Management of bacterial meningitis i current status and future prospects

Outcome from bacterial meningitis in infants and children has not appreciably changed in a 14-year period from 1969 to 1982 at Children's Medical Center and Parkland Memorial Hospital, Dallas, Texas. Overall, the case-fatality rate was 6.4 percent; it was 4.6 percent for 414 patients managed in 1969 to 1972 and 3.9% for 376 patients in 1981 and 1982. In neonatal meningitis due to group B streptococci or coliform bacilli, the fatality rates were comparable in 1969 to 1972 and 1981 and 1982; ampicillin and an aminoglycoside were the mainstays of therapy during these periods. Because of changing susceptibilities of gram-negative enteric bacilli to the aminoglycosidic agents, Haemophilus influenzae to ampicillin and possibly chloramphenicol and of Streptococcus pneumoniae to penicillin, alternatives to conventional therapy must be developed and thoroughly tested. Assessment of new antimicrobial agents in the rabbit model of experimental meningitis provides valuable information on penetration of drug into cerebrospinal fluid, on achievable bactericidal activity in spinal fluid and on the bacteriologic effect of single dose or nine hour infusion therapy. These data are directly applicable to therapy in infants and children with meningitis. Although newer antimicrobial agents such as moxalactam, cefotaxime, or ceftriaxone have greatly enhanced bactericidal activity against the commonly encountered pathogens, outcome from meningitis will not be substantially improved with therapy using these agents. Improved outcome will more likely occur with the advent of therapeutic modalities that prevent or rapidly decrease cerebral edema and cerebritis, thereby preserving cerebral perfusion pressure and cellular integrity.