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Clinicians vary widely in meningitis testing, prescription practices
Many clinicians do not test for susceptibility to penicillin, and therapeutic practices diverge often between adult and pediatric infectious disease physicians, according to CDC study results published online.
Andrew Terranella, MD, MPH, and other CDC researchers looked at responses from an online survey of pediatric and adult clinicians about meningococcal disease management. Of the 650 respondents, there was wide variability about a definitive therapy for meningococcal disease; with pediatric infectious disease clinicians more likely to use this medication over clinicians who primarily treat adult patients.
The researchers said more than two-thirds of clinicians reported routinely performing susceptibility testing for Neisseria meningitidis, and there were differences in chemoprophylaxis practices.
The researchers also said because N. meningitidis remains a “serious cause of bacterial meningitis and sepsis in children and young adults, with a case fatality rate of 10%,” it is important to consider uniform methods of diagnosis and treatment, both of which remain in debate.
“Consideration of these practice differences will be important when revising and communicating management guidelines,” Terranella and colleagues concluded. “Efforts to harmonize pediatric and adult practice guidelines should consider these practice differences.”
Disclosure: Dr. Terranella reports no relevant financial disclosures.
Perspective
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This is a study of how ID specialists practice. It is not a guide as to what is correct practice, and it may not even be a guide as to what ID physicians believe is correct. The authors point out that for some issues there is legitimate uncertainty, such as the best policy for screening for complement deficiency in patients with meningococcal disease. It is possible that there is some “defensive” practice going on. That is, physicians may believe that there is lack of evidence for clinical resistance to penicillin treatment for patients with meningococcal disease, or that narrow-spectrum antibiotics are better than broad-spectrum antibiotics for treating meningococcal disease, but they continue treating with third-generation cephalosporins anyway. Personally, I have followed the AAP Red Book recommendations and narrowed treatment to penicillin when the lab identifies the isolate as Neisseria meningitidis.
There are some real surprises in their findings. I was surprised that more than one-third of responding ID specialists report that antibiotic susceptibility of N. meningitidis is unavailable to them. I was even more surprised that 15% of adult ID specialists would give chemoprophylaxis to contacts of asymptomatic pharyngeal carriers of N. meningitidis. The authors favor developing a set of harmonized guidelines for adult and pediatric ID specialists. Perhaps this is a good idea, but these data point out areas where intensive review of the literature or more definitive studies should be encouraged.
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