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Guidelines for managing acute bacterial meningitis

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7245.1290 (Published 13 May 2000) Cite this as: BMJ 2000;320:1290

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Beta-lactam allergy and bacterial meningitis

Dear editor,

The treatment of bacterial meningitis in a patient with suspected
allergy to penicillin and/or amoxycillin is a difficult issue. After a
discussion about this topic at our hospital the following treatment
guideline seemed reasonable:

When the history of penicillin and/or amoxycillin allergy was without
urticaria, laryngeal edema, hypotension or asthma (suggesting IgE-mediated
allergy) the benefit of giving a third-generation cephalosporin outweighs
the risk of a severe allergic reaction to this agent.

When the history of penicillin and/or amoxycillin allergy suggests a
IgE-mediated allergic reaction, treatment with azthreonam (against H.
influenzae and N. meningitidis) and vancomycin (against Streptococcus
pneumoniae) with or without rifampicin can safely be started.

However, a desensitization procedure with penicillin should be
started as soon as possible. This procedure only takes about 4 hours when
it is not complicated by allergic reactions (1). After this procedure
third-generation cephalosporins can be given safely when there was no
history of cefalosporin allergy.

Carbepenems should probable be avoided in penicillin allergic
patients (2) and the usefulness of the newer fluoroquinolones for
bacterial meningitis needs further clinical confirmation.

Sincerely,

Bart Rijnders

(1) Sanford JP, Gilbert DN, Moellering jr RC, Sande MA. The Sanford
guide to antimicrobial therapy 1997 (Belgian Edition). Vienna, VA., USA:
Antimicrobial Therapy Inc., 1997: 175-6.

(2) Saxon A, Adelman DC, Patel A, Hajdu R, Calandra GB . Imipenem
cross-reactivity with penicillin in humans. J Allergy Clin Immunol 1988
Aug;82(2):213-7

Competing interests: No competing interests

16 May 2000
B J A Rijnders
UZ Leuven
Hospital