patient basis is definitely inappropriate. Dr. Reddy and his group should be commended for promptly initiating treatment in this...'I devastating illness. tD ..~~~~~~~~~~~~~~~~~. Second, the patient was treated with gentamicin at 7 mg/kg/day, which is less than the recommended dose for a 15-day-old infant. The serumconcentration time curves of gentamicin after 2.5 mg/kg in infants one to four weeks of age demonstrate peak serum values of 2.7 to 6.4 ,ig/ml (mean 4.1 ,ug/ml), and eight-hour levels of 0.7 to Neonatal Meningitis and Ven1.4 ,ug/ml.3 It is because of this phartriculitis macokinetic property of the drug in inTo the Editor: fants over one week of age that the recDr. Reddy's article (J Natl Med ommended dose for gentamicin is 7.5 Assoc 70:347-348) reaffirms the unmg/kg/day for neonates more than satisfactory treatment of gram-negative seven days of age (2.5 mg/kg/dose, bacterial meningitis in the neonate (in every 8 hours).4 their case due to Enterobacter cloacae) Third, there was no mention of a reeven in modem times."2 Several aspeat lumbar puncture, 24 hours after pects about their case, however, detreatment was started, to assess the efserve comment. ficacy of the initial treatment; hence First, the patient probably already one can only conclude that it was not had meningitis when she was first seen done until much later. One wonders by her physician. A history of lethargy, whether the child already had venirritability, hypothermia, and anorexia triculitis, which could explain her subin a neonate is diagnostic of sepsis sequent course. and/or meningitis until proven otherVentriculitis is a frequent complicawise; a trial of oral antibiotic on an outtion of neonatal meningitis,5'6 particu__...

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larly that caused by gram-negative bacilli. Recent data indicate that ventriculitis almost invariably complicates the course of the disease even in the early stages.7 Systemic antibiotics, in the proper dose, usually are not associated with adequate levels of these antibiotics in the ventricles.8 The current recommendation9 is to have a ventricular tap performed by a neurosurgeon, if the second lumbar CSF (24 hours after initiating treatment) reveals microorganisms and if ventriculitis is present (50 WBC/mm3 or more, and positive smear and/or culture), gentamicin (or another aminoglycoside effective against the bacteria) is instilled in a total dose of 2-2.5 mg daily. Therapy is continued until cultures are negative. Preliminary data from authoritative sources from this country as well as abroad using direct intraventricular instillation of gentamicin show encouraging results.7'9 The last item concerns the diagnosis of hydrocephalus. If our aim were to prevent further destruction of neurons by progressive increases in intracranial Continued on next page

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Riboflavin (Vitamin B2) ..... Pyridoxine HCI (Vitamin B) . Niacinamide .............. Calcium pantothenate...... Cyanocobalamin (Vitamin B12)......

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pressure due to hydrocephalus, then we should attempt to diagnose the process as early as possible, even before the head starts to grow excessively. Postponement of diagnostic studies in the case presented because of diarrhea (no mention of hydration status) is inappropriate. Volpe and coworkers10 have shown the occurrence of ventricular dilatation after neonatal intrcranial hemorrhage before the occurrence of rapid head growth. Similar pathophysiologic events possibly occur in inflammation of the ventricles due to bacterial infection. Noninvasive diagnostic procedures'l-13 are available for documenting dilatation of the ventricles and raised intracranial pressures. Early changes can be detected by serial examinations, if the initial ones are

equivocal. In an infant with meningitis due to gram-negative bacilli, nothing short of an aggressive attitude and approach is warranted. Carlos Chua, MD Fellow, Neonatology Department of Pediatrics

Southern Illinois University School of Medicine Springfield, Illinois

Literature Cited 1. Overall JC: Neonatal bacterial meningitis. J Pediatr 76:499-511, 1970 2. Heckmatt JZ: Coliform meningitis in the newborn. Arch Dis Child 51:569-575, 1976 3. McCracken GH, Chrane DF, Thomas ML: Pharmacologic evaluation of gentamicin in newborn infants. J lnf Dis 124(suppl):214, 1971 4. Report of the Committee on Infectious Disease. American Academy of Pediatrics. Evanston, III, 1977, p 314 5. Berman PH, Banker BQ: Neonatal meningitis: A clinical and pathological study of 29 cases. Pediatrics 38:6-24, 1966 6. Salmon JH: Ventriculitis complicating meningitis. Am J Dis Child 124:3540, 1972 7. Lee EL, Robinson MJ, Thong ML, et al: Intraventricular chemotherapy in neonatal meningitis. J Pediatr 91:991-995, 1977 8. McCracken GH, Jones LG: Gentamicin in the neonatal period. Am J Dis Child 120:524-533, 1970 9. McCracken GH: Intraventricular treatment of neonatal meningitis due to gramnegative bacilli. J Pediatr 91:1037-1038, 1977 10. Volpe JJ, Pasternak JF, Allan WC: Ventricular dilation preceding rapid head growth following neonatal intraventricular hemorrhage. Am J Dis Child 131:1212-1215, 1977 11. McCullough DC, Kufta C, Axelbaum SP, et al: Computerized axial tomography in clinical pediatrics. Pediatrics 59:173-181, 1977 12. Naidich TP, Epstein F, Lin JP, et al: Evaluation of pediatric hydrocephalus by computed tomography. Radiology 119:337-345, 1976 13. Salmon JH, Hajjar W, Bada H: The fontogram: A non-invasive intracranial pressure monitor. Pediatrics 60:721-725, 1977

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