Volume 87 Number 5
Letters to the Editor
interested and competent family pediatrician should not maintain his interest and participation during the acute phase o f the illness and assume control when the acute phase is over? Though I should like to avoid the necessity o f commenting on Dr. Preston's last statement concerning enlistment of an available neonatologist's services on an elective rather than a required basis, I cannot. But I would refer him to the third paragraph o f his letter. He provides the answer: " .. but what i f for pride, embarrassment, jealousy, or honest ignorance he fails to seek expert help when he is woefully stretched beyond his capabilities?" My guess is that Dr. Preston would be among the first to enlist whatever help is available that he deems pertinent to any o f his sick patients, be they neonates or adolescents. When an infant intensive care unit is available, patients in it should be the primary responsibility o f the neonatologist in charge. Realistically, such an arrangement requires 24-hour coverage by a neonatologist. But there are more implications in Dr. Preston's letter than the specific issue he raises in respect to neonatal medical care. The questions he poses lead directly to the overall failures in the provision or delivery of health care within a given community. True regional planning is long overdue? A n d where is the fault? With all, to be sure-laymen, politicians, but basically can we deny that it is principally within the medical profession itself'?. The solution might be simple if those of us in medicine were to operate on the stated basis of the great merchant, John Wanamaker: The customer must be served. W.E.N. REFERENCE
1. Nelson, WE: Planning for pediatric care, J PEDIATR. 82:180, 1973.
Treatment of tuberculous meningitis To the Editor: I greatly appreciated the excellent review of antimicrobial therapy by McCracken and Eichenwald,' 2 but I would like to express my disagreement that streptomycin is a drug o f choice in Mycobacterium tuberculosis meningitis. In vivo streptomycin suppresses but does not eradicate the tubercle bacillus, :~probably because it penetrates poorly into macrophages~; the effective concentration on intracellular bacilli is ten times greater than that on extracellular ones. ~Therefore, if in 1975 its exact place among antituberculous drugs is difficult to assign but can be estimated by Canetti's work,:' I wonder if it is a drug of choice, since the authors omitted listing it for treatment of pulmonary tuberculosis in their Table I.' Furthermore, streptomycin does not penetrate normal meninges ~ ' nor severely inflamed ones, ~, 7 and does not always attain therapeutic cerebrospinal fluid (CSF) levels2 So, if streptomycin is prescribed, it should be only at the initial phase of treatment, and perhaps it is better to associate it with pyrazinamide. 7
837
I think that ethionamide must be preferred to streptomycin for its activity is nearly double in vitro and in experimental infection ~ and produces significant concentrations in CSF o f individuals whos e meninges are normal or inflamed? Its use is hampered by frequent gastrointestinal side effects, especially with high doses, ~ which would be less frequent, at least in males, if prothionamide is used? I believe that the two drugs of choice are isoniazide and ethionamide. In the initial phase I agree with the authors' recommendation of ethambutol, which penetrates only inflamed meninges, reaching therapeutic levels, ~'but for no longer than the fifth month of treatment since one patient of Place and associates 6 tested in the sixth month had no ethambutol in CSF. ~ Rifampicin could also be used in the initial phase, because it attains bactericidal concentrations in CSF only in the first two months of treatment ~ but with great variations among individuaIs or at different times in the same patient? Finally, as the authors point out, clindamycin colitis is not as unusual as stated~; in a prospective study Tedesco identified proctoscopically pseudomembranous colitis in 10% of 200 patients given clindamycin parenterally or orally. TM Serge Kernbaum, M.D. Service du Professeur Bastin Universite Paris VII Hospital Claude Bernard 10, Avenue de la Porte d'Aubervilliers 75019 Paris, France REFERENCES
1. McCracken G, and Eichenwald H: Antimicrobial therapy: therapeutic recommendations and a review of newer drugs, Part I: Therapy of infectious conditions, J PEmATR 85:297, 1974. 2. McCracken G, and Eichenwald H: Antimicrobial therapy: Therapeutic recommendations and a review o f newer drugs, Part II: The clinical pharmacology of the newer antimicrobial drugs, J PEDIATR 85:451, 1974. 3. Weinstein L: Antibiotics in Goodman L and Gilman L, editors: The pharmacological basis of therapeutics, ed 4, New York, 1970, The McMillan Company. 4. Garrod L, Lambert H, and O'Grady F: Antibiotic and chemotherapy, ed 4, Ed~nbourgh, 1973, ChurchiI1 Livingstone. 5. Canetti G, Kaczmierzak A, and Lelirzin M: U n classement des drogues antituberculeuses selon les taux sanguins chez l'homme, Rev Tuberculose Pneumol 35:5, 1971. 6. Place V, Pyle M, and de la Huerga U: Ethambutol in tuberculous meningitis, Am. Rev. Respir. Dis. 99-783, 1969. 7. Forgan-Smith R, Ellard G, Newton D, and Mitchinson D: Pyrazinamide and other drugs in tuberculous meningitis, Lancet 2:374, 1973. 8. Woehle R, Viallier J, Guerin tiC, and Bertoye A: Passage de la Rifampicine dans le liquide c6phalo-rachidien au cours des m6ningites tuberculeuses, Lyon Med 227:837, 1972. ,9. D'Oliveira G: Cerebrospinal concentrations of Rifampin in meningeal tuberculosis , Am Rev Respir Dis 106:432, 1972. 10. Editorial: Lincomycin and clindamycin colitis, Br Med J 4:65, 1974.
