Vancomycin-resistant Enterococcus faecium meningitis successfully treated with chloramphenicol

A new strategy to fight antimicrobial resistance: the revival of old antibiotics

The increasing prevalence of hospital and community-acquired infections caused by multidrug-resistant (MDR) bacterial pathogens is limiting the options for effective antibiotic therapy. Moreover, this alarming spread of antimicrobial resistance has not been paralleled by the development of novel antimicrobials. Resistance to the scarce new antibiotics is also emerging. In this context, the rational use of older antibiotics could represent an alternative to the treatment of MDR bacterial pathogens. It would help to optimize the armamentarium of antibiotics in the way to preserve new antibiotics and avoid the prescription of molecules known to favor the spread of resistance (i.e., quinolones). Furthermore, in a global economical perspective, this could represent a useful public health orientation knowing that several of these cheapest “forgotten” antibiotics are not available in many countries. We will review here the successful treatment of MDR bacterial infections with the use of old antibiotics and discuss their place in current practice.

First Confirmed Case of Vancomycin-ResistantEnterococcus faeciumMeningitis in Turkey:

Vancomycin-resistant enterococci are unusual etiologic agents of bacterial meningitis and pose significant therapeutic difficulties. We report the first confirmed case of nosocomial vancomycin-resistant Enterococcus faecium meningitis in Turkey. The patient was treated with chloramphenicol and cerebrospinal fluid cultures became negative, but clinical success was not achieved. We also review the previously reported cases of vancomycin-resistant Enterococcus faecium meningitis.

Successful treatment of vancomycin-resistant Enterococcus faecium ventriculitis with combined intravenous and intraventricular chloramphenicol in a newborn

Vancomycin-resistant Enterococcus faecium (VRE) infection is a rare event in paediatric patients and often occurs under immunosuppression or after surgical intervention. We report what we believe to be the first paediatric case of ventriculitis due to VRE (in a 2-month-old infant) to be successfully treated with combined intravenous (i.v.) and intraventricular chloramphenicol after failure of i.v. linezolid and intraventricular gentamicin.

Failure of vancomycin treatment for meningitis caused by vancomycin-susceptible Enterococcus faecium

This case report describes a nosocomial vancomycin-sensitive Enterococcus faecium meningitis with poor response to vancomycin. E. faecium infections continue to represent a therapeutic challenge in Europe, even in countries where vancomycin resistance is still rare. In the case of vancomycin-sensitive E. faecium meningitis, intravenous chloramphenicol should be considered as a treatment option.

Elimination of vancomycin-resistant enterococci from a neonatal intensive care unit following an outbreak

A policy of weekly faecal cultures for vancomycin-resistant enterococci (VRE) was instituted following the investigation of an outbreak of VRE in our neonatal intensive care unit in 2005. We found that 11 of 18 patients were infected or colonised during the outbreak, including three cases of bloodstream infection and one case of meningitis. This report describes the utility of the surveillance policy in maintaining a VRE-free environment. The outbreak investigation showed that all VRE isolated were Enterococcus faecium of the vanA type. Pulsed-field gel electrophoresis suggested that the outbreak was caused by a single strain. Control of the outbreak was achieved by enhanced contact isolation precautions, cohorting of patients and staff, improved environmental decontamination and closure of the unit to new admissions. The patients with bloodstream infections and meningitis were treated successfully with linezolid. Approximately one year after the outbreak, weekly surveillance detected two patients with faecal carriage of VRE whose periods of admission overlapped. Early intensive intervention was associated with disappearance of the organism from the neonatal intensive care unit. No further cases of colonisation or disease have occurred in the unit in the two and a half years since then.

Enterococcal meningitis: a clinical study of 39 cases and review of the literature

