A case report of intraventricular tigecycline therapy for intracranial infection with extremely drug resistant Acinetobacter baumannii

Analysis of tigecycline in the cerebrospinal fluid and serum of patients with Acinetobacter baumannii central nervous system infection

Aim: This study aimed to establish a method to determine tigecycline (TGC) in the cerebrospinal fluid (CSF) and serum of 12 patients with multidrug-resistant Acinetobacter baumannii (MDRAB) central nervous system infection (CNSI) and evaluate the correlation of TGC in CSF and serum samples. Materials & methods: TGC in CSF and serum was detected by high-performance liquid chromatography with tandem mass spectrometry. Results: In all 12 patients, the CSF-to-serum ratio of TGC at a steady-state trough concentration ranged from 21.46 to 44.46%, and the mean value was 31.61 ± 8.13%. The correlation of TGC in CSF and serum was 0.5065. Conclusion: CNSI might have no potential to increase the penetration ability of TGC into the CSF. The correlation between the concentrations of TGC in CSF and serum at steady state was demonstrated to be positive.

Clinical Experience with Off-Label Intrathecal Administration of Selected Antibiotics in Adults: An Overview with Pharmacometric Considerations

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.

Intrathecal tigecycline is a safe and effective treatment for central nervous system infections

Both the safety and effectiveness of intrathecal tigecycline (TGC) for treatment of infections of the central nervous system (CNS) are discussed using the clinical findings from a study of a recent patient who came to our attention, along with a literature review. Although penetration into the CNS is low (approximately 11%), intraventricular TGC could help treat patients with severe post- neurosurgical CNS infections. The use of multiple routes of TGC administration appears to be encouraging and should be considered in managing life-threatening intraventricular infections.

Intrathecal or Intraventricular Tigecycline Therapy for Central Nervous System Infection Associated with Carbapenem-Resistant Klebsiella pneumoniae

PURPOSE

Infection with carbapenem-resistant Klebsiella pneumoniae (CRKP) is a great challenge. Central nervous system (CNS) infection caused by CRKP is rarely reported, and effective treatment is limited. Thus, this study aimed to assess intrathecal (IT) or intraventricular (IVT) injection of tigecycline for clearing infection with CRKP in CNS.

PATIENTS AND METHODS

Two patients who had intracranial infection with CRKP after craniotomy were treated in our institution and analyzed retrospectively, summarizing their therapeutic schedules.

RESULTS

They all had a fever with the positive results of cerebrospinal fluid (CSF) test, and CSF culture showed positive for CPKP, which was sensitive only to tigecycline. In addition, the MIC of polymyxin B was not tested due to the limited laboratory conditions. After IT or IVT injection of tigecycline treatment, the temperature of the patients became normal in 3 days, with normal levels of white blood cells, protein, glucose and chlorine concentrations in the CSF. Crucially, twice CSF cultures also became negative with no clinical symptoms of intracranial infection after IT or IVT injection of tigecycline treatment. Moreover, there were no adverse drug reactions observed.

CONCLUSION

IT or IVT injection of tigecycline may be a bright choice to control intracranial infection with CRKP.

Intravenous plus intraventricular tigecycline-amikacin therapy for the treatment of carbapenem-resistant Klebsiella pneumoniae ventriculitis: A case report

RATIONALE

Central nervous system infections (CNSIs) are one of the most serious complications after neurosurgery, especially carbapenem-resistant bacterial meningitis. Owing to the poor blood-brain barrier permeability of most antibiotics, the treatment of CNSIs by intraventricular (IVT) administration is becoming a hot topic in clinical research. Currently, the treatment of CNSIs caused by carbapenem-resistant Klebsiella pneumoniae is mainly based on intraventricular injection of an antibiotic combined with one or more other systemic intravenous (IV) antibiotics, whereas there are few case reports of intraventricular injection of 2 antibiotics.

PATIENT CONCERNS

A 57-year-old man with an open craniocerebral injury presented with dyspnea, high fever, and seizures associated with surgery.

DIAGNOSIS

Intracranial infection caused by carbapenem-resistant K. pneumoniae was diagnosed.

