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Madadi AK, Sohn MJ. Comprehensive Therapeutic Approaches to Tuberculous Meningitis: Pharmacokinetics, Combined Dosing, and Advanced Intrathecal Therapies. Pharmaceutics 2024; 16:540. [PMID: 38675201 PMCID: PMC11054600 DOI: 10.3390/pharmaceutics16040540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Tuberculous meningitis (TBM) presents a critical neurologic emergency characterized by high mortality and morbidity rates, necessitating immediate therapeutic intervention, often ahead of definitive microbiological and molecular diagnoses. The primary hurdle in effective TBM treatment is the blood-brain barrier (BBB), which significantly restricts the delivery of anti-tuberculous medications to the central nervous system (CNS), leading to subtherapeutic drug levels and poor treatment outcomes. The standard regimen for initial TBM treatment frequently falls short, followed by adverse side effects, vasculitis, and hydrocephalus, driving the condition toward a refractory state. To overcome this obstacle, intrathecal (IT) sustained release of anti-TB medication emerges as a promising approach. This method enables a steady, uninterrupted, and prolonged release of medication directly into the cerebrospinal fluid (CSF), thus preventing systemic side effects by limiting drug exposure to the rest of the body. Our review diligently investigates the existing literature and treatment methodologies, aiming to highlight their shortcomings. As part of our enhanced strategy for sustained IT anti-TB delivery, we particularly seek to explore the utilization of nanoparticle-infused hydrogels containing isoniazid (INH) and rifampicin (RIF), alongside osmotic pump usage, as innovative treatments for TBM. This comprehensive review delineates an optimized framework for the management of TBM, including an integrated approach that combines pharmacokinetic insights, concomitant drug administration strategies, and the latest advancements in IT and intraventricular (IVT) therapy for CNS infections. By proposing a multifaceted treatment strategy, this analysis aims to enhance the clinical outcomes for TBM patients, highlighting the critical role of targeted drug delivery in overcoming the formidable challenges presented by the blood-brain barrier and the complex pathophysiology of TBM.
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Affiliation(s)
- Ahmad Khalid Madadi
- Department of Biomedical Science, Graduate School of Medicine, Inje University, 75, Bokji-ro, Busanjin-gu, Busan 47392, Republic of Korea;
| | - Moon-Jun Sohn
- Department of Biomedical Science, Graduate School of Medicine, Inje University, 75, Bokji-ro, Busanjin-gu, Busan 47392, Republic of Korea;
- Department of Neurosurgery, Neuroscience & Radiosurgery Hybrid Research Center, College of Medicine, Inje University Ilsan Paik Hospital, 170, Juhwa-ro, Ilsanseo-gu, Goyang City 10380, Republic of Korea
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2
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Li MT, Wu QQ, Li JB, Chen JS. Intrathecal or intraventricular antimicrobial therapy for post-neurosurgical Gram-negative bacillary meningitis or ventriculitis: a systematic review and meta-analysis. Int J Antimicrob Agents 2024; 63:107033. [PMID: 37967659 DOI: 10.1016/j.ijantimicag.2023.107033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 11/17/2023]
Abstract
PURPOSE Extensively-drug-resistant Gram-negative bacteria (XDR GNB)-related post-neurosurgical infection is closely related to mortality, which represents a major challenge for neurosurgeons. There is an urgent need to review and evaluate methods to reduce mortality. METHODS Both international and Chinese databases were searched independently from their inception to 15 June 2023. A meta-analysis was conducted using RevMan 5.4 to compare the efficacy and safety of intravenous (IV) treatment in combination with intrathecal or intraventricular (ITH/IVT) treatment with IV treatment alone for post-neurosurgical meningitis or ventriculitis due to GNB. Mortality, microbiological clearance and adverse events were considered as primary outcomes. RESULTS In total, 18 eligible studies involving 602 patients were included in the meta-analysis. The IV + ITH/IVT group was associated with significantly lower mortality (especially in the XDR GNB subgroup) and acceptable safety. In terms of microbiological clearance, a significant decrease was shown in the XDR GNB subgroup. Significant benefits were shown in laboratory parameters and clinical symptoms after patients were treated with ITH/IVT. CONCLUSION Additional ITH/IVT treatment may promote XDR GNB clearance and reduce mortality. In addition, ITH/IVT administration can improve clinical symptoms and cerebrospinal fluid indicators of patients with post-neurosurgical infections. Significantly, ITH/IVT treatment does not increase the incidence of adverse events at the recommended dose.
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Affiliation(s)
- Meng-Ting Li
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou City, Guangdong Province, China
| | - Qi-Quan Wu
- Department of Pharmacy, Ganzhou People's Hospital, Jiangxi Ganzhou, China
| | - Jia-Bao Li
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou City, Guangdong Province, China
| | - Ji-Sheng Chen
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou City, Guangdong Province, China.
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Nwabor OF, Chukamnerd A, Terbtothakun P, Nwabor LC, Surachat K, Roytrakul S, Voravuthikunchai SP, Chusri S. Synergistic effects of polymyxin and vancomycin combinations on carbapenem- and polymyxin-resistant Klebsiella pneumoniae and their molecular characteristics. Microbiol Spectr 2023; 11:e0119923. [PMID: 37905823 PMCID: PMC10715205 DOI: 10.1128/spectrum.01199-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/27/2023] [Indexed: 11/02/2023] Open
Abstract
IMPORTANCE This study provides insights into the mechanisms of polymyxin resistance in K. pneumoniae clinical isolates and demonstrates potential strategies of polymyxin and vancomycin combinations for combating this resistance. We also identified possible mechanisms that might be associated with the treatment of these combinations against carbapenem- and polymyxin-resistant K. pneumoniae clinical isolates. The findings have significant implications for the development of alternative therapies and the effective management of infections caused by these pathogens.
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Affiliation(s)
- Ozioma Forstinus Nwabor
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Arnon Chukamnerd
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Pawarisa Terbtothakun
- Division of Biological Science, Faculty of Science and Natural Product Research Center of Excellence, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Lois Chinwe Nwabor
- Department of Biomedical Sciences and Biomedical Engineering, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Komwit Surachat
- Department of Biomedical Sciences and Biomedical Engineering, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
- Faculty of Medicine, Translational Medicine Research Center, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Sittiruk Roytrakul
- Functional Proteomics Technology Laboratory, National Center for Genetic Engineering and Biotechnology, National Science and Technology Development Agency, Pathumthani, Thailand
| | - Supayang Piyawan Voravuthikunchai
- Faculty of Science, Center of Antimicrobial Biomaterial Innovation-Southeast Asia and Natural Product Research Center of Excellence, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Sarunyou Chusri
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
- Department of Biomedical Sciences and Biomedical Engineering, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Yang X, Guo C, Wu G, Zhao K, Xiang D, Xu D, Liu D, He Y. Treatment of Central Nervous System Infection Caused by Multidrug-Resistant Acinetobacter baumannii with Intravenous and Intraventricular Colistin Sulfate: A Case Report and Literature Review. Infect Drug Resist 2023; 16:6029-6038. [PMID: 37719653 PMCID: PMC10503561 DOI: 10.2147/idr.s425415] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/05/2023] [Indexed: 09/19/2023] Open
Abstract
Purpose Due to the spread of antimicrobial-resistant bacteria and poor penetration of many antimicrobial drugs across the blood-brain barrier following intravenous administration, treatment of central nervous system (CNS) infections is challenging, especially infections caused by carbapenem-resistant organisms (CRO). Intraventricular (IVT) infusion of antimicrobial drugs could be a choice. This report aims to describe a patient with CNS infection caused by carbapenem-resistant Acinetobacter baumannii (CRAB) which was successfully treated with IVT combined with intravenous (IV) colistin sulfate. Methods A case of CNS infection caused by CRAB after a craniocerebral injury was presented. The patient was treated with IVT together with IV colistin sulfate. Moreover, literature on the regimens and safety of colistin sulfate were also reviewed and summarized. Results Intraventricular (50,000 U, qd/100,000 U, qd) combined with IV (500,000 U, q12h/500,000 U, q8h) colistin sulfate was given to the patient, and the CNS infection was successfully controlled. The patient was finally transferred back to a local hospital for rehabilitation treatment. No nephrotoxicity or neurotoxicity was observed during the therapy. Conclusion IV combined with IVT colistin sulfate is effective in the treatment of CNS infections caused by CRAB. IVT concomitant IV colistin sulfate might be a therapeutic option worth considering in the treatment of CNS infections caused by CRO.
