Pseudomonas aeruginosa infection in an intrathecal baclofen pump: successful treatment with adjunct intra-reservoir gentamicin

The presence of Candida parapsilosis with intrathecal baclofen pump in a person with high cervical spinal cord injury; infection or colonization? A Case Report

INTRODUCTION

Intrathecal baclofen (ITB) therapy is an effective method of treating spasticity in persons with spasticity due to spinal cord injury (SCI), but complications are not rare and can include spinal fluid leaks, infection, and catheter/pump malfunction.

CASE PRESENTATION

This study presents information related to an adult male patient with traumatic SCI and a history of two prior ITB pump pocket infections that required removal due to pump infection. The patient then developed skin erosion over the third pump, and the fluid around the pump grew methicillin-sensitive Staphylococcus aureus, diphtheroids, and Candida parapsilosis. The patient was initially treated with antibiotics and anti-fungal medication without removal of the ITB pump. The ITB pump was eventually removed 27 months later, and the fourth pump was implanted 10 months later.

DISCUSSION

ITB pumps can be an effective treatment modality for spasticity in people with SCI; however, complications, including infection, can occur and require pump removal. This case illustrates a case of possible Candida colonization of the ITB pump, which was eventually removed.

Intrathecal Baclofen Pump Infection With Meningitis: Effective Treatment by Radical Debridement and Intrareservoir Baclofen-Vancomycin Co-Infusion

OBJECTIVES

Intrathecal baclofen pump associated central nervous system (CNS) infection and meningitis is a rare but serious complication and may have dire consequences. Due to bacterial biofilm formation, the optimal treatment strategy is usually for removal of the pump, followed by systemic antibiotics for treatment of local and CNS infection. We describe this case of a patient with recurrent Staphylococcus aureus pump site empyema and meningitis leading to status dystonicus, who was successfully managed with radical debridement and intrareservoir baclofen-vancomycin co-infusion.

MATERIALS AND METHODS

We retrospectively report a case of infected intrathecal baclofen pump with meningitis and provide a full review of literature.

CONCLUSIONS

To the best of our knowledge, this is the first reported case of intrathecal baclofen (ITB)-associated pump site empyema and meningitis successfully treated with this technique. In selected cases where surgical explantation is deemed not feasible, this method can provide clinicians with an additional option for pump salvage and retention, while eradicating CNS infection and maintaining optimal control of spasticity and dystonia.

Baclofen Pumps: Uses and Complications

Intrathecal baclofen therapy, given via an implanted pump in the abdominal wall either as a continuous infusion or bolus dosing, has been used for more than 25 years to treat the spasticity and dystonia associated with various brain and spinal cord conditions. Pediatric clinicians occasionally encounter baclofen pumps, and in the pediatric setting, significant morbidity can arise from their use. This article presents the background, mechanism of action, uses, and complications of intrathecal baclofen therapy and discusses various management strategies should complications occur.

Intrathecal baclofen pump infection treated by adjunct intrareservoir teicoplanin instillation

Background:

The delivery of intrathecal baclofen via pumps is gaining increasing use in the management of intractable spasticity. One of the rare but devastating complications of this method is infection. In the majority of cases, removal of the device is required, despite appropriate intravenous antibiotic therapy. We report a case that highlights the use of intrareservoir teicoplanin to achieve sterilization of the infected pump system in a patient in whom removal of the pump was not an easy option.

Case Description:

We describe our experience on a patient with cerebral palsy in whom Staphylococcus epidermidis pump infection developed due to contamination of the infusion reservoir during refilling procedure, which was successfully sterilized in situ by the combined use of systemic antibiotics and intrareservoir coadministration of baclofen with teicoplanin. The infection was eradicated and baclofen therapy was continued uninterrupted.