INTERVENTIONS

On the advice of a clinical pharmacist, the patient was given tigecycline (100 mg IV + 3 mg IVT q12h) combined with amikacin (0.8 g IV + 30 mg IVT qd) antiinfective therapy. Ultimately, the pathogens in the cerebrospinal fluid were eradicated after 7 days, and the CNSIs were completely cured after 14 days.

OUTCOMES

The patient recovered and was discharged from the hospital without adverse reactions.

LESSONS

A series of in vitro and in vivo synergy tests of carbapenem-resistant K. pneumoniae showed that tigecycline combined with aminoglycosides had good synergistic effects and effectively suppressed bacterial resistance selection. Intravenous plus intraventricular tigecycline-amikacin seems to be a safe and effective treatment option for carbapenem-resistant K. pneumoniae CNSIs.

Two Cases Report of Intrathecal Tigecycline Therapy for Intracranial Infection with Acinetobacter baumannii and Review of Literatures

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.

Intrathecal Injection of Tigecycline and Polymyxin B in the Treatment of Extensively Drug-Resistant Intracranial Acinetobacter baumannii Infection: A Case Report and Review of the Literature

Purpose

Intracranial infection after neurosurgery is one of the most serious complications, especially extensively drug-resistant (XDR) Acinetobacter baumannii (A. baumannii) seriously affects the prognosis of patients. At present, there is little experience in the treatment of this infection and limited effective treatment options, like tigecycline or polymyxin B. Therefore, this report aims to describe the efficacy of tigecycline combined with polymyxin B by intrathecal (ITH) injection in the treatment of XDR intracranial infection with A. baumannii.

Methods

We report a case of intracranial infection with XDR A. baumannii after ventricular drainage, treated by daily ITH and intravenous (IV) tigecycline, combined with polymyxin B ITH route. Moreover, tigecycline and polymyxin B treatments for XDR intracranial infection with A. baumannii that were reported in the literature were also reviewed and summarized.

Results

The white blood cells (WBCs) of the patient’s cerebrospinal fluid dropped to normal, and the symptoms of intracranial infection disappeared. The patient finally obtained good clinical results and transferred to the local hospital.

Conclusion

The polymyxin B ITH route is an ideal treatment strategy for XDR A. baumannii. The IV plus ITH tigecycline may be an effective treatment option. However, more researches should be conducted to confirm our observation.

Does Tigecycline Have a Place in Therapy for Rickettsial Infection of the Central Nervous System?

This brief report documents the safety and efficacy of high-dose tigecycline as a salvage-therapy in in a case series of five patients with serious central nervous system (CNS) rocky mountain spotted fever (RMSF). These severily ill patients were unable to take any oral drug therapy, parenteral doxycycline was unavailable and absorption of oral doxycycline was a concern in these critically ill patients. As far as we know, we report the successfull use of tigecycline for the treatment of rickettsial meningitis for the first time in Italy. We suggest more studies on tigecycline in severe CNS infections from Rickettsia species and multi-drug resistant bacteria, especially the use of tigecycline at higher than standard doses in these life-threathening infectious diseases.

Dose optimisation of antibiotics used for meningitis

PURPOSE OF REVIEW

Central nervous system (CNS) infections such as ventriculitis and meningitis are associated with significant morbidity and mortality. In part, this may be due to increased difficulties in achieving a therapeutic antibiotic concentration at the site of infection due to both the pharmacokinetic (PK) changes observed during critical illness and the reduced antibiotic penetration through the blood brain barrier. This paper reviews the pharmacodynamics (PD) and CNS PKs of antibiotics used for Gram-negative bacterial CNS infections to provide clinicians with practical dosing advice.

RECENT FINDINGS

Recent PK studies have shown that currently used intravenous antibiotic dosing regimens may not achieve a therapeutic exposure within the CNS, even for reportedly 'susceptible' bacteria per the current clinical meningitis breakpoints. Limited data exist for new β-lactam antibiotic/β-lactamase inhibitor combinations, which may be required for multidrug resistant infections. Intraventricular antibiotic administration, although not a new concept, has further evidence demonstrating improved patient outcomes compared with intravenous therapy alone, despite the ongoing paucity of PK studies guiding dosing recommendations.