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Affiliation(s)
- Xueping Yang
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
- Department of Pharmacy, Jingzhou Hospital of Traditional Chinese Medicine, Jingzhou, 434000, People’s Republic of China
| | - Changhong Guo
- Department of Scientific Education, Jingzhou Hospital of Traditional Chinese Medicine, Jingzhou, 434000, People’s Republic of China
| | - Guangjie Wu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
| | - Kai Zhao
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
| | - Dong Xiang
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
| | - Dong Xu
- Department of Infection Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
| | - Dong Liu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
| | - Yan He
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
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Fursova NK, Fursov MV, Astashkin EI, Fursova AD, Novikova TS, Kislichkina AA, Sizova AA, Fedyukina GN, Savin IA, Ershova ON. Multidrug-Resistant and Extensively Drug-Resistant Acinetobacter baumannii Causing Nosocomial Meningitis in the Neurological Intensive Care Unit. Microorganisms 2023; 11:2020. [PMID: 37630581 PMCID: PMC10458171 DOI: 10.3390/microorganisms11082020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/31/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023] Open
Abstract
Acinetobacter baumannii is one of the significant healthcare-associated meningitis agents characterized by multidrug resistance and a high mortality risk. Thirty-seven A. baumannii strains were isolated from thirty-seven patients of Moscow neuro-ICU with meningitis in 2013-2020. The death rate was 37.8%. Strain susceptibility to antimicrobials was determined on the Vitek-2 instrument. Whole-genome sequencing was conducted using Illumina technology; the sequence types (ST), capsular types (KL), lipooligosaccharide outer core locus (OCL), antimicrobial resistance genes, and virulence genes were identified. The prevalent ST was ST2, belonging to the international clone IC2, and rarer, ST1, ST19, ST45, ST78, ST106, and ST400, with prevalence of KL9 and OCL1. Twenty-nine strains belonged to multidrug-resistant (MDR) and eight extensively drug-resistant (XDR) categories. Genes conferring resistance to beta-lactams (blaPER, blaGES, blaADC, blaCARB, blaCTX-M, blaTEM, and blaOXA-types), aminoglycosides (aac, aad, ant, aph, and arm), tetracyclines (tet), macrolides (msr and mph), phenicols (cml, cat, and flo), sulfonamides (dfr and sul), rifampin (arr), and antiseptics (qac) were identified. Virulence genes of nine groups (Adherence, Biofilm formation, Enzymes, Immune evasion, Iron uptake, Regulation, Serum resistance, Stress adaptation, and Antiphagocytosis) were detected. The study highlights the heterogeneity in genetic clones, antimicrobial resistance, and virulence genes variability among the agents of A. baumannii meningitis, with the prevalence of the dominant international clone IC2.
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Affiliation(s)
- Nadezhda K. Fursova
- Department of Molecular Microbiology, State Research Center for Applied Microbiology and Biotechnology, Territory “Kvartal A”, 142279 Obolensk, Russia; (E.I.A.); (A.D.F.); (T.S.N.)
| | - Mikhail V. Fursov
- Department of Training and Improvement of Specialists, State Research Center for Applied Microbiology and Biotechnology, Territory “Kvartal A”, 142279 Obolensk, Russia;
| | - Evgeny I. Astashkin
- Department of Molecular Microbiology, State Research Center for Applied Microbiology and Biotechnology, Territory “Kvartal A”, 142279 Obolensk, Russia; (E.I.A.); (A.D.F.); (T.S.N.)
| | - Anastasiia D. Fursova
- Department of Molecular Microbiology, State Research Center for Applied Microbiology and Biotechnology, Territory “Kvartal A”, 142279 Obolensk, Russia; (E.I.A.); (A.D.F.); (T.S.N.)
| | - Tatiana S. Novikova
- Department of Molecular Microbiology, State Research Center for Applied Microbiology and Biotechnology, Territory “Kvartal A”, 142279 Obolensk, Russia; (E.I.A.); (A.D.F.); (T.S.N.)
| | - Angelina A. Kislichkina
- Department of Culture Collection, State Research Center for Applied Microbiology and Biotechnology, Territory “Kvartal A”, 142279 Obolensk, Russia; (A.A.K.); (A.A.S.)
| | - Angelika A. Sizova
- Department of Culture Collection, State Research Center for Applied Microbiology and Biotechnology, Territory “Kvartal A”, 142279 Obolensk, Russia; (A.A.K.); (A.A.S.)
| | - Galina N. Fedyukina
- Department of Immunochemistry of Pathogenic Microorganisms, State Research Center for Applied Microbiology and Biotechnology, Territory “Kvartal A”, 142279 Obolensk, Russia;
| | - Ivan A. Savin
- Department of Clinical Epidemiology, National Medical Research Center of Neurosurgery Named after Academician N.N. Burdenko, 125047 Moscow, Russia; (I.A.S.); (O.N.E.)
| | - Olga N. Ershova
- Department of Clinical Epidemiology, National Medical Research Center of Neurosurgery Named after Academician N.N. Burdenko, 125047 Moscow, Russia; (I.A.S.); (O.N.E.)
