LETTER TO THE EDITOR
|Year : 2017 | Volume
| Issue : 1 | Page : 74-75
Multidrug-resistant Acinetobacter meningitis treated by intrathecal colistin
Rajesh K Singh, Sanjeev K Bhoi, Jayantee Kalita, Usha K Misra
Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||07-Jul-2016|
|Date of Decision||04-Sep-2016|
|Date of Acceptance||13-Sep-2016|
|Date of Web Publication||9-Feb-2017|
Usha K Misra
Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareily Road, Lucknow - 226 014, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singh RK, Bhoi SK, Kalita J, Misra UK. Multidrug-resistant Acinetobacter meningitis treated by intrathecal colistin. Ann Indian Acad Neurol 2017;20:74-5
|How to cite this URL:|
Singh RK, Bhoi SK, Kalita J, Misra UK. Multidrug-resistant Acinetobacter meningitis treated by intrathecal colistin. Ann Indian Acad Neurol [serial online] 2017 [cited 2022 Dec 2];20:74-5. Available from: https://www.annalsofian.org/text.asp?2017/20/1/74/199908
We describe a case of iatrogenic Acinetobacter iwoffii multidrug-resistant meningitis who responded to intrathecal colistin.
A 50-year-old hypertensive woman following right thalamic hemorrhage with intraventricular extension [Figure 1] underwent external ventricular drainage (EVD) on 5th day of illness because of hydrocephalus. In next 4 days, she developed fever and the EVD was removed on 16th day of illness. She was referred for persistent fever and deteriorating consciousness. On admission, she was comatose with neck stiffness and hemiparesis. Her hemoglobin was 8.9 g/dl, white cell count 8000/mm 3, with 80% polymorphs, erythrocyte sedimentation rate 82 mm at 1st h; blood sugar, serum creatinine, blood and urine cultures were normal. Cerebrospinal fluid (CSF) revealed 209 mg/dl protein, 100 cells/mm 3 with neutrophil 10%, lymphocyte 90%, glucose 36 mg/dl, and Gram-negative bacilli. She was prescribed injection cefepime 2 g 8 hourly and vancomycin 500 mg BD. CSF culture revealed A. iwoffii sensitive to colistin (minimum inhibitory concentration [MIC] <1 µg/ml) and cefoperazone-sulbactam only. She was prescribed cefoperazone-sulbactam and vancomycin, but fever persisted. Repeat CSF on 35th day of illness revealed 200 mg/dl protein and 100/mm 3 cells with neutrophil 10%, lymphocyte 90%, and sugar 21 (blood sugar 149) mg/dl. CSF smear did not reveal bacteria but grew A. iwoffii sensitive to colistin only. Colistin 8 mg intrathecal and 72 mg intravenous (IV) was given. Dose of colistin was increased to 16 mg from 12th day and continued for 17 days. She became afebrile after 4 days of colistin. CSF culture on 12th and 17th day of colistin was sterile, so she was discharged and remained well at 1-month follow-up.
|Figure 1: Noncontrast computed tomography of the brain showing right thalamic bleed with intraventricular extension and external ventricular drain|
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Acinetobacter infection is a rare cause of community-acquired meningitis in children but is increasingly recognized as the nosocomial infection. Alarmingly, the isolates of Acinetobacter are resistant to most or even all commercially available antibiotics. Acinetobacter meningitis is common after neurosurgery, head and face injury, EVD, and shunt surgery. For neurosurgery-related meningitis, Infectious Diseases Society of America (IDSA) recommends vancomycin with ceftazidime/cefepime or meropenem. These guidelines are inadequate for Acinetobacter meningitis, especially because of increasing resistance. Out of 2000 isolates of Acinetobacter worldwide, the sensitivity to cefepime was 47.7% and ceftazidime 44.6%. In another study, Acinetobacter isolates meropenem MIC of 0.25 µg/mL or lower was found in 27%–28% isolates only. In most nosocomial meningitis, there may be mild alteration in blood–brain barrier thereby reducing entry of antibiotics into the CSF. Intrathecal or intraventricular colistin in Acinetobacter meningitis was successful in 10 of 11 episodes. Thirty-four patients with nosocomial Acinetobacter meningitis  and 18 patients with multidrug-resistant ventriculomeningitis have been treated with intrathecal and intraventricular colistin, respectively. IDSA recommends intrathecal colistin 5 mg in adults and 2 mg in children for 3 weeks. The duration of therapy is decided by three negative cultures on separate days. CSF should be repeated after 4 days of IV therapy. The median duration of therapy needed to sterilize CSF is 3 days. If CSF is still growing Acinetobacter, the therapy should be changed and CSF repeated after 4 days. This patient highlights the concern of Acinetobacter meningitis after EVD and responses to intrathecal colistin combined therapy.
We acknowledge Mr. Rakesh Kumar Nigam and Mr. Shakti Kumar for secretarial help.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gales AC, Jones RN, Sader HS. Global assessment of the antimicrobial activity of polymyxin B against 54 731 clinical isolates of Gram-negative bacilli: Report from the SENTRY antimicrobial surveillance programme (2001-2004). Clin Microbiol Infect 2006;12:315-21.
Jones RN, Sader HS, Beach ML. Contemporary in vitro
spectrum of activity summary for antimicrobial agents tested against 18569 strains non-fermentative Gram-negative bacilli isolated in the SENTRY antimicrobial surveillance program (1997-2001). Int J Antimicrob Agents 2003;22:551-6.
Falagas ME, Bliziotis IA, Tam VH. Intraventricular or intrathecal use of polymyxins in patients with Gram-negative meningitis: A systematic review of the available evidence. Int J Antimicrob Agents 2007;29:9-25.
Fotakopoulos G, Makris D, Chatzi M, Tsimitrea E, Zakynthinos E, et al.
Outcomes in meningitis/ventriculitis treated with intravenous or intraventricular plus intravenous colistin. Acta Neurochir (Wien) 2016;158:603-10.
De Bonis P
Lofrese G, Scoppettuolo G, Spanu T, Cultrera R, Labonia M, et al.
Intraventricular versus intravenous colistin for the treatment of extensively drug resistant Acinetobacter baumannii
meningitis. Eur J Neurol 2016;23:68-75.
Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, et al.
Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004 1;39:1267-84.
Vasen W, Desmery P, Ilutovich S, Di Martino A. Intrathecal use of colistin. J Clin Microbiol 2000;38:3523.
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