SUMMARY

Clinicians should obtain the bacterial minimum inhibitory concentration when treating patients with CNS Gram-negative bacterial infections and consider the underlying PK/PD principles when prescribing antibiotics. Therapeutic drug monitoring, where available, should be considered to guide dosing. Intraventricular therapy should also be considered for patients with ventricular drains to optimise clinical outcomes.

Sequential intraventricular injection of tigecycline and polymyxin B in the treatment of intracranial Acinetobacter baumannii infection after trauma: a case report and review of the literature

BACKGROUND

Intracranial infection after craniotomy is one of the most serious postoperative complications, especially multidrug-resistant (MDR) or extensively drug-resistant (XDR) bacterial meningitis, and strongly affects the prognosis of patients. Current treatment experience regarding these infections is scarce.

CASE PRESENTATION

We report a case of severe intracranial infection of XDR Acinetobacter baumannii (A. baumannii) that was treated by intravenous (IV) injection, sequential intraventricular (IVT) injection of tigecycline and polymyxin B, and other anti-infective drugs. Good results were obtained, and the patient was eventually discharged from the hospital. This case is characterized by intracranial infection.

CONCLUSIONS

The polymyxin B IV + IVT pathway is an ideal treatment strategy for XDR A. baumannii. The tigecycline IVT pathway is also a safe treatment option.

Intrathecal Antibacterial and Antifungal Therapies

Intrathecal administration of anti-infectives is indicated in central nervous system infections by multiresistant pathogens when drugs that can reach adequate cerebrospinal fluid (CSF) concentrations by systemic therapy are not available. Antibiotics that readily pass the blood-brain and blood-CSF barriers and/or that have low toxicity allowing an increase in the daily dosage should not be used for intrathecal therapy. Intrathecal therapy is accompanied by systemic treatment. Antibacterials indispensable for intrathecal therapy include aminoglycosides, colistin, daptomycin, tigecycline, and vancomycin. Limited experience suggests the utility of the antifungals amphotericin B and caspofungin. Intraventricular administration ensures distribution throughout the CSF compartment, whereas intralumbar dosing often fails to attain adequate antibiotic concentrations in the ventricles. The individual dose is determined by the estimated size of the CSF space and by the estimated clearance from CSF. For moderately lipophilic anti-infectives with a molecular weight above approximately 1,000 g/mol, as well as for hydrophilic drugs with a molecular weight above approximately 400 g/mol, one daily dose is normally adequate. The ventricular drain should be clamped for 15 to 120 min to facilitate the distribution of the anti-infective in the CSF space. Therapeutic drug monitoring of the trough levels is necessary only in cases of therapeutic failure.

Intraventricular Plus Intravenous Tigecycline for the Treatment of Daptomycin Nonsusceptible Vancomycin-Resistant Enterococci in an Infant with Ventriculoperitoneal Shunt Infection

BACKGROUND

Ventriculoperitoneal (VP) shunt infection, which is 1 of the most important complications of VP shunt is observed at a rate of 4%-17%. Staphylococcus epidermidis is the most common causative agent. Vancomycin-resistant Enterococcus (VRE) is an increasingly common nosocomial pathogen that rarely causes central nervous system infections globally. Current treatment options that have shown appreciable activity against various VRE infections include daptomycin, linezolid, inquinupristin/dalfopristin, and tigecycline. Daptomycin has a particular mode of action and a potent bactericidal activity, making it a useful addition to the clinician's antibiotic collection. Global surveillance data indicate <1.0% rates of daptomycin resistance in enterococci.

CASE DESCRIPTION

Here, we describe, to the best of our knowledge, the first case of successful intraventricular plus intravenous use of tigecycline to treat VP shunt infections caused by daptomycin resistant VRE faecium.

CONCLUSION

Tigecycline is a life-saving option in the treatment of resistant nosocomial infections but it has not yet been approved for use and there are not enough data in terms of dose and side effects associated with its use in children.

A case report of intraventricular and intrathecal tigecycline infusions for an extensively drug-resistant intracranial Acinetobacter baumannii infection

RATIONALE

The treatment of intracranial Acinetobacter baumannii infections is made difficult by multidrug-resistance poor drug penetration through the blood-brain barrier (BBB). Although tigecycline appears to be effective against A baumannii, it is only administered intravenously because it does not readily cross the BBB. The addition of intraventricular (IVT) or intrathecal infusions of tigecycline could revolutionize clinical therapy for intracranial A baumannii infections. However, there are few reports on the successful use of such treatments.