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Muller AE, van Vliet P, Koch BCP. Clinical Experience with Off-Label Intrathecal Administration of Selected Antibiotics in Adults: An Overview with Pharmacometric Considerations. Antibiotics (Basel) 2023; 12:1291. [PMID: 37627711 PMCID: PMC10451962 DOI: 10.3390/antibiotics12081291] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/30/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Drain-associated intracerebral infections are life-threatening emergencies. Their treatment is challenging due to the limited penetration of antibiotics to the site of infection, resulting in potentially inadequate exposure. The emergence of multidrug-resistant pathogens might force the use of off-label intrathecal (IT) doses of antibiotics. We reviewed the literature on general aspects determining intrathecal dosing regimen, using pharmacometric knowledge. We summarised clinical experience with IT doses of antibiotics that are usually not used intrathecally, as well as the outcome of the cases and concentrations reached in the cerebrospinal fluid (CSF). Factors determining the IT regimen are the size of the ventricle system and the CSF drainage volume. With regard to pharmacometrics, pharmacokinetic/pharmacodynamic indices are likely similar to those in non-cerebral infections. The following number (N) of cases were described: benzylpenicillin (>50), ampicillin (1), ceftazidime (2), cephaloridine (56), ceftriaxone (1), cefotiam (1), meropenem (57), linezolid (1), tigecycline (15), rifampicin (3), levofloxacin (2), chloramphenicol (3) and daptomycin (8). Many side effects were reported for benzylpenicillin in the 1940-50s, but for the other antibiotics, when administered correctly, all side effects were minor and reversible. These data might help when choosing an IT dosing regimen in case there is no alternative option due to antimicrobial resistance.
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Affiliation(s)
- Anouk E. Muller
- Department of Medical Microbiology, Haaglanden Medisch Centrum, 2512 VA The Hague, The Netherlands
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Center for Antimicrobial Treatment Optimization Rotterdam (CATOR), 3015 GD Rotterdam, The Netherlands;
| | - Peter van Vliet
- Department of Intensive Care Medicine, Haaglanden Medisch Centrum, 2512 VA The Hague, The Netherlands;
| | - Birgit C. P. Koch
- Center for Antimicrobial Treatment Optimization Rotterdam (CATOR), 3015 GD Rotterdam, The Netherlands;
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
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Georgakopoulou VE, Spandidos DA, Papalexis P, Gkoufa A, Aravantinou-Fatorou A, Angelopoulou E, Trakas I, Trakas N, Fotakopoulos G. Outcomes in meningitis‑ventriculitis treated with intravenous or intrathecal plus intravenous colistin: A meta‑analysis. Exp Ther Med 2023; 25:293. [PMID: 37206561 PMCID: PMC10189601 DOI: 10.3892/etm.2023.11992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/20/2023] [Indexed: 05/21/2023] Open
Abstract
The aim of the present meta-analysis was to provide further evidence on the management of bacterial ventriculitis or meningitis (BVM) and to compare the efficacy of intravenous (IV) or intravenous plus intrathecal (IV/ITH) treatment with colistin. The present meta-analysis included full-text articles published between 1980 and 2020 that compared outcomes in meningitis-ventriculitis treated with IV or IV/ITH colistin. The collected variables included the first author's name, country, study period covered, publication year, the total number of patients and follow-up, Glasgow Coma Scale score upon admission, treatment duration, Acute Physiological and Chronic Health Evaluation II score, the length of intensive unit (ICU) stay, treatment efficacy and mortality for both groups. To avoid publication bias, the final aim was to collect a homogenous pool of manuscripts, including only articles that compared only two modalities. After applying all exclusion and inclusion criteria, seven of 55 articles were left in the final article pool. The total number of patients in those seven articles was 293, divided into two groups (186 in the IV and 107 in the IV/ITH group). As regards ICU stay and mortality, the findings illustrated a statistically significant difference between the two groups. On the whole, the findings of the present study support the addition of ITH colistin to its IV administration for the effective treatment of BVM.
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Affiliation(s)
- Vasiliki Epameinondas Georgakopoulou
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Correspondence to: Dr Vasiliki Epameinondas Georgakopoulou, Department of Infectious Disease and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma Street, 11527 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Petros Papalexis
- Unit of Endocrinology, First Department of Internal Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | - Aikaterini Gkoufa
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Aikaterini Aravantinou-Fatorou
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Efthalia Angelopoulou
- Department of Neurology, Aiginition University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Ilias Trakas
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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Varma S, Sharad N, Kiro V, Srivastava S, Ningombam A, Bindra A, Gupta D, Malhotra R, Mathur P. Microbiological Profile and the Resistance Pattern of Pathogens in Neurosurgical Patients from a New Delhi Trauma Center. World Neurosurg 2023; 173:e436-e441. [PMID: 36828276 DOI: 10.1016/j.wneu.2023.02.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Neurosurgical patients are considered to be at higher risk for infections including nosocomial infections compared with other critically ill individuals. Empirical antimicrobial therapy is of utmost importance for the survival of infected neurosurgical patients. METHODS The microbial distribution and antimicrobial resistance patients from January 2012 to December 2021 (10 years) were analyzed retrospectively. Identification was done using VITEK-2 and MALDI-TOF systems. Antimicrobial susceptibility testing was determined by the Kirby Bauer Disk Diffusion Agar method (Clinical and Laboratory Standards Institute) and VITEK-2. RESULTS A total of 48,474 samples were received, out of which 10,134 (21%) had growth. Respiratory specimens showed the maximum isolation of pathogens (42% n = 4292). The predominant bacterial pathogens were gram negative (n = 8972; 88.5%), whereas gram positives were only 11.5% (n = 1162) of the total organisms. Among the gram positives, the most common was Staphylococcus aureus (64.6%), and among gram negatives, the most common pathogen was Acinetobacter baumanni (38.6%). The weighted average of the drug-resistance profile across all gram positives was >50% for fluoroquinolones (levofloxacin, ciprofloxacin), gentamicin, erythromycin, and ampicillin, and in the case of gram negatives it was >90% for ampicillin-sulbactam, ticarcillin, cefazolin, cefotaxime, and ceftriaxone. Thirty-two patients were found to have candidemia, out of which 6 were C. albicans and the rest were nonalbican. Six neurosurgery patients had infection with C. auris, 4 from blood samples and 2 from urine. CONCLUSIONS This study will add to the current knowledge and provide a better understanding of pathogen profile and resistance patterns in traumatic brain injury patients.
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Affiliation(s)
- Sharin Varma
- Department of Microbiology, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Neha Sharad
- Department of Microbiology, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Vandana Kiro
- Department of Microbiology, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Smriti Srivastava
- Department of Microbiology, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Aparna Ningombam
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Ashish Bindra
- Depaertment of Neuroanaesthesia, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Deepak Gupta
- Department of Neurosurgery, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Rajesh Malhotra
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Purva Mathur
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India.