Conclusions:

Removal of intrathecal baclofen pump is not necessary as the first measure in cases with mild clinical symptomatology. In view of the fact that pumps for intrathecal drug delivery are very costly, salvage of the device may be attempted in selected cases, although it is not generally recommended. Combined infusion of baclofen and an antibiotic through the pump makes it possible to maintain treatment for spasticity, sterilize the pump reservoir and flow tubes, and effectively treat infections that develop during the use of these systems.

Efficacy of intraoperative vancomycin powder use in intrathecal baclofen pump implantation procedures: single institutional series in a high risk population

We aimed to assess the efficacy of intraoperative vancomycin powder in intrathecal baclofen pump placement patients, a high risk population. A retrospective review was conducted using prospectively collected data at an academic tertiary care unit. The neurosurgical adult patient population was queried for all intrathecal baclofen pump implantation procedures. Patients were then reviewed for the use of intraoperative crystalline vancomycin powder. Those with a history of prior surgical site infection, chronic systemic infections or osteomyelitis were excluded. Anhydrous, crystalline vancomycin was utilized in the wound bed after completion of implantation, distributed evenly in the case of multiple incisions. Patients received 500 mg or 1,000 mg of crystallized vancomycin, evenly distributed through the wound layers based on a 70 kg weight cutoff. Intraoperative institutional standards of infection prophylaxis were unchanged throughout the study period. Infection rate of baclofen pump placement prior to the use of vancomycin powder from 2001-2009 at the same institution was monitored. Wound infection rate was tracked for a 12 month postoperative period. Six patients out of 26 baclofen pump implantations (23%) in this cohort were identified to have seven infections despite vancomycin powder placement in the lumbar and catheter wounds. Prior infection rates have been investigated for intrathecal drug delivery systems from 2001 to 2009 at the same institution with an overall infection rate of 3% (8/274). The use of vancomycin powder in patients with implants in this series did not reduce infection rates compared to published historical controls, and was elevated compared to institutional controls. Further prospective study of this high risk patient population is warranted.

Infectious complications of intrathecal baclofen pump devices in a pediatric population

BACKGROUND

Intrathecal baclofen (ITB) is an effective therapy for spasticity and dystonia in pediatric populations; however, there are associated infectious complications.

METHODS

Patients who had an initial ITB device implanted at our center were followed to determine the proportion of patients with infectious and noninfectious complications, identify risk factors for infection and describe the clinical presentations, treatment and outcomes of infectious complications.

RESULTS

Over the 15-year study period, 139 patients had an initial ITB device placed. The mean age at placement was 13.6 years (range: 6 months to 41 years). In the first year of follow-up, 83% had no complications or secondary procedures, 17% had at least 1 secondary procedure and 5% had an infectious complication. The median time until infection was 14 days (mean 33 ± 42 days). Patients with secondary spasticity or dystonia were more likely to have infections than patients with cerebral palsy (86% versus 14%; P < 0.0001). In the 94 patients with a first secondary procedure, 29% had at least 1 other procedure and 8% had an infection in the 1 year follow-up. Overall, 24 patients had 27 infections; 22% superficial, 33% deep and 45% organ space. Staphylococcus aureus was isolated in 50% of those with cultures obtained. Explantation was required in 59% of patients with an infection and differed by infection type: superficial (17%), deep (44%) and organ space (92%) (P = 0.004).

CONCLUSIONS

Infectious complications were relatively uncommon; however, when present, frequently led to the explantation of the ITB pump device.

Evaluation of salvage techniques for infected baclofen pumps in pediatric patients with cerebral palsy

OBJECT

Intrathecal baclofen therapy has been used successfully for intractable spasticity in children with cerebral palsy. Infections are rare, but they are potentially life threatening if complicated by bacteremia or meningitis. Treatment without removal of the system is desirable if it can be done safely and effectively.

METHODS

The Authors reviewed the records of 207 patients ranging from 3 to 18 years of age with cerebral palsy who underwent placement or revision of a baclofen pump. They identified 38 patients with suspected or documented infectious complications. Initial attempts were made to eradicate infection with the devices in situ in all patients. Methods and effectiveness of pump salvage were evaluated.