To describe the clinical features and outcome of enterococcal meningitis, we retrospectively reviewed the charts of 39 cases seen at 2 tertiary hospitals during a 25 years and collected 101 additional, previously reported cases for review. Among these 140 cases, there were 82 cases (59%) of postoperative meningitis and 58 cases (41%) of spontaneous meningitis. Eighty-six patients (61%) were adults and 54 (39%) were children. Patients with spontaneous meningitis had a higher frequency of community-acquired infection (50% versus 18%; p < 0.01), severe underlying diseases (67% versus 22%; p < 0.01), and associated enterococcal infection (29% versus 8%; p < 0.01) than patients with postoperative meningitis. The clinical presentation was similar in both groups, but patients with spontaneous infection had a higher frequency of bacteremia (58% versus 12%; p < 0.01), and a lower frequency of mixed infection (9% versus 29%; p < 0.01). Spontaneous meningitis in children was associated with a significantly lower frequency of fever, altered mental status, headache, and meningeal signs (p < 0.01), probably explained by the high proportion of neonates in this age-group. Most infections were caused by Enterococcus faecalis, which accounted for 76% of the isolates identified at the species level. Fifteen of the 25 cases due to Enterococcus faecium were produced by vancomycin-resistant strains. Most patients were treated with ampicillin, penicillin, or vancomycin, with or without aminoglycosides, for a median period of 18 days (range, 1-85 d). Overall mortality was 21%. The mortality rate was higher in spontaneous than in postoperative meningitis (33% versus 12%; p < 0.01), but was similar in patients treated with beta-lactams (18%), glycopeptides (14%), or other antibiotics (25%), as well as in patients treated with monotherapy (16%) or combination therapy (22%). An adverse outcome correlated significantly with advanced age, the presence of severe underlying diseases, associated enterococcal infection, bacteremia, septic shock, and the absence of fever at presentation. Shunt removal was associated with a lower mortality. Multivariate analysis showed that the presence of severe underlying diseases was the only prognostic factor associated with mortality (odds ratio = 6.8, 95% confidence intervals = 2.7-17.5, p < 0.01).

Treatment of central nervous system infection by vancomycin-resistant enterococcus faecium

Enterococci are uncommon causes of CNS infection. We describe a case of ventriculitis and Ommaya reservoir infection due to vancomycin-resistant Enterococcus faecium successfully treated with the combination of i.v. quinupristin/dalfopristin and i.v. linezolid. The patient deteriorated after receiving three dosages of intraventricular quinupristin/dalfopristin. He recovered after discontinuation of intraventricular quinupristin/dalfopristin.

Linezolid treatment of vancomycin-resistant Enterococcus faecium ventriculitis

The successful treatment of a 7-month-old infant with shunt-associated ventriculitis caused by vancomycin-resistant Enterococcus faecium is presented. Linezolid was administered intravenously every 8 h; children have a greater volume of distribution and total body clearance than adults and therefore require more frequent dosing. The patient tolerated the therapy without adverse effects.