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Liu D, Niu J, Chen G, Xu L. Treatment of Carbapenem-Resistant Multidrug-Resistant Gram-Negative Bacilli with Intracerebroventricular Injection of Polymyxin B: A Retrospective Study. Infect Drug Resist 2022; 15:7653-7666. [PMID: 36579127 PMCID: PMC9791995 DOI: 10.2147/idr.s392818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose We evaluated the efficacy and administration time of intraventricular (IVT) polymyxin B in the treatment of carbapenem-resistant and multidrug-resistant/extensively drug-resistant (MDR/XDR) Gram-negative bacilli in central nervous system (CNS) infections and investigated prognostic factors. Patients and Methods This retrospective analysis comprised 41 post-surgical carbapenem-resistant CNS infections from October 2016 to October 2021. All patients were treated with effective intravenous antibiotics and IVT polymyxin B. Patient characteristics, therapeutic procedure, symptoms, cerebrospinal fluid (CSF) examination, laboratory tests, and complications were recorded. The effectiveness of IVT polymyxin B was evaluated using temperature, Glasgow Coma Scale, CSF contents, bacterial clearance rate, cure rate, and mortality. Mortality between early (7 days) and late administration of IVT polymyxin B was compared. Prognostic factors were evaluated using the pupillary light reflex and multiloculated hydrocephalus. Results The 41 patients acquired carbapenem-resistant MDR/XDR bacteria, including 24 Klebsiella pneumoniae, 15 Acinetobacter baumannii, 3 Pseudomonas aeruginosa, and 1 Enterobacter cloacae. The bacterial clearance rate was 32/41 (78.0%), and 9 patients (22.0%) with uncured bacterial infections died. Adverse events included 1 case of skin pigmentation. Among the 32 cured patients, 31 received a ventriculoperitoneal shunt, and 1 patient had an extraventricular drainage tube removed. Mortality in the late (>7 days) group was higher (39.1% vs 0%, P < 0.05). The group without pupillary light reflex showed a higher death rate (41.2% vs 8.3%; P < 0.05). The multiloculated hydrocephalus group had a higher mortality rate than that of the normal group (34.8% vs 5.6%, P < 0.05). All 32 cured patients were followed up for 9 to 66 months, and all survived without recurrent infections. Conclusion Intraventricular polymyxin B is an effective treatment for carbapenem-resistant MDR/XDR Gram-negative bacilli, with a 78% cure rate and significant mortality reduction if administered within 7 days of bacterial identification. Multiloculated hydrocephalus and the pupillary light reflex may be used as prognostic indicators of mortality.
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Affiliation(s)
- Dongsheng Liu
- Departments of Neurosurgery of Aviation General Hospital, Beijing, 100012, People’s Republic of China
| | - Jianxing Niu
- Departments of Neurosurgery of Aviation General Hospital, Beijing, 100012, People’s Republic of China
| | - Guoqiang Chen
- Departments of Neurosurgery of Aviation General Hospital, Beijing, 100012, People’s Republic of China,Guoqiang Chen, Departments of Neurosurgery of Aviation General Hospital, No. 3, Anwai Beiyuan, Beiyuan Road, Chaoyang District, Beijing, 10001, People’s Republic of China, Tel +86 13311396583, Fax +86 10-59520156, Email
| | - Long Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, 100070, People’s Republic of China,Correspondence: Long Xu, Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, National Clinical Research Center for Neurological Diseases (NCRC-ND), No. 119 Nansihuanxilu Road, Fengtai District, Beijing, 100070, People’s Republic of China, Tel +86 13911129912, Fax +86 10-59976095, Email
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Li H, Yu W, Wang G, Cai H. Outcome of Using Intraventricular Plus Intravenous Polymyxin B in Post-neurosurgical Patients With Multi/Extensively Drug-Resistant Gram-Negative Bacteria-Induced Intracranial Infection. Front Med (Lausanne) 2022; 9:913364. [PMID: 35872774 PMCID: PMC9301479 DOI: 10.3389/fmed.2022.913364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/15/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Post-neurosurgical central nervous system (CNS) infection caused by multidrug-resistant (MDR)/extensively drug-resistant (XDR) Gram-negative bacteria remains a major clinical challenge. This study describes our experience of treating such patients with combined intraventricular (IVT) and intravenous (IV) polymyxin B administration. Methods This retrospective study included six patients with post-neurosurgical CNS infections of carbapenem-resistant Acinetobacter baumannii (CRAB) or carbapenem-resistant Klebsiella pneumoniae (CRKP). All patients were treated in the intensive care unit (ICU) of First Affiliated Hospital, Zhejiang University School of Medicine (Hangzhou, China) between November 2020 and November 2021, and all received IVT plus IV polymyxin B. Data including patients' characteristics, therapeutic process, symptoms, cerebrospinal fluid (CSF) examination, laboratory tests, and complications were collected. Results Six patients with post-neurosurgical CNS infection were enrolled in the study. The patients comprised five males and one female, and the average age was 58 years (range, 38–73 years). Four out of the six cases were CRAB-positive in CSF culture, while two cases were CRKP-positive. The mean duration of polymyxin B administration was 14 ± 5.69 days (range, 6–20 days). The average period of patients reaching CSF sterilization was 10.33 ± 3.67 days (range, 5–14 days). All six cases were cured without acute kidney injury or epilepsy. Conclusion IVT plus IV polymyxin B is a safe and effective treatment for post-neurosurgical patients with intracranial infection caused by MDR/XDR Gram-negative bacteria.
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Ye Y, Kong Y, Ma J, Shi G. Carbapenem-Resistant Gram-Negative Bacteria-Related Healthcare-Associated Ventriculitis and Meningitis: Antimicrobial Resistance of the Pathogens, Treatment, and Outcome. Microbiol Spectr 2022; 10:e0025322. [PMID: 35467409 PMCID: PMC9241620 DOI: 10.1128/spectrum.00253-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/08/2022] [Indexed: 11/20/2022] Open
Abstract
Carbapenem-resistant Gram-negative bacteria (CRGNB)-related health care-associated ventriculitis and meningitis (HCAVM) is dangerous. We aimed to report the antimicrobial resistance of the pathogens, treatment, and outcome. All cases with CRGNB-related HCAVM in2012-2020 were recruited. Antimicrobial agents were classified as active, untested, or inactive using antimicrobial susceptibility tests. The treatment stage was classified as empirical or targeted according to the report of pathogens. The treatment effect was classified as ineffective or effective according to HCAVM-related parameters. Overall, 92 cases were recruited. For most antimicrobial agents, the resistance rate was higher than 70.0%. The polymyxin resistance rate was the lowest at 11.6%. The chloramphenicol, trimethoprim-sulfamethoxazole, amikacin, levofloxacin, and tetracycline resistance rates were relatively low, ranging from 21.1% to 64.1%. The meropenem resistance rate was 81.9%. There was no significant trend for any antimicrobial agent tested. Meropenem was the most common antimicrobial agent used in empirical treatment; trimethoprim-sulfamethoxazole and polymyxin were the most used active antimicrobial agents, and meropenem/sulbactam and polymyxin were the most used untested antimicrobial agents in targeted treatment. In total, 42 (45.7%) cases received ineffective treatments. The ineffective treatment rate of cases that received active antimicrobial agents was lower than that of cases that received untested antimicrobial agents and cases that received inactive antimicrobial agents (29.3% [12/41] versus 46.2% [18/39] versus 100.0% [12/12], P < 0.001). Antimicrobial resistance was prevalent but without increasing trends. Active antimicrobial agents are necessary. Additionally, untested antimicrobial agents, including meropenem/sulbactam and polymyxin, might be optional. Inactive antimicrobial agents must be replaced. IMPORTANCE Carbapenem-resistant Gram-negative bacteria-related health care-associated ventriculitis and meningitis is a clinical threat because of the poor outcome and challenges in treatment. We reached several conclusions: (i) the antimicrobial resistance of pathogens is severe, and some antimicrobial agents represented by polymyxin are optional according to the antimicrobial susceptibility tests; (ii) in the background that the portion of carbapenems resistance in Gram-negative bacteria is increasing, there is no increasing trend for the antimicrobial resistance of carbapenem-resistant Gram-negative bacteria in the 9-year study; (iii) meropenem is the main antimicrobial agent in treatment, and trimethoprim-sulfamethoxazole, tigecycline, polymyxin, and meropenem/sulbactam are commonly used in the targeted treatment; (iv) the treatment effect was poor and affected by the treatment: timely active antimicrobial agents should be given. And untested antimicrobial agents represented by polymyxin and meropenem/sulbactam might be optional. Inactive antimicrobial agents must be replaced.
