1. 32 y.o pregnant female presented to the ER complaining of headache, fever and vomiting. LP was done. CSF was cloudy and CSF analysis showed: low glucose, elevated protein, and high WBCs with the presence of neutrophils. Patient was started on Vancomycin, Ceftriaxone, and Acyclovir as empiric therapy. CSF culture showed gram positive diplococcus bacteria so Acyclovir was discontinued. Ceftriaxone and Vancomycin were continued.
· Was anything missing in the empiric therapy?
· What is wrong in the management?
· What is your choice of antibiotics to treat her?
listeria is a specifc pathogen during pregancy, a physiological state of immuunsuppression, so this is a specific issue during pregnancy
may also result in preterm delivery, with neonatal sepsis
meconium stained amniotic fluid in a preterm is quite specifiic for listeria
any data on the foetus ?
although rare, tuberculous meningitis also should be checked, since it can concomittantly occur. More detailed information about her pregnancy status should have been given for such a patient.
in my view i suggest you to discontinue of vancomycine i think in this case doesn't need of this and in its empiric therapy ceftriaxone only or may give with ampicilline, amoxicillin.
Agree with others: Gram positive diplococci in keeping with S. meningitidis. Some are penicillin resistant. If that had not been available, high dose IV amoxicillin should be given for Listerial cover. In the UK, vancomycin is not routinely used - rather we use ceftriaxone as standalone (+/- acyclovir +/- amoxicillin if risk of Listeria). I would also have advised IV dexamethasone: This has been shown to reduce neurological sequelae and reduce S. meningitidis related mortality. Also, this may protect against preterm labour.
http://www.cochrane.org/CD004405/ARI_corticosteroids-bacterial-meningitis
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