Departments of 1 Neurosurgery; 2 Infectious Diseases, Soroka Medical Center and Ben Gurion Center for Health Sciences, P.O. Box 151, Beer Sheva, 84101, Israel
Keywords: post-neurosurgical infections , polymyxins , meningitis
Sir,
Post-neurosurgical meningitis is a serious complication. When this disease is caused by a multidrug-resistant pathogen, the management of such a case is challenging. Multidrug-resistant Acinetobacter baumanii has become one of the more common nosocomial pathogens in hospitals. Infections caused by this bacterium are more common in patients with severe underlying diseases, and after multiple courses of antibiotic treatment.1 When the infection involves the meninges, the choice of an antibiotic is further limited by the bloodbrain barrier. Intrathecal treatment is often the last resort in such cases.2 Polymyxins have not been used frequently, and in cases of multiple resistance, might be one of the only options. This class of antibiotic has been given intrathecally only to very few patients.3,4 We present a case of Acinetobacter meningitis, cured by intrathecal polymyxin E.
A 49-year-old woman had a history of recurrent craniotomies (in another hospital) due to a recurrent meningioma in the base of her skull. She was blind in both eyes and anosmic, since the first operation in 1989. Her history included serious complications such as CSF leak and recurrent meningitis. She first presented to our neurosurgical department in 1999 with recurrence of the tumour in the lower frontal lobes and invasion of the sphenoidal, ethmoidal and right maxillary sinuses. In the first operation in our department, which was carried out via subcranial approach, the tumour was totally removed with reconstruction of the large bone defect at the base of the skull using an artificial dural patch. On the fourth day after surgery, her temperature was 38°C and she was lethargic. Piperacillintazobactam was started as empirical treatment. On the 11th day, her temperature was 40.2°C with CSF rhinorrhoea, evidenced by high glucose levels in the fluid. Meropenem and vancomycin were substituted for the piperacillintazobactam combination. On the 18th day, she developed signs of septic shock. After haemodynamic resuscitation, she was operated on again, the artificial dural patch was removed and the base of the skull reconstructed with fascia lata. Microscopy of the patch tissue revealed Gram-negative bacilli. Ceftazidime and ciprofloxacin were given, while continuing vancomycin. After 3 days, cultures obtained during surgery grew Acinetobacter baumannii and Enterobacter cloacae. Blood and CSF cultures were negative. Six days later, she was fully alert with daily peaks of fever up to 38°C. All the antibiotics were stopped after the completion of the course. Four days later, she developed meningitis and CSF rhinorrhoea. Ceftriaxone, co-amoxiclav and meropenem were started. Acinetobacter was cultured from the CSF leak. Minocycline was added after culture results were available. Because of CSF leak, she was operated on again; this time trans-nasal endoscopic insertion of a fascia lata patch was carried out. During the following 3 weeks, she was febrile with fluctuations in her consciousness. High pressure of CSF during lumbar puncture and enlarged ventricles on CT scan, diagnosed communicating hydrocephalus. A ventriculo-peritoneal shunt was inserted, after negative CSF cultures were available. No other source of the fever could be found on physical examination and imaging studies. As a result of massive CSF leak, the base of the skull was reconstructed again, this time with a free galeal flap from her fronto-temporo-parietal scalp. Cultures from the removed flap grew Acinetobacter, methicillin-resistant Staphylococcus aureus (MRSA) and Enterobacter. Ampicillinsulbactam and vancomycin were started. There was no clinical response.
As a result of multiple adhesions in the peritoneal cavity, the peritoneal end of her shunt was externalized. CSF cultures, obtained from the external shunt after removal of dead space CSF, grew Acinetobacter baumannii, resistant to all cephalosporins, aminoglycosides and carbapenems, except for sulbactam and polymyxin E. The isolates from the patch and CSF obtained from the shunt shared the same antibiogram. Culture results during her hospital course are summarized in Table 1.
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Post-operative meningitis in neurosurgery is a serious complication. The causative organisms are not the usual pathogens causing meningitis, but rather the opportunistic organisms implicated in hospital-acquired infections. These vary according to local flora. The Acinetobacter isolated was susceptible only to sulbactam and polymyxins. This multi-resistant isolate was possibly due to prolonged treatment with multiple antibiotics. Sulbactam is bacteriostatic for this bacterium.5 Experience with this drug is limited to one case report.6 We elected to treat the patient with intrathecal polymyxin E,4 in spite of the numerous central nervous system side effects that have been reported, and the limited experience with this treatment modality. Rapid improvement of the patient's mental status and the disappearance of fever and other inflammatory symptoms proved that this rare application of polymyxin is effective in Gram-negative meningitis.
Footnotes
* Corresponding author. Tel: +972-8-6400781; Fax: +972-8-6403026; Email: moni{at}bgumail.bgu.ac.il
References
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