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Affiliation(s)
- Yi Ye
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yueyue Kong
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiawei Ma
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Huang G, Lai W, Wu D, Huang Q, Zhong Q, Ye X. Two Cases Report of Intrathecal Tigecycline Therapy for Intracranial Infection with Acinetobacter baumannii and Review of Literatures. Infect Drug Resist 2022; 15:2211-2217. [PMID: 35502226 PMCID: PMC9056109 DOI: 10.2147/idr.s357087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/01/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To explore the treatment scheme for intracranial infection with Acinetobacter baumannii. METHODS We retrospective analyzed two cases of patients of intracranial infection with Acinetobacter baumannii. RESULTS The intracranial infection was controlled effectively by the scheme to intravenous"tigecycline + cefperazone-sulbactam"combined with intrathecal tigecycline injection, the two patients recover well with 21 months' follow-up. CONCLUSIONS Tigecycline-based drug scheme combined with intrathecal tigecycline injection can achieve the effect of controlling intracranial infection. Lumbar cisterna drainage tube plays a major role in controlling intracranial infection.
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Affiliation(s)
- Guanlin Huang
- Department of Neurosurgery, Ganzhou People’s Hospital, Ganzhou, Jiangxi, 341000, People’s Republic of China
| | - Wentao Lai
- Department of Neurosurgery, Ganzhou People’s Hospital, Ganzhou, Jiangxi, 341000, People’s Republic of China
| | - Daxing Wu
- Department of Neurosurgery, Ganzhou People’s Hospital, Ganzhou, Jiangxi, 341000, People’s Republic of China
| | - Qianliang Huang
- Department of Neurosurgery, Ganzhou People’s Hospital, Ganzhou, Jiangxi, 341000, People’s Republic of China
| | - Qi Zhong
- Department of Neurosurgery, Ganzhou People’s Hospital, Ganzhou, Jiangxi, 341000, People’s Republic of China
| | - Xinyun Ye
- Department of Neurosurgery, Ganzhou People’s Hospital, Ganzhou, Jiangxi, 341000, People’s Republic of China
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Benli A, Şimşek-Yavuz S, Eraksoy H. Intrathecal Colistin Induced Chemical Meningitis in a Case of Multi-Drug Resistant Acinetobacter baumannii Meningitis. INFECTIOUS DISEASES & CLINICAL MICROBIOLOGY 2022; 4:76-80. [PMID: 38633541 PMCID: PMC11022816 DOI: 10.36519/idcm.2022.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/28/2022] [Indexed: 04/19/2024]
Abstract
The possibility of encountering multi-drug resistant Gram-negative bacteria is higher in nosocomial meningitis. These bacteria are clinically important because of their higher mortality rate, and colistin is almost the only treatment option in resistant strains. However, intrathecal administration of colistin can result in chemical meningitis. We reported a case with chemical meningitis during the intravenous sulbactam plus colistin and intrathecal colistin therapy for multi-drug resistant Acinetobacter baumannii meningitis. Cerebrospinal fluid findings of the patient improved after discontinuation of intrathecal colistin therapy. This reversible complication may occur during intrathecal therapy. Discontinuation of intrathecal therapy or reducing the antibiotic dose will be the most appropriate approach to manage such cases.
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Affiliation(s)
- Aysun Benli
- Department of Infectious Diseases and Clinical Microbiology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Serap Şimşek-Yavuz
- Department of Infectious Diseases and Clinical Microbiology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Haluk Eraksoy
- Department of Infectious Diseases and Clinical Microbiology, İstanbul University School of Medicine, İstanbul, Turkey
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Li K, Wang L, Wen L, Wang J, Li M. Intrathecal therapy for tuberculous meningitis: propensity-matched cohort study. Neurol Sci 2021; 43:2693-2698. [PMID: 34708262 DOI: 10.1007/s10072-021-05690-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 07/12/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The study aimed to determine the safety and efficacy of intrathecally administered isoniazid (INH) and prednisolone in addition to systemic anti-TB therapy and compare it with systemic anti-TB therapy alone in adult patients with tuberculous meningitis (TBM). METHODS In this retrospective study, patients were categorized into two groups: Group A patients received systematic anti-TB therapy alone, Group B patients received IT INH (50 mg) and prednisolone (25 mg) twice a week together with the same standard systemic anti-TB therapy as Group A, in addition to the standard systemic anti-TB therapy. Functional outcomes were compared between the two groups in a prosperity-matched cohort using propensity score matching (PSM) method. RESULTS A total of 198 patients with TBM were enrolled. After PSM, 30 patients from each group were analyzed, so that there was no significant difference in the characteristics of the two groups. Mortality at follow-up was significantly lower among patients receiving additional IT therapy (4/30, 13.3%) compared with matched patients receiving systemic anti-TB therapy alone (11/30, 36.7%, P value = 0.037). CONCLUSIONS In this propensity score-matched cohort, the addition of IT INH and prednisolone to systemic anti-TB therapy could be effective for the better outcome among adult TBM patients. Further large-scale, prospective, and randomized controlled trials are warranted to the best timing and indication of IT therapy.
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Affiliation(s)
- Kunyi Li
- Department of Neurology, the Second People's Hospital of Chengdu, Chengdu, 610000, China
| | - Lijun Wang
- Department of Neurology, Institute of Neurology, Ruijin Hospital Affiliated to School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lan Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jian Wang
- Department of Neurology, the Second People's Hospital of Chengdu, Chengdu, 610000, China
| | - Maolin Li
- Department of Neurology, People's Hospital of Deyang City, No. 173, North Taishan, Road, Deyang, Sichuan, China.
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Kumar S, Anwer R, Azzi A. Virulence Potential and Treatment Options of Multidrug-Resistant (MDR) Acinetobacter baumannii. Microorganisms 2021; 9:microorganisms9102104. [PMID: 34683425 PMCID: PMC8541637 DOI: 10.3390/microorganisms9102104] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/18/2021] [Accepted: 09/21/2021] [Indexed: 12/12/2022] Open
Abstract
Acinetobacter baumannii is an opportunistic pathogen which is undoubtedly known for a high rate of morbidity and mortality in hospital-acquired infections. A. baumannii causes life-threatening infections, including; ventilator-associated pneumonia (VAP), meningitis, bacteremia, and wound and urinary tract infections (UTI). In 2017, the World Health Organization listed A. baumannii as a priority-1 pathogen. The prevalence of A. baumannii infections and outbreaks emphasizes the direct need for the use of effective therapeutic agents for treating such infections. Available antimicrobials, such as; carbapenems, tigecycline, and colistins have insufficient effectiveness due to the appearance of multidrug-resistant strains, accentuating the need for alternative and novel therapeutic remedies. To understand and overcome this menace, the knowledge of recent discoveries on the virulence factors of A. baumannii is needed. Herein, we summarized the role of various virulence factors, including; outer membrane proteins, efflux pumps, biofilm, penicillin-binding proteins, and siderophores/iron acquisition systems. We reviewed the recent scientific literature on different A. baumannii virulence factors and the effective antimicrobial agents for the treatment and management of bacterial infections.
