Cohen R, de La Rocque F, Varon E, Geslin P
Service de microbiologie, CHI Créteil, France.
Pediatrie. 1993;48(1):37-49.
The choice of antibiotics in bacterial meningitis must integrate several parameters. i) The bacterial epidemiology of community acquired meningitis: Haemophilus influenzae (Hi) Neisseria meningitidis (Nm), Streptococcus pneumoniae (Sp) represents more than 95% of cases; ii) The increase of antibiotic bacterial resistance, particularly preoccupying for Sp; iii) The microbiological properties and pharmacokinetics of antibiotics, especially their penetration in CSF: the concentrations achieved must be several times higher than the MBC. In fact, CSF is not favourable to the antibiotic activity; iv) The results of clinical comparative trials; v) The contribution of animal models to the knowledge of meningitis physiopathology. Third generation cephalosporins (cefotaxime, ceftriaxone) satisfy this objective for Hi, Nm, and penicillin sensitive strains of Sp. For penicillin resistant Sp, no treatment can achieve antibiotic CSF concentrations higher than ten times the MBC. An increase in dosage of cephalosporins, the use of an other regimen (Vancomycin or imipenem) and antibiotic association (rifamycin, fosfomycin) are needed.
细菌性脑膜炎抗生素的选择必须综合考虑几个参数。i）社区获得性脑膜炎的细菌流行病学：流感嗜血杆菌（Hi）、脑膜炎奈瑟菌（Nm）、肺炎链球菌（Sp）占病例的95%以上；ii）抗生素细菌耐药性的增加，尤其是肺炎链球菌令人担忧；iii）抗生素的微生物学特性和药代动力学，特别是它们在脑脊液中的渗透：达到的浓度必须比最低杀菌浓度（MBC）高几倍。事实上，脑脊液不利于抗生素发挥活性；iv）临床对比试验的结果；v）动物模型对脑膜炎病理生理学知识的贡献。第三代头孢菌素（头孢噻肟、头孢曲松）对流感嗜血杆菌、脑膜炎奈瑟菌和青霉素敏感的肺炎链球菌菌株符合这一目标。对于耐青霉素的肺炎链球菌，没有哪种治疗方法能使脑脊液中的抗生素浓度高于最低杀菌浓度的十倍。需要增加头孢菌素的剂量、使用其他方案（万古霉素或亚胺培南）以及联合使用抗生素（利福霉素、磷霉素）。