Treatment options for vancomycin-resistant enterococcal infections

Serious infection with vancomycin-resistant enterococci (VRE) usually occurs in patients with significantly compromised host defences and serious co-morbidities, and this magnifies the importance of effective antimicrobial treatment. Assessments of antibacterial efficacy against VRE have been hampered by the lack of a comparator treatment arm(s), complex treatment requirements including surgery, and advanced illness-severity associated with a high crude mortality. Treatment options include available agents which don't have a specific VRE approval (chloramphenicol, doxycycline, high-dose ampicillin or ampicillin/sulbactam), and nitrofurantoin (for lower urinary tract infection). The role of antimicrobial combinations that have shown in vitro or animal-model in vivo efficacy has yet to be established. Two novel antimicrobial agents (quinupristin/ dalfopristin and linezolid) have emerged as approved therapeutic options for vancomycin-resistant Enterococcus faecium on the basis of in vitro susceptibility and clinical efficacy from multicentre, pharmaceutical company-sponsored clinical trials. Quinupristin/dalfopristin is a streptogramin, which impairs bacterial protein synthesis at both early peptide chain elongation and late peptide chain extrusion steps. It has bacteriostatic activity against vancomycin-resistant E. faecium [minimum concentration to inhibit growth of 90% of isolates (MIC(90)) = 2 microg/ml] but is not active against Enterococcus faecalis (MIC(90 )= 16 microg/ml). In a noncomparative, nonblind, emergency-use programme in patients who were infected with Gram-positive isolates resistant or refractory to conventional therapy or who were intolerant of conventional therapy, quinupristin/dalfopristin was administered at 7.5 mg/kg every 8 hours. The clinical response rate in the bacteriologically evaluable subset was 70.5%, and a 65.8% overall response (favourable clinical and bacteriological outcome) was observed. Resistance to quinupristin/dalfopristin on therapy was observed in 6/338 (1.8%) of VRE strains. Myalgia/arthralgia was the most frequent treatment-limiting adverse effect. In vitro studies which combine quinupristin/dalfopristin with ampicillin or doxycyline have shown enhanced killing effects against VRE; however, the clinical use of combined therapy remains unestablished. Linezolid, an oxazolidinone compound that acts by inhibiting the bacterial pre-translational initiation complex formation, has bacteriostatic activity against both vancomycin resistant E. faecium (MIC(90) = 2 to 4 microg/ml) and E. faecalis (MIC(90) = 2 to 4 microg/ml). This agent was studied in a similar emergency use protocol for multi-resistant Gram-positive infections. 55 of 133 evaluable patients were infected with VRE. Cure rates for the most common sites were complicated skin and soft tissue 87.5% (7/8), primary bacteraemia 90.9% (10/11), peritonitis 91.7% (11/12), other abdominal/pelvic infections 91.7% (11/12), and catheter-related bacteraemia 100% (9/9). There was an all-site response rate of 92.6% (50/54). In a separate blinded, randomised, multicentre trial for VRE infection at a variety of sites, intravenous low dose linezolid (200mg every 12 hours) was compared to high dose therapy (600 mg every 12 hours) with optional conversion to oral administration. A positive dose response (although statistically nonsignificant) was seen with a 67% (39/58) and 52% (24/46) cure rate in the high- and low-dose groups, respectively. Adverse effects of linezolid therapy have been predominantly gastrointestinal (nausea, vomiting, diarrhoea), headache and taste alteration. Reports of thrombocytopenia appear to be limited to patients receiving somewhat longer courses of treatment (>14 to 21 days). Linezolid resistance (MIC > or = 8 microg/ml) has been reported in a small number of E. faecium strains which appears to be secondary to a base-pair mutation in the genome encoding for the bacterial 23S ribosome binding site. At present a comparative study between the two approved agents for VRE (quinupristin/dalfopristin and linezolid) has not been performed. Several investigational agents are currently in phase II or III trials for VRE infection. This category includes daptomycin (an acidic lipopeptide), oritavancin (LY-333328; a glycopeptide), and tigilcycline (GAR-936; a novel analogue of minocycline). Finally, strategies to suppress or eradicate the VRE intestinal reservoir have been reported for the combination of oral doxycyline plus bacitracin and oral ramoplanin (a novel glycolipodepsipeptide). If successful, a likely application of such an approach is the reduction of VRE infection during high risk periods in high risk patient groups such as the post-chemotherapy neutropenic nadir or early post-solid abdominal organ transplantation.

Successful treatment of vancomycin-resistant enterococcus meningitis with linezolid: Case report and review of the literature

OBJECTIVE

To describe the successful treatment of a case of vancomycin-resistant enterococcus meningitis with linezolid.

DESIGN

Case report and review of the literature.

PATIENTS

The patient is a 35-yr-old man who suffered a cerebellar hemorrhage after embolization of a cerebellar arteriovenous malformation. The patient underwent ventriculostomy drainage and craniectomy. The patient was on broad-spectrum antibiotics for pneumonia including vancomycin. The patient remained febrile and grew vancomycin-resistant Enterococcus faecium from the cerebrospinal fluid.

INTERVENTIONS

The patient was treated with intravenous chloramphenicol without success. On postoperative day 16, the patient was begun on intravenous linezolid.

MAIN RESULTS

The patient received 4 wks of intravenous linezolid with complete eradication of the meningitis.

CONCLUSIONS

Intravenous linezolid appears to be a safe and effective therapy for vancomycin-resistant enterococcus meningitis.

Vancomycin-resistant Enterococcus faecium meningitis successfully managed with linezolid: case report and review of the literature

Enterococci cause serious illness in immunocompromised patients and severely ill, hospitalized patients. Resistance to vancomycin has increased in frequency during the past few years. Limited therapeutic options are available for vancomycin-resistant enterococcal infections and the optimum therapy has not been established. We report a case of nosocomial vancomycin-resistant Enterococcus faecium meningitis in the setting of hyperinfection with Strongyloides stercoralis that was successfully treated with linezolid. We also review the previously reported cases of vancomycin-resistant E. faecium meningitis.

Antienterococcal antibiotics

The treatment of severe enterococcal infections based on the currently available antibacterial agents is difficult. The help of the microbiology laboratory for determining MICs, MBCs, and most effective synergistic combinations is crucial. There is a need for good prospective multicenter clinical trials to improve the prognosis of such infections by defining therapeutic strategies better. Such a requirement is highly suitable for the treatment of infections caused by enterococci exhibiting acquired resistance mechanisms to the available agents. The current clinical development of new compounds looks promising in these persistently life-threatening infections mostly occurring in deficient hosts.