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Affiliation(s)
- Sunil Kumar
- Department of Biotechnology, Maharishi Markandeshwar (Deemed to Be University), Mullana, Ambala 133207, India;
| | - Razique Anwer
- Department of Pathology, College of Medicine, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh 13317-4233, Saudi Arabia;
| | - Arezki Azzi
- Department of Biochemistry, College of Medicine, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh 13317-4233, Saudi Arabia
- Correspondence:
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Antimicrobial use in central nervous system infections. Curr Opin Infect Dis 2021; 34:255-263. [PMID: 33741793 DOI: 10.1097/qco.0000000000000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Central nervous system (CNS) infections are associated with high rates of morbidity and mortality. The purpose of this review is to summarize current antimicrobial therapies, as well as, updates in the management of community-acquired meningitis and healthcare-associated meningitis and ventriculitis. RECENT FINDINGS Due to the increasing rates of multidrug resistant and extensively-drug resistant organisms, available antimicrobials are limited. Novel treatment options include newer systemic antimicrobials and antimicrobials that have previously limited data in the management of CNS infections. Although limited by retrospective data, intrathecal (IT) and intraventricular (IVT) routes of administration offer the opportunity for antimicrobials that conventionally have minimal cerebrospinal fluid (CSF) penetration to achieve high CSF concentrations while minimizing systemic exposure. SUMMARY Updates in the use of systemic, IT, and IVT antimicrobials offer promise as therapeutic options for CNS infections. Additional pharmacokinetic and prospective data are needed to confirm these findings.
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Alvarez-Vega M, Boga JA, Fernandez-Suarez J, Martinez-Sela M, Moran-Suarez N, Rodríguez-Guardado A. Multidrug-resistant Acinetobacter meningitis in neurosurgical patients with intraventricular catheters: assessment of different treatments-authors' response. J Antimicrob Chemother 2021; 75:783-784. [PMID: 31977047 DOI: 10.1093/jac/dkz541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Marco Alvarez-Vega
- Neurosurgery Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - José A Boga
- Microbiology Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - María Martinez-Sela
- Internal Medicine Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Noelia Moran-Suarez
- Internal Medicine Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Azucena Rodríguez-Guardado
- Infectious Diseases Unit, Hospital Universitario de Cabueñes, Gijón, Spain and University of Oviedo, Oviedo, Spain
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Nau R, Sörgel F, Eiffert H. Central nervous system infections and antimicrobial resistance: an evolving challenge. Curr Opin Neurol 2021; 34:456-467. [PMID: 33767092 DOI: 10.1097/wco.0000000000000931] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Antimicrobial resistance is an increasing threat to patients also in nosocomial central nervous system (CNS) infections. The present review focusses on optimizing intravenous treatment in order to achieve sufficient concentrations of antibiotics in the different compartments of the CNS when the causative pathogens have reduced sensitivity to antibiotics or/and the impairment of the blood-cerebrospinal fluid (CSF) and blood-brain barrier is mild. RECENT FINDINGS Experience has been gathered with treatment protocols for several established antibiotics using increased doses or continuous instead of intermittent intravenous therapy. Continuous infusion in general does not increase the average CSF concentrations (or the area under the concentration-time curve in CSF) compared to equal daily doses administered by short-term infusion. In some cases, it is postulated that it can reduce toxicity caused by high peak plasma concentrations. In case reports, new β-lactam/β-lactamase inhibitor combinations were shown to be effective treatments of CNS infections. SUMMARY Several antibiotics with a low to moderate toxicity (in particular, β-lactam antibiotics, fosfomycin, trimethoprim-sulfamethoxazole, rifampicin, vancomycin) can be administered at increased doses compared to traditional dosing with low or tolerable adverse effects. Intrathecal administration of antibiotics is only indicated, when multiresistant pathogens cannot be eliminated by systemic therapy. Intravenous should always accompany intrathecal treatment.
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Affiliation(s)
- Roland Nau
- Department of Neuropathology, University Medical Center Göttingen, Georg-August-University Göttingen, Göttingen.,Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen
| | - Fritz Sörgel
- Institute for Biomedical and Pharmaceutical Research (IBMP), Nuremberg-Heroldsberg.,Institute of Pharmacology, West German Heart and Vascular Centre, University of Duisburg-Essen, Essen
| | - Helmut Eiffert
- Department of Neuropathology, University Medical Center Göttingen, Georg-August-University Göttingen, Göttingen.,MVZ Wagnerstibbe für Medizinische Mikrobiologie, Göttingen, amedes-Gruppe, Germany
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Sharma R, Goda R, Borkar SA, Katiyar V, Agarwal S, Kumar A, Mohapatra S, Kapil A, Suri A, Kale SS. Outcome following postneurosurgical Acinetobacter meningitis: an institutional experience of 72 cases. Neurosurg Focus 2020; 47:E8. [PMID: 31370029 DOI: 10.3171/2019.5.focus19278] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors aimed to evaluate the antimicrobial susceptibility pattern of Acinetobacter isolates responsible for nosocomial meningitis/ventriculitis in the neurosurgical ICU. The authors also sought to identify the risk factors for mortality following Acinetobacter meningitis/ventriculitis. METHODS This was a retrospective study of 72 patients admitted to the neurosurgical ICU between January 2014 and December 2018 with clinical and microbiological diagnosis of nosocomial postneurosurgical Acinetobacter baumanii meningitis/ventriculitis. Electronic medical data on clinical characteristics, underlying pathology, CSF cytology, antibiotic susceptibilities, and mortality were recorded. To evaluate the outcome following nosocomial postneurosurgical Acinetobacter meningitis/ventriculitis, patients were followed up until discharge or death in the hospital. Kaplan-Meier survival analysis and multivariable Cox proportional hazards models were used to compute factors affecting survival. RESULTS The study population was divided into two groups depending on the final outcome of whether the patient died or survived. Forty-three patients (59.7%) were included in the survivor group and 29 patients (40.3%) were included in the nonsurvivor group. Total in-hospital mortality due to Acinetobacter meningitis/ventriculitis was 40.3% (29 cases), with a 14-day mortality of 15.3% and a 30-day mortality of 25%. The 43 (59.7%) patients who survived had a mean length of hospital stay of 44 ± 4 days with a median Glasgow Outcome Scale-Extended score at discharge of 6. On univariate analysis, age > 40 years (p = 0.078), admission Glasgow Coma Scale (GCS) score ≤ 8 (p = 0.003), presence of septic shock (p = 0.011), presence of external ventricular drain (EVD) (p = 0.03), CSF white blood cell (WBC) count > 200 cells/mm3 (p = 0.084), and comorbidities (diabetes, p = 0.036; hypertension, p = 0.01) were associated with poor outcome. Carbapenem resistance was not a risk factor for mortality. According to a multivariable Cox proportional hazards model, age cutoff of 40 years (p = 0.016, HR 3.21), GCS score cutoff of 8 (p = 0.006, HR 0.29), CSF WBC count > 200 cells/mm3 (p = 0.01, HR 2.76), presence of EVD (p = 0.001, HR 5.42), and comorbidities (p = 0.017, HR 2.8) were found to be significant risk factors for mortality. CONCLUSIONS This study is the largest case series reported to date of postneurosurgical Acinetobacter meningitis/ventriculitis. In-hospital mortality due to Acinetobacter meningitis/ventriculitis was high. Age older than 40 years, GCS score less than 8, presence of EVD, raised CSF WBC count, and presence of comorbidities were risk factors for mortality.
