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Previous Volume 345:1644-1645 November 29, 2001 Number 22 Next

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To the Editor: Vochem et al. (Aug. 2 issue)¹ describe a neonate with disseminated Pseudomonas aeruginosa infection that was associated with a contaminated tub bath. Of concern is the description of ampicillin, cefotaxime, and gentamicin as "antipseudomonal chemotherapy" and their use after the isolation of P. aeruginosa from the patient's blood and cerebrospinal fluid.

Although this regimen may not have influenced the outcome in this case, neither ampicillin nor cefotaxime has substantial activity against P. aeruginosa. Gentamicin is characterized by enhanced penetration across the blood–brain barrier in neonates, but it also may not reach bactericidal levels in the cerebrospinal fluid. Effective treatment of P. aeruginosa meningitis requires high doses of a third-generation cephalosporin with adequate penetration of the cerebrospinal fluid, such as ceftazidime.² Aminoglycosides may be used as adjunctive treatment in severe cases or if the initial therapy fails or there is a relapse. Other agents that have good in vitro activity and adequate penetration and for which there are reports of clinical success include meropenem,³ ciprofloxacin,⁴ and aztreonam.⁵

David W. Wareham, M.B., B.S.
Barts and the London National Health Service Trust
London E1 1BB, United Kingdom
dwareham{at}msn.com

References

1. Vochem M, Vogt M, Döring G. Sepsis in a newborn due to Pseudomonas aeruginosa from a contaminated tub bath. N Engl J Med 2001;345:378-379. [Free Full Text]
2. Norrby SR. Role of cephalosporins in the treatment of bacterial meningitis in adults: overview with special emphasis on ceftazidime. Am J Med 1985;79:56-61.
3. Klugman KP, Dagan R. Carbapenem treatment of meningitis. Scand J Infect Dis Suppl 1995;96:45-48. [Medline]
4. Lipman J, Allworth A, Wallis SC. Cerebrospinal fluid penetration of high doses of intravenous ciprofloxacin in meningitis. Clin Infect Dis 2000;31:1131-1133. [Medline]
5. Kilpatrick M, Girgis N, Farid Z, Bishay E. Aztreonam for treating meningitis caused by gram-negative rods. Scand J Infect Dis 1991;23:125-126. [Medline]

To the Editor: We agree that the combination of ampicillin, gentamicin, and cefotaxime should not be promoted as therapy for established P. aeruginosa meningitis. Indeed, we used this combination of antibiotics in our patient only when meningitis was clinically evident, there were findings suggestive of sepsis, and the causative organism had not yet been identified. Our treatment is in complete accordance with general recommendations for the antibiotic treatment of neonates at risk for sepsis.¹

Immediately after the identification of P. aeruginosa in the specimens, the antibiotic regimen was altered, and ampicillin was replaced by piperacillin. A further change was initiated when information on the pattern of antibiotic sensitivity was available; treatment was continued with the use of ceftazidime and piperacillin; cefotaxime and gentamicin were withdrawn. Nevertheless, the infecting P. aeruginosa strain was still sensitive to cefotaxime and gentamicin, though we agree that the two drugs may not have substantial activity against P. aeruginosa in the cerebrospinal fluid. Two days after the initiation of the empirical antimicrobial treatment, a cerebrospinal fluid specimen was sterile.

Gerd Döring, Ph.D.
University of Tübingen
D-72074 Tübingen, Germany
gerd.doering{at}uni-tuebingen.de

Matthias Vochem, M.D.
Olgaspital
70176 Stuttgart, Germany

References

1. Klaus MH, Fanaroff AA, eds. Care of the high-risk neonate. 5th ed. Philadelphia: W.B. Saunders, 2001.

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