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Dear Sirs,

I read with great interest the article by Furyk et al. (2011). I congratulate the authors for discussing the prevalence, epidemiology and management of neonatal meningitis from the available literature. But there are a few important points that require commenting on.

The authors state that there is no consensus on the definition of the neonatal or early infant period. Many studies define the neonatal period as up to 30 or 90 days of age, and WHO defines ‘young infant’ as ≤60 days. The authors also state that the onset of early neonatal infection is <7 days and the onset of late neonatal infection >7 days. This is not true. The neonatal period is defined as ≤28 days, with early neonatal sepsis (EOS) onset being within the first 72 h of life, and late neonatal sepsis (LOS) onset being after the first week of life (although LOS occurring in very low-birth-weight neonates in neonatal intensive care units is defined as those occurring at >72 h of life) (Cloherty et al. 2009). Infants with early onset sepsis (EOS) usually present with respiratory symptoms (respiratory distress and pneumonia), meningitis is rare and the source of infection is generally the maternal genital tract. The source of infection in late onset sepsis (LOS) is either hospital acquired or community acquired, and neonates usually present with septicaemia, pneumonia or meningitis (Sankar et al. 2008). LOS in developing countries is mainly community acquired because of the greater number of out of hospital deliveries. Thus, it is important that, the aetiological profile and management of both the EOS and LOS be described separately. But Furyk et al. (2011) have presented combined data and also have included young infants (not neonates), thus precluding any meaningful conclusion to be drawn.

The authors report that the most commonly reported symptoms include fever, irritability, poor feeding and seizures. Neonatal meningitis is not an isolated entity. As described above, it usually presents as a part of the sepsis syndrome of EOS or LOS. So, neonates with sepsis may present with one or more of the following symptoms and signs: hypothermia or fever, lethargy, poor cry, refusal to suck, features of shock (poor perfusion, prolonged capillary refill time, respiratory symptoms (respiratory distress, apnoea) and derangement in blood sugar value (Sankar et al. 2008; Mathur et al. 2010). Hypothermia rather than fever is more common in pre-term or low-birth-weight neonates (common category in developing countries). Hence, the authors’ descriptions of the most common symptoms are common in young infants rather than neonates.

Regarding the diagnosis of neonatal meningitis, the authors propose that a CSF study should be performed on all neonates where sepsis is suspected unless a contraindication exists. This is not totally true, as this holds true only for late onset sepsis. In EOS, lumbar puncture is indicated in the presence of a positive blood culture or if the clinical picture is consistent with septicaemia. CSF study is not indicated if antibiotics have been started solely on the basis of presence of risk factors (Sankar et al. 2008; Cloherty et al. 2009). CSF cell count and glucose level decrease significantly with time. Reliance on WBC counts of delayed samples can result in under diagnosis (Rajesh et al. 2010). Regarding the treatment part, the duration of antibiotic for meningitis (with or without positive blood/CSF culture) should be 21 days (though the authors have not suggested any duration) (Sankar et al. 2008; Cloherty et al. 2009).

References

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  2. References
  • Cloherty JP, Eichenwald EC & Stark AR (2009) . Manual of Neonatal Care, 6th edn. Kluwer, New Delhi, India.
  • Furyk JS, Swann O & Molyneux E (2011) Systematic review: neonatal meningitis in the developing world. Tropical Medicine International Health 16, 672679.
  • Mathur NB, Marmu K & Kumar S (2010) Systemic inflammatory response syndrome in home delivered neonates: a prospective observational study. Indian Journal of Pediatrics 77, 11091113.
  • Rajesh NT, Dutta S, Prasad R & Narang A (2010) Effect of delay in analysis on neonatal cerebrospinal fluid parameters. Archives of Diseases in Childhood Fetal & Neonatal Edition 95, F25F29.
  • Sankar MJ, Agarwal R, Deorari AK & Paul VK (2008) Sepsis in the newborn. Indian Journal of Pediatrics 75, 261266.