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Affiliation(s)
| | | | | | | | | | | | - Sarita Mohapatra
- 3Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Arti Kapil
- 3Microbiology, All India Institute of Medical Sciences, New Delhi, India
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Abdallah M, Alsaleh H, Baradwan A, Alfawares R, Alobaid A, Rasheed A, Soliman I. Intraventricular Tigecycline as a Last Resort Therapy in a Patient with Difficult-to-Treat Healthcare-Associated Acinetobacter baumannii Ventriculitis: a Case Report. ACTA ACUST UNITED AC 2020; 2:1683-1687. [PMID: 32838183 PMCID: PMC7415013 DOI: 10.1007/s42399-020-00433-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2020] [Indexed: 12/21/2022]
Abstract
Healthcare-associated ventriculitis and meningitis is a common complication in patients who suffer from head trauma or have undergone a neurosurgery. Healthcare-associated ventriculitis and meningitis is associated with significant morbidity and mortality. Complications of healthcare-associated ventriculitis and meningitis include persistent vegetative state, moderate and severe disability, and death. Acinetobacter baumannii is the causative pathogen in 3.6–11.2% of cases of healthcare-associated ventriculitis and meningitis. Cases of difficult-to-treat healthcare-associated A. baumannii ventriculitis and meningitis are being reported more frequently. However, in most of these cases, a combination of intravenous (IV) and intraventricular (IVT)/intrathecal colistin achieves good therapeutic outcome. This report describes a clinical case of difficult-to-treat healthcare-associated A. baumannii ventriculitis. The A. baumannii strain was sensitive to colistin and trimethoprim-sulfamethoxazole, intermediate to tigecycline, and resistant to other antibiotics. While colistin was the drug of choice in our case, the patient developed anaphylactoid reaction during the IV administration of the loading dose of colistin, which mandated us to discontinue colistin and complicated the treatment of our patient. The patient did not respond to a combination of IV antibiotics that included meropenem, trimethoprim-sulfamethoxazole, and tigecycline. However, when IVT tigecycline was added as a last-resort therapeutic option, the patient’s ventriculitis dramatically improved, and the patient was discharged from the hospital. Physicians who treat patients with healthcare-associated A. baumannii ventriculitis might resort to IVT tigecycline when they run out of therapeutic options.
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Affiliation(s)
- Mohammad Abdallah
- Pharmaceutical Care Services, King Saud Medical City, Riyadh, Saudi Arabia
| | - Hamzeh Alsaleh
- Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Abdallah Baradwan
- The Division of Infectious Diseases, King Saud Medical City, Riyadh, Saudi Arabia
| | | | - Abdulaziz Alobaid
- Pharmaceutical Care Services, King Saud Medical City, Riyadh, Saudi Arabia
| | - Akram Rasheed
- Department of Nursing Education and Development, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ibrahim Soliman
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
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Yang W, Wu X, Li Z, Yuan Q, Wu G, Yu J, Wu X, Du Z, Hu J, Zhou L. Trends of Intra-Cranial Bacterial Infection in Patients Requiring Emergency Neurosurgery. Surg Infect (Larchmt) 2020; 21:677-683. [PMID: 31944897 DOI: 10.1089/sur.2019.317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Intra-cranial bacterial infection is a serious complication in emergency neurosurgical patients, and few data are available on the trends of these infections and the rates of antibacterial drug resistance. Methods: We surveyed retrospectively the patients with intra-cranial bacterial infection in our emergency neurosurgical center between January 2009 and December 2018. Demographic characteristics, causative bacteria, and antimicrobial susceptibility test results were collected. Results: A total of 100 patients with intra-cranial bacterial infection, 1.41% of our patients, were enrolled. There were 123 strains of bacteria cultured from the cerebrospinal fluid (CSF), consisting of 96 strains of gram-negative (GN) bacteria and 27 strains of gram-positive (GP) bacteria. Compared with the GP bacteria, the percentage of GN bacteria increased to 75.0% of the total near the end of the study. Compared with Acinetobacter baumannii, Klebsiella pneumoniae also showed an uptrend. Most of the bacteria were multi-drug-resistant (MDR). We further analyzed the consistency of CSF and sputum cultures from the same patient. The ratio of Klebsiella pneumoniae and Acinetobacter baumannii to the corresponding strains in the CSF were 77.0% and 62.0%. Conclusions: The bacteria recovered from the CSF were mainly GN. The tendency of GN bacteria showed an uptrend, especially for Klebsiella pneumoniae. Furthermore, most of the bacteria were MDR.
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Affiliation(s)
- Weijian Yang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhiqi Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Gang Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jian Yu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xuehai Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhuoying Du
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Liangfu Zhou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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Brotis AG, Churis I, Karvouniaris M. Local complications of adjunct intrathecal antibiotics for nosocomial meningitis associated with gram-negative pathogens: a meta-analysis. Neurosurg Rev 2019; 44:139-152. [PMID: 31875280 DOI: 10.1007/s10143-019-01226-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/21/2019] [Accepted: 12/11/2019] [Indexed: 10/25/2022]
Abstract
Direct delivery of antibiotics to the ventricular system offers an alternative for the management of nosocomial meningitis. However, the available literature frequently results in controversial findings regarding its safety. The present meta-analysis aimed at summarizing the risk of local complications after the administration of intraventricular/intrathecal (IVT/IT) antibiotics for the treatment of ventriculitis/meningitis (VM) associated with gram-negative pathogens. We systematically searched the medical literature from 1964 until July 2018, for clinical studies reporting on complications after the index treatment. The quality of the eligible studies was classified as "high," "moderated," and "low" for randomized controlled trials, observational studies, and case series, respectively. The results were summarized as pooled frequencies, estimated by the random- or fixed-effects models, according to the inter-study heterogeneity. The publication bias was visualized in trim-and-fill funnel plots. Τhe analysis included twenty-three primary studies with 229 patients. The overall complication rate was as high as 0.13 (95% CI 0.08; 0.19, I2 = 9%); chemical meningitis and seizures represented the majority of the complications, with an occurrence rate of 0.11 (95% CI 0.07; 0.17, I2 = 0%) and 0.07 (95% CI 0.04; 0.12; I2 = 0%), respectively. The meta-analysis was based on studies of "moderate" and "low" reporting quality, while the publication bias after inspecting of the funnel plots revealed significant asymmetry. The present review denotes the absence of large, high-quality studies in the field. Nevertheless, IVT/IT was associated with moderate morbidity, mainly attributed to chemical meningitis and seizures. Further high-quality studies are still required before this therapeutic modality becomes broadly established.