RESULTS

Of the 38 patients identified, 13 (34.2%) had documented infections; 11 had deep wound/pocket empyemas and 2 had meningitis. Eight patients with deep wound infections received intravenous antibiotics alone. All required pump explantation. The remaining 3 patients underwent a washout procedure as well; the infection was cured in 1 patient. Both patients with meningitis received intravenous and intrathecal antibiotics, and both required device explantation. In addition, 25 patients (65.8%) had excessive or increasing wound erythema. No objective criteria to document a superficial infection were present. The wounds were considered suspicious and were managed with serial examinations and oral antibiotics. The erythema resolved in 24 of the 25 patients.

CONCLUSIONS

In general, observation, wound care, and oral antibiotics are sufficient for wounds that are suspicious for superficial infection. For deep-seated infection, antibiotic therapy alone is generally insufficient and explantation is required. Washout procedures can be considered, but failures are common.

Baclofen pump implantation and spinal fusion in children: techniques and complications

STUDY DESIGN

Retrospective clinical and radiographic review of complications related to intrathecal baclofen therapy (ITB) and posterior spine fusion (PSF) in patients with cerebral palsy.

OBJECTIVE

To report the technical considerations and complications associated with ITB in patients undergoing PSF.

SUMMARY OF BACKGROUND DATA

A common treatment for spasticity in children with cerebral palsy is ITB. This population also has a high incidence of severe spinal deformities requiring PSF.

METHODS

There were 4 groups: A, 26 patients with PSF before ITB; B, 11 patients who underwent PSF and ITB concurrently; C, 25 patients with PSF after ITB; and D, the control group: 103 patients with ITB only. Complications and infections were tabulated from a retrospective chart review and ongoing surveillance data. Multiple chi analyses were used to compare the number of patients who experienced complications and infections among the groups. The operative sequence and catheter management techniques for the various scenarios are described in detail in the text.

RESULTS

The outcome by group was as follows: group A had 5 catheter malfunctions and 2 infections at the pump site, group B had 2 catheter malfunctions, 1 hypermobile pump and 1 infection at the spinal site, group C had 3 catheter malfunctions, 1 infection at the pump site and 1 infection at the spinal site. The control group had 23 catheter malfunctions, 5 pump failures, 8 infections at the pump site, and 1 infection at the spinal site. Multiple chi analyses showed no difference in the number of infection or device/catheter complications among any of the groups.

CONCLUSION

The rate of ITB therapy complications is not increased despite PSF in any order of the procedures. There are technical details in each situation that require attention. With understanding of the appropriate techniques of catheter management, ITB pumps can be implanted and managed without an increased complication rate before, during or after spinal fusion surgery.

Intrathecal baclofen does not inhibit the growth of different bacterial species and Candida albicans

BACKGROUND

The antimicrobial activity of intrathecal baclofen was investigated. Several different microorganisms were used: Staphylococcus aureus (beta-lactamase-positive and beta-lactamase-negative strains); S epidermidis; Enterococcus faecalis; Klebsiella pneumoniae; Escherichia coli; Pseudomonas aeruginosa; and Candida albicans.

METHODS

Three experimental approaches were used to assess baclofen antimicrobial activity: (1) determination of the MIC; (2) determination of the MBC; and (3) kinetic time-kill assay. Experiments were performed according to current methods of the NCCLS.

RESULTS

As compared with control organisms exposed to physiologic saline, organisms exposed to baclofen over a 10-day period failed to reduce the number of viable cells by at least 3 log(10), as requested by NCCLS criteria.

CONCLUSIONS

Because the viability of the investigated organisms was not reduced over that of microbial suspensions exposed to physiologic saline, we conclude that intrathecal baclofen has no measurable activity against different bacterial species and C albicans.

