, the American Academy of Pediatrics (AAP) has revised previous recommendations for the treatment of children with serious infections possibly caused by Streptococcus pneumoniae. The recommendations appear in the February 1997 issue of Pediatrics.

The report discusses the epidemiology and mechanism of antimicrobial resistance. The report also includes information on distinguishing aseptic from bacterial meningitis and the optimal treatment for both meningeal and nonmeningeal infections. Infection control measures are discussed in the report.

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Standard antibiotic therapy is still recommended for immunocompetent patients with possible invasive pneumococcal infections who do not have meningitis and are not critically ill. In patients who are critically ill and in those who are immunocompromised or have an underlying problem, changes in initial standard therapy should be considered. The AAP emphasizes the importance of restricting the use of vancomycin, because it is the only antibiotic effective in all S. pneumoniae infections. Therefore, the AAP States that patients with suspected aseptic meningitis should not initially receive vancomycin therapy.

Sixteen AAP recommendations are divided into the categories of susceptibility testing; management of children with bacterial meningitis possibly caused by S. pneumoniae; management of children with probable aseptic meningitis; management of nonmeningeal invasive pneumococcal infections that require hospitalization of the patient; management of nonmeningeal invasive pneumococcal infections in the immunocompromised host, and the use of vancomycin.

Bacterial Meningitis Possibly

Caused by S. pneumoniae

The following recommendations include those for the treatment of children with bacterial meningitis possibly caused by S. pneumoniae. These recommendations have been excerpted from the AAp statement:

* Vancomycin plus cefotaxime or ceftriaxone should be administered initially to all children over one month of age with definite or probable bacterial meningitis.

In infants Under one month of age, consideration should be given to the addition of vancomycin to the usual antibiotic combination for neonatal sepsis especially if: (1) the cerebrospinal fluid smear shows characteristic gram-positive diplococci or (2) bacterial antigen testing supports a diagnosis of pneumococcal meningitis.

For children with immediate hypersensitivity to the beta-lactam antibiotics, the combination of vancomycin plus rifampin should be considered.

* A lumbar puncture should be considered after 24 to 48 hours to evaluate therapy if (1) the organism is nonsusceptible to penicillin bY quantitative (minimal inhibitory concentration [MIC]) or oxacillin disc testing, the results from cefotaxime and ceftriaxone quantitative susceptibility testing are not yet available, and the child's condition has not improved or has worsened or (2) the child has received dexamethasone which might interfere with the ability to interpret the clinical response.

* Once the results of susceptibility testing are available, modifications of therapy should be made (modifications of therapy are discussed in the AAP report). If the organism is susceptible to penicillin or cefotaxime or ceftriaxone, vancomycin should be discontinued and penicillin or cefotaxime or ceftriaxone should be continued. Vancomycin plus cefotaxime or ceftriaxone should be continued only if the organism is nonsusceptible to penicillin and to cefotaxime or ceftriaxone.

* The addition of rifampin or substitution of rifampin for vancomycin after 24 to 48 hours of therapy could be considered if the organism is susceptible to rifampin and if (1) after 24 to 48 hours, despite therapy with vancomycin plus cefotaxime or ceftriaxone, the clinical condition has worsened; (2) the follow-up Gram-stained smear or culture of cerebrospinal fluid indicates failure to eradicate or to substantially reduce the number of organisms or (3) the organism has an unusually high cefotaxime or ceftriaxone MIC of 4 [Mu]g per mL or greater. Consultation with an infectious disease specialist should be considered.

Use of Vancomycin

* When vancomycin is started, a urinalysis should be performed, and serum creatinine and blood urea nitrogen concentrations should be determined. Renal function should then be followed closely and appropriate dosage modifications made if renal function is compromised.

Physicians should consider determining trough serum concentrations for children who have renal impairment, are critically ill, are receiving concurrent ototoxic or nephrotoxic drugs or are under three months of age. Trough concentrations of vancomycin, which can be obtained before the third dose, should be 10 to 15 [Mu]g per mL or less.

* A peak serum vancomycin concentration can be obtained 30 to 60 minutes after completion of a 30-minute infusion in the patient whose condition does not improve or in the patient with an infection caused by an organism resultant to penicillin, cefotaxime and ceftriaxone. Therapeutic peak serum vancomycin concentrations for meningitis fall within the range of 35 to 40 [Mu]g per mL.

Health Care Industry

AAP establishes treatment recommendations for invasive pneumococcal infections

American Family Physician, June, 1997

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