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Affiliation(s)
- Alexandros G Brotis
- Department of Neurosurgery, University Hospital of Larissa, Biopolis, Larissa, Greece.
| | - Isaac Churis
- Intensive Care Unit, General Hospital of Giannitsa, Giannitsa, Greece
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23
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Nørgaard SM, Jensen CS, Aalestrup J, Vandenbroucke-Grauls CMJE, de Boer MGJ, Pedersen AB. Choice of therapeutic interventions and outcomes for the treatment of infections caused by multidrug-resistant gram-negative pathogens: a systematic review. Antimicrob Resist Infect Control 2019; 8:170. [PMID: 31709047 PMCID: PMC6830003 DOI: 10.1186/s13756-019-0624-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/09/2019] [Indexed: 12/24/2022] Open
Abstract
Background Antimicrobial resistance is an increasingly serious threat to public health, and the increased occurrence of multidrug-resistant (MDR) bacteria is a concern in both high-income and low- and middle-income countries. The purpose of this systematic review was to identify and critically appraise current antimicrobial treatment options for infections with MDR Gram-negative bacteria. Methods A literature search for treatment of MDR extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae, A. baumannii, and P. aeruginosa was conducted in MEDLINE in January 2019. Relevant studies published in English, German, and French that evaluated clinical success, microbiological success, and 30-day mortality outcomes were included. The population of interest was adult patients. Results Of 672 studies, 43 met the inclusion criteria. Carbapenems are the most common antibiotics used for the treatment of ESBL-producing Enterobacteriaceae. The clinical and microbiological success was similar for group 1 carbapenems (imipenem, meropenem, or doripenem), group 2 carbapenems (ertapenem), and non-carbapenem antibiotics. Mortality data were contradictory for group 1 carbapenems compared to group 2 carbapenems. The most common treatment option for A. baumannii and P. aeruginosa infections was intravenous colistin, regardless of infection site. Clinical success and mortality were similar in A. baumannii infections treated with colistin combination therapy vs. colistin monotherapy, whereas heterogeneous results were found with respect to microbiological success. Monotherapy and colistin combination therapy were used against P. aeruginosa with clinical and microbiological success (70–100%) depending on the infection site and severity, and the antibiotic used. Ceftazidime-avibactam therapy for ESBL-producing Enterobacteriaceae and P. aeruginosa showed good clinical success in one study. Conclusion We did not find robust evidence for antibiotic treatment of any infection with MDR Gram-negative bacteria, including ESBL-producing Enterobacteriaceae, A. baumannii, and P. aeruginosa, that would lead to a firm recommendation for one specific antibiotic over another or for monotherapy over combination therapy. The choice of antibiotic treatment should be based on susceptibility testing balancing the expected clinical success rate against the risk of development of antibiotic resistance and the risk of severe side effects.
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Affiliation(s)
- Sarah Melissa Nørgaard
- 1Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus, N Denmark
| | - Camilla Skaarup Jensen
- 1Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus, N Denmark
| | - Josefine Aalestrup
- 1Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus, N Denmark
| | - Christina M J E Vandenbroucke-Grauls
- 3Medical Microbiology and Infection Control, Amsterdam University Medical Centers, Vrije Universiteit, De Boelelaan 1117 Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Mark G J de Boer
- 2Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Alma Becic Pedersen
- 1Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus, N Denmark
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24
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Hu Y, He W, Yao D, Dai H. Intrathecal or intraventricular antimicrobial therapy for post-neurosurgical intracranial infection due to multidrug-resistant and extensively drug-resistant Gram-negative bacteria: A systematic review and meta-analysis. Int J Antimicrob Agents 2019; 54:556-561. [PMID: 31398478 DOI: 10.1016/j.ijantimicag.2019.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/26/2019] [Accepted: 08/01/2019] [Indexed: 01/30/2023]
Abstract
This review investigated the effectiveness and safety of intrathecal (ITH) or intraventricular (IVT) antimicrobial therapy for post-neurosurgical intracranial infection due to multidrug-resistant (MDR) and extensively drug-resistant (XDR) Gram-negative bacteria. Electronic databases including PubMed, EMBASE and the Cochrane Library databases were searched for clinical studies that compared the addition of ITH/IVT therapy with intravenous (IV) monotherapy in the treatment of post-neurosurgical intracranial infection due to MDR/XDR Gram-negative bacteria. Eligible articles were analysed using Stata/SE software v.12.0. Publication bias was assessed using Begg's funnel plot and Egger's test. Nine studies involving 296 patients were included. The odds ratio (OR) for death (IV+ITH/IVT versus IV) reported in the included studies ranged from 0.02-0.93. The overall pooled OR was 0.15 [95% confidence interval (CI) 0.08-0.28; P < 0.001] and the risk of mortality was significantly different between the two groups. Microbiological clearance was significantly different between the two groups, with a pooled OR of 0.02 (95% CI 0.01-0.10; P < 0.001). In observational studies, addition of ITH/IVT antimicrobial therapy is associated with a lower risk of mortality and a higher microbiological clearance rate, with mild adverse effects, in patients with post-neurosurgical intracranial infection due to MDR/XDR Gram-negative bacteria. A well-designed randomised controlled trial is necessary to address this important issue.
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Affiliation(s)
- Yangmin Hu
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
| | - Wei He
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
| | - Difei Yao
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
| | - Haibin Dai
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China.
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25
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Le Tilly O, Bretonnière C, Grégoire M. La pharmacologie des antibiotiques dans le liquide cérébrospinal. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Le liquide cérébrospinal (LCS) est produit par les plexus choroïdes des ventricules cérébraux avec pour rôle de protéger le système nerveux central des agressions mécaniques (chocs) et infectieuses (virus, bactéries, parasites) et de lui apporter des nutriments essentiels à son fonctionnement optimal. Il est anatomiquement à l'interface entre le compartiment sanguin, le liquide interstitiel cérébral et le compartiment lymphatique. Sa composition est fortement influencée par ces structures. Deux barrières permettent de réguler le passage moléculaire dans le système nerveux central et limitent fortement l'accès à ce dernier : la barrière hématoencéphalique et la barrière hématoméningée. La diffusion des antibiotiques dans le LCS, mais également dans le parenchyme cérébral dépend de plusieurs facteurs : la taille de la molécule, sa lipophilie, la liaison aux protéines plasmatiques et l'intégrité des barrières hématoencéphalique et hématoméningée. Les phénomènes d'inflammation méningée observés dans les méningites bactériennes augmentent la perméabilité des barrières et facilitent la diffusion des agents antibiotiques. Les molécules diffusant le mieux dans le LCS sont les fluoroquinolones, le linézolide, l'association triméthoprime- sulfaméthoxazole, la rifampicine et la fosfomycine. Les bêtalactamines présentent une diffusion assez faible mais qui augmente fortement en cas d'inflammation méningée. Des posologies journalières très élevées permettent de contourner l'écueil de la diffusion. De nombreux paramètres influencent la diffusion des antibiotiques dans le LCS. Le choix de l'antibiothérapie adaptée se fait en fonction de ces paramètres et du type d'infection à traiter en concertation pluridisciplinaire.
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