Letters to the Editor
interested and competent family pediatrician should not maintain his interest and participation during the acute phase o f the illness and assume control when the acute phase is over? Though I should like to avoid the necessity o f commenting on Dr. Preston's last statement concerning enlistment of an available neonatologist's services on an elective rather than a required basis, I cannot. But I would refer him to the third paragraph o f his letter. He provides the answer: " .. but what i f for pride, embarrassment, jealousy, or honest ignorance he fails to seek expert help when he is woefully stretched beyond his capabilities?" My guess is that Dr. Preston would be among the first to enlist whatever help is available that he deems pertinent to any o f his sick patients, be they neonates or adolescents. When an infant intensive care unit is available, patients in it should be the primary responsibility o f the neonatologist in charge. Realistically, such an arrangement requires 24-hour coverage by a neonatologist. But there are more implications in Dr. Preston's letter than the specific issue he raises in respect to neonatal medical care. The questions he poses lead directly to the overall failures in the provision or delivery of health care within a given community. True regional planning is long overdue? A n d where is the fault? With all, to be sure-laymen, politicians, but basically can we deny that it is principally within the medical profession itself'?. The solution might be simple if those of us in medicine were to operate on the stated basis of the great merchant, John Wanamaker: The customer must be served. W.E.N. REFERENCE
1. Nelson, WE: Planning for pediatric care, J PEDIATR. 82:180, 1973.
Treatment of tuberculous meningitis To the Editor: I greatly appreciated the excellent review of antimicrobial therapy by McCracken and Eichenwald,' 2 but I would like to express my disagreement that streptomycin is a drug o f choice in Mycobacterium tuberculosis meningitis. In vivo streptomycin suppresses but does not eradicate the tubercle bacillus, :~probably because it penetrates poorly into macrophages~; the effective concentration on intracellular bacilli is ten times greater than that on extracellular ones. ~Therefore, if in 1975 its exact place among antituberculous drugs is difficult to assign but can be estimated by Canetti's work,:' I wonder if it is a drug of choice, since the authors omitted listing it for treatment of pulmonary tuberculosis in their Table I.' Furthermore, streptomycin does not penetrate normal meninges ~ ' nor severely inflamed ones, ~, 7 and does not always attain therapeutic cerebrospinal fluid (CSF) levels2 So, if streptomycin is prescribed, it should be only at the initial phase of treatment, and perhaps it is better to associate it with pyrazinamide. 7
837
I think that ethionamide must be preferred to streptomycin for its activity is nearly double in vitro and in experimental infection ~ and produces significant concentrations in CSF o f individuals whos e meninges are normal or inflamed? Its use is hampered by frequent gastrointestinal side effects, especially with high doses, ~ which would be less frequent, at least in males, if prothionamide is used? I believe that the two drugs of choice are isoniazide and ethionamide. In the initial phase I agree with the authors' recommendation of ethambutol, which penetrates only inflamed meninges, reaching therapeutic levels, ~'but for no longer than the fifth month of treatment since one patient of Place and associates 6 tested in the sixth month had no ethambutol in CSF. ~ Rifampicin could also be used in the initial phase, because it attains bactericidal concentrations in CSF only in the first two months of treatment ~ but with great variations among individuaIs or at different times in the same patient? Finally, as the authors point out, clindamycin colitis is not as unusual as stated~; in a prospective study Tedesco identified proctoscopically pseudomembranous colitis in 10% of 200 patients given clindamycin parenterally or orally. TM Serge Kernbaum, M.D. Service du Professeur Bastin Universite Paris VII Hospital Claude Bernard 10, Avenue de la Porte d'Aubervilliers 75019 Paris, France REFERENCES
1. McCracken G, and Eichenwald H: Antimicrobial therapy: therapeutic recommendations and a review of newer drugs, Part I: Therapy of infectious conditions, J PEmATR 85:297, 1974. 2. McCracken G, and Eichenwald H: Antimicrobial therapy: Therapeutic recommendations and a review o f newer drugs, Part II: The clinical pharmacology of the newer antimicrobial drugs, J PEDIATR 85:451, 1974. 3. Weinstein L: Antibiotics in Goodman L and Gilman L, editors: The pharmacological basis of therapeutics, ed 4, New York, 1970, The McMillan Company. 4. Garrod L, Lambert H, and O'Grady F: Antibiotic and chemotherapy, ed 4, Ed~nbourgh, 1973, ChurchiI1 Livingstone. 5. Canetti G, Kaczmierzak A, and Lelirzin M: U n classement des drogues antituberculeuses selon les taux sanguins chez l'homme, Rev Tuberculose Pneumol 35:5, 1971. 6. Place V, Pyle M, and de la Huerga U: Ethambutol in tuberculous meningitis, Am. Rev. Respir. Dis. 99-783, 1969. 7. Forgan-Smith R, Ellard G, Newton D, and Mitchinson D: Pyrazinamide and other drugs in tuberculous meningitis, Lancet 2:374, 1973. 8. Woehle R, Viallier J, Guerin tiC, and Bertoye A: Passage de la Rifampicine dans le liquide c6phalo-rachidien au cours des m6ningites tuberculeuses, Lyon Med 227:837, 1972. ,9. D'Oliveira G: Cerebrospinal concentrations of Rifampin in meningeal tuberculosis , Am Rev Respir Dis 106:432, 1972. 10. Editorial: Lincomycin and clindamycin colitis, Br Med J 4:65, 1974.
