Management of Shunt Related Infections

Successful treatment of multidrug-resistant Acinetobacter baumannii meningitis with ampicillin sulbactam in primary hospital

Introduction: Acinetobacter baumannii nosocomial infections, especially those due to multi-drug resistant strains, are increasingly detected. We want to find the effective treatment measures about multi-resistant Acinetobacter baumannii infections through this research.Methodology: The clinical features and the outcomes of twelve cases of nosocomial Acinetobacter baumannii meningitis treated with ampicillin sulbactam and intrathecal use of amikacin are reported in primary hospital. All the patients had fever, neck stiffness or meningeal signs, and a low consciousness level, and in their cerebrospinal fluid (CSF), pleocytosis, a low glucose level, and an elevated protein level were noted. For all CSF isolates were resistant to at least two antibiotics used in empirical therapy (third and fourth generation cephalosporins, carbapenems or piperacillin/tazobactam). Four cases sputum culture prompted the growth of Acinetobacter baumannii. Two CSF isolates were intermediate resistant to ampicillin sulbactam, only sensitive to amikacin. The two patients were treated with ampicillin sulbactam and intrathecal use of amikacin.Results: The dosages and the duration of treatment with ampicillin sulbactam were 2 g/1 g every 6 hours and 9-21days. Eleven patients were cured and one patient died of meningitis (8.3%). This patient died of severe respiratory Acinetobacter baumannii infection and severe sepsis. One patient had mild nausea and discomfort, given metoclopramide therapy. There were no serious side effects with the ampicillin sulbactam treatment.Conclusions: In conclusion, ampicillin sulbactam may be effective as therapy for meningitis caused by Acinetobacter baumannii resistant to imipenem and other β-lactam drugs. Meanwhile, continuous lumbar external drainage and intermittent intrathecal use of amikacin were necessary methods.

Bacteria causing ventriculoperitoneal shunt infections in a Kenyan population

OBJECT

Ventriculoperitoneal shunt (VPS) infections are a major cause of morbidity and mortality in patients with hydrocephalus. Most data about these infections come from the Western literature. Few data about infecting organisms in Africa are available, yet knowledge of these organisms is important for the prevention and treatment of infectious complications. The purpose of this study was to determine the organisms cultured from infected shunts in a rural Kenyan hospital.

METHODS

The authors conducted a retrospective study of patients with VPS infections recorded in the neurosurgical database of BethanyKids at Kijabe Hospital between September 2010 and July 2012.

RESULTS

Among 53 VPS infections confirmed by culture, 68% occurred in patients who were younger than 6 months. Seventy-nine percent of the infections occurred within 2 months after shunt insertion. Only 51% of infections were caused by Staphylococcus species (Staphylococcus aureus 25%, other Staphylococcus species 26%), whereas 40% were caused by gram-negative bacteria. All S. aureus infections and 79% of other Staphylococcus infections were sensitive to cefazolin, but only 1 of 21 gram-negative bacteria was sensitive to it. The majority of gram-negative bacterial infections were multidrug resistant, but 17 of the 20 gram-negative bacteria were sensitive to meropenem. Gram-negative bacterial infections were associated with worse outcomes.

CONCLUSIONS

The high proportion of gram-negative infections differs from data in the Western literature, in which Staphylococcus epidermidis is by far the most common organism. Once a patient is diagnosed with a VPS infection in Kenya, immediate treatment is recommended to cover both gram-positive and gram-negative bacterial infections. Data from other Sub-Saharan countries are needed to determine if those countries have the same increased frequency of gram-negative infections.

Intraventricular and intrathecal colistin as the last therapeutic resort for the treatment of multidrug-resistant and extensively drug-resistant Acinetobacter baumannii ventriculitis and meningitis: a literature review

Acinetobacter baumannii ventriculitis/meningitis due to the emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains has become a clinical entity of considerable importance in recent years. A review of the available literature regarding intraventricular (IVT) or intrathecal (ITH) administration of colistin in MDR and XDR A. baumannii ventriculitis/meningitis was conducted and a total of 83 episodes in 81 patients were identified (71 cases in adults and 10 in children and neonates). Colistin was administered via the IVT and ITH route in 52 and 22 cases, respectively, whilst in 7 cases the exact route was not identified. The median dose of local colistin was 125000 IU (10mg) with a range of 20000 IU (1.6 mg) to 500000 IU (40 mg) in adults, whilst a dose of 2000 IU/kg (0.16 mg/kg) up to 125000 IU (10mg) was used in the paediatric population. The median duration of treatment of IVT/ITH polymyxin E was 18.5 days, whilst the median time to achieve sterilisation of cerebrospinal fluid was 4 days. The rate of successful outcome was 89%, and toxicity related to treatment mainly manifested as reversible chemical ventriculitis/meningitis was reported in nine cases (11%). Nowadays, IVT and ITH colistin represents the last resort treatment of MDR and XDR A. baumannii ventriculitis/meningitis, offering a unique, rather safe and successful mode of therapy.