Baclofen pump pocket infection: a case report of successful salvage with muscle flap

Programmable pump for continuous infusion of intrathecal baclofen, an agonist of the inhibitory neurotransmitter gamma-aminobutyric acid, is nowadays being widely used to control spasticity. The most common complications leading to explantation of the pumps are skin breakdown and infection at the pump implantation site which cannot be effectively treated without pump removal. We report a 37-year-old man who developed a baclofen pump pocket infection that did not respond to antibiotic therapy. Because the continuation of intrathecal baclofen administration was critical to the patient, and because the high cost of the pump precluded its prompt replacement, the pump was salvaged using the ipsilateral rectus abdominis muscle that was elevated on its inferior vascular pedicle and wrapped around the pump. Abdominal skin was then approximated, leaving a small portion of exposed muscle overlying the refill site that was covered by a split-thickness skin graft. Continuous intrathecal baclofen administration was never discontinued. Three months later, the pump's refill site could be easily identified manually for pump refill. There were no signs of recurrent infection during the 2-year follow-up period.

Prolonged intrathecal baclofen withdrawal syndrome. Case report and discussion of current therapeutic management

The authors describe a patient who experienced a prolonged course of intrathecal baclofen withdrawal syndrome after removal of an implantable baclofen pump for treatment of pump infection and meningitis. The current literature outlines management options for the acute management of this syndrome. In this report the authors discuss the long-term presentation of this syndrome and suggest a treatment strategy for management of the syndrome. A 37-year-old man who presented with a baclofen pump infection and meningitis experienced acute onset of intrathecal baclofen withdrawal syndrome 12 hours after the pump had been surgically removed. The patient's symptoms evolved into a severe, treatment-refractory withdrawal syndrome lasting longer than 1 month. Oral baclofen replacement with adjunctive administration of parenteral gamma-aminobutyric acid agonists only served to stabilize the patient's critical condition throughout his hospital course. Replacement of the baclofen pump and restoration of intrathecal delivery of the medication was necessary to trigger the patient's dramatic recovery and complete reversal of the withdrawal syndrome within approximately 48 hours. These findings indicate that a more direct method of treating infected baclofen pumps than immediate surgical removal is necessary to prevent the onset of intrathecal baclofen withdrawal syndrome. Various options for preventing the onset of the syndrome while simultaneously treating the infection are discussed.

Treatment of spasticity with intrathecal Baclofen administration: long-term follow-up, review of 40 patients

STUDY DESIGN

Case series of a consecutive sample. Retrospective audit.

OBJECTIVE

To analyze the long-term safety and efficacy of intrathecal baclofen (ITB), and technical incidents.

SETTING

Neurosurgical and Physical Medicine Departments of two university hospitals in western France.

METHODS

The medical records of 40 patients who underwent ITB pump placement for the treatment of severe chronic spasticity were reviewed. Patients were eligible independently of the origin of the spasticity (spinal cord origin 33, brain damage 8). They underwent a final assessment with clinical examination and questionnaire in 2001. Ashworth scale scores were assessed, patient satisfaction was rated on a visual analog scale (VAS), functional independence before and after treatment was classified as bed-ridden, wheelchair dependent or ambulant, and the frequency and nature of complications were noted.

RESULTS

The average follow-up period was of 4 years. The average Ashworth score at the final assessment was 1.8+/-0.6. Average patients satisfaction was 7.4/10+/-2.21 on VAS. In all, 85% would have undergone the procedure again if they had to make the decision. In 85% of the cases the ambulation status was unchanged. Technical incidents occurred at least once in 37% of the patients (due to the catheter in 58% and to the pump in 42%). They included catheter disconnections (4), migration (4), kinks (3), obstruction (3), development of fibrosis (3), disconnection of pump reservoir (2), porosity of pump membrane (2), unexplained pump dysfunction (4) leakage, and subcutaneous collection (5). Severe pharmacological side effects requiring transfer to intensive care unit occurred in 12% of cases, 80% of which were directly related to pump refill procedures.

CONCLUSION

ITB remained effective in the long term and patients were satisfied. Nevertheless, complications were frequent, involving mainly the catheters, which would require further technical improvements.