Cefotaxime versus penicillin-chloramphenicol in purulent meningitis: a controlled single-blind clinical trial

In a prospective, controlled, randomized single-blind clinical trial, treatment with cefotaxime (CTX) was compared with that with standard therapy (ST), which consisted of a penicillin-chloramphenicol combination with or without sulphadiazine, in 31 patients (excluding neonates) with proven bacterial meningitis. The two groups of patients were comparable in age, sex, clinical presentation and causative pathogens. The case fatality rate was 12.5% for the CTX group and 20% for the ST group, but this difference was not significant. The times taken for the cerebrospinal fluid (CSF) to become sterile and the temperature to normalize, the mean duration of treatment, complications and adverse effects were similar for the two regimens. Neurological or developmental abnormalities on follow-up were not significantly different for the two groups. It is concluded that CTX is a suitable alternative for treatment of bacterial meningitis in infants and children.     

Treatment of purulent meningitis in childhood

Treatment of bacterial meningitis in children requires the choice of the optimal antimicrobial substance: besides the in vitro susceptibility also pharmacokinetic parameters (CSF penetration and elimination) have to be considered. A careful medical history and a few laboratory tests (gram-stain and antigen determination) provide a preliminary bacterial diagnosis within less than one hour. In addition to the identification of the causative organism also the determination of the number of colony forming units per milliliter CSF is of crucial importance. A rapid bacterial cell kill of high numbers of pneumococci, meningococci and streptococci group B overwhelms the CSF with endotoxins with rapidly increasing cerebral edema. Applying a slowly increasing dosage regimen proved effective in preventing this detrimental effects. Supportive therapy e.g. treatment of septic shock, disseminated intravascular coagulation, cerebral edema and anticonvulsive therapy is of paramount importance. Inadequate ADH secretion in the majority of patients requires a restricted fluid and electrolyte supplementation. By this combined therapeutic approach a remarkable low lethality rate and a low number of patients with late sequelae was seen.     

Cefotaxime monotherapy in bacterial meningitis in childhood

Bacterial meningitis in 20 children was treated with cefotaxime. 17 children received this antibiotic throughout the disease as monotherapy, three were changed to Penicillin G (2) or ampicillin (1), after sensitivity of the pathogen was known, although cefotaxime had been effective. All bacterial isolates were highly susceptible to cefotaxime. All CSF cultures were sterile at second tap, performed 24 to 48 hrs after therapy was started. Cefotaxime and desacetyl-cefotaxime concentrations in CSF, measured by HPLC in 9 patients were in the range of 4 to 34 (average 17.6) mg/l and 2.1 to 82 (average: 15.1) mg/l, representing a CSF-serum ratio of 8 to 74% (average 45.6%) for cefotaxime and 25 to 151% (average: 73.7%) for desacetyl-cefotaxime. Clinical outcome was favourable in 17 patients. There were one death and late neurological deficits in three. Cefotaxime monotherapy is recommended instead of standard therapy with chloramphenicol and/or ampicillin because of superior antibacterial activity, lower toxicity and lesser side-effects for primary meningitis in children caused by N. meningitides, S. pneumoniae, or H. influenzae type b.     

Serous phase of purulent meningitis simulating tuberculous meningitis

Summary and Conclusions A paucity of references in the literature and in the standard text-books on paediatrics to the relation of organisms causing purulent meningitis to production of a C.S.F. picture of “serous” meningitis resembling tuberculous meningitis is pointed out; its diagnostic significance as well as the problem of management arising therefrom is discussed. Most cases of purulent meningitis under active treatment on their way to recovery pass through a phase during which the C.S.F. presents a picture of “serous” meningitis indistinguishable from that of tuberculous meningitis, except in respect of the presence of tubercle bacilli in the C.S.F. in the latter. A similar picture is produced when cases of purulent meningitis are treated haphazardly with antibacterial agents. In cases of meningitis presenting a C.S.F. picture suggestive of tuberculous meningitis, when seen for the first time, a careful history of previous treatment with antibacterial drugs should be elicited. In doubtful cases, especially if no other evidence of tuberculosis is present or if the Mantoux test is negative, a diagnosis of tuberculous meningitis must be deferred until tubercle bacilli are recovered from the C.S.F. In such instances of “serous” meningitis a blunderbuss treatment is justified until a definite diagnosis is arrived at. From the Dept. of Pediatrics, M.G.M. Medical College, Indore, M.B. Paper read at the Eighth All-India Pediatric Conference, Vellore, on December 21, 1956.     

Gyriform calcifications following purulent meningitis

The case is presented of an 8-month-old boy who develped gyriform calcifications in the parieto-occipital region 5 months after purulentE. coli meningitis. Subcortical calcifications were also evident, and the entire region was contracted. It is apparent that severely damaged parenchyma due to purulent meningitis can produce cortical/subcortical calcifications.