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The patient's immunizations were up to date, including the pneumococcal conjugate vaccine (PCV7), which virtually all kids get, and pneumococcal polysaccharide vaccine (PPV23), which should be given to all patients post-splenectomy (also patients with renal or hepatic disease, other immunocompromise, or over the age of 50). The latter provides some protection from the 23 most common strains of strep pneumo, but not all strains.

Steroids have been shown to be of clear benefit in bacterial meningitis from s. pneumo, H. influenza (not so common anymore in the US since the HIB vaccine), and inconclusive in neisseria. They reduce morbidity and mortality in the first 2, so they are virtually standard therapy. (strep pneumo is now the most common cause of meningitis overall). The inflammatory cascade, which rapidly leads to cerebral edema, does the damage, so interrupting this with steroids is appropriate. There will be an inflammatory "burst" with the first dose of antibiotics as the bacteria are killed off en masse, so the decadron should be given with this first dose of antibiotics in the emergency department. While it is true that steroids may decrease CSF penetration of the vancomycin, it is felt to be an appropriate measure in the undifferentiated patient. Alternatively, rifampin can be used instead of vanc. Steroids can always be discontinued later if felt that they are hampering therapy.


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