PATIENT CONCERNS

We report the case of a 17-year-old male who presented with high fever and neck rigidity after intracranial drainage.

DIAGNOSIS

Intracranial infection with extensively drug-resistant A baumannii after intracranial drainage.

INTERVENTIONS

On the advice of a clinical pharmacist, the patient was administered intrathecal infusions of tigecycline after treatment failure with IVT tigecycline.

OUTCOMES

The patient's body temperature returned to normal. Thereafter, the patient was in good clinical condition without signs of cerebrospinal fluid infection and tuberculosis.

LESSONS

However, when central nervous system infections fail IVT tigecycline, clinicians should consider changing to intrathecal tigecycline infusions rather than raising the dose of IVT tigecycline. In addition, the co-administration of tigecycline with other drugs that can penetrate the BBB should not be ruled out.

Intraventricular tigecycline for the treatment of shunt infection: a case in pediatrics

Ventriculoperitoneal (VP) shunt infections are seen in 3%-17% of patients with VP shunts. These infections may cause severe morbidity and mortality. Staphylococci are the most common cause of CSF shunt-associated infections, although gram-negative bacteria (especially multidrug-resistant [MDR] and extensive drug-resistant [XDR] bacteria) also play an important role. Due to increased antibiotic resistance, sometimes off-label usage of antibiotics is considered. Tigecycline is one of these antibiotics. It should not be used unless there are no other antibiotic treatment options available, especially in children. It belongs to the glycylcycline class of antibiotic agents and inhibits protein translation in bacteria by binding to the 30S ribosomal subunit. The authors describe the case of a patient who had an XDR Klebsiella pneumoniae-positive VP shunt infection. After removal of his VP shunt, an external ventricular drain was inserted, and the patient was treated with a combination of intravenous (1.2 mg/kg/day) and intraventricular (4 mg/day) tigecycline in addition to his meropenem (120 mg/kg/day) treatment. On the 7th day of the combined therapy, his CSF culture was sterile. Because tigecycline distribution into the tissues is not sufficient with intravenous administration, combining it with intraventricular infusion can provide new treatment methods. However, further studies are needed for its use as a treatment method in children.

Multidrug Resistant Brain Abscess Due to Acinetobacter baumannii Ventriculitis Cleared by Intraventricular and Intravenous Tigecycline Therapy: A Case Report and Review of Literature

Objective: Ventricular infection from multidrug-resistant (MDR) Acinetobacter baumannii (A. baumannii) is one of the most severe complications of craniotomy. However, the availability of effective therapeutic options for these infections is limited. Thus, this report aims to describe the efficacy of abscess clearance by intraventricular and intravenous tigecycline therapy in managing patients with multidrug-resistant A. baumannii ventriculitis after neurosurgery. Moreover, the current literature on the use of tigecycline therapy for these life-threatening infections is reviewed and summarized, and a treatment regimen based on the available data is proposed.

Methods: A patient with multidrug-resistant A. baumannii ventriculitis was admitted in our hospital and was provided with a detailed therapeutic schedule. Tigecycline treatments for multidrug-resistant A. baumannii ventriculitis that were reported in the literature were also reviewed and summarized.

Results: The patient in our hospital underwent abscess clearance on a ventriculoscope and was subsequently subjected to multi-route tigecycline therapy 14 days after the start of the continuous ventricular irrigation (CVI) tigecycline and 3 days after the intraventricular (IVT) tigecycline. The signs of ventriculitis disappeared, and the Acinetobacter cerebrospinal fluid (CSF) load steadily decreased until CSF sterilization. Literature review identified seven cases of ventricular infection from multidrug-resistant A. baumannii treated with tigecycline. In the eight cases, all patients were male adults (>18 years), with a mean age of 46.1 (range: 22–75) years. Meningitis/ventriculitis was secondary to neurosurgery procedures for the management of various central nervous system diseases in all cases. A good clinical outcome was achieved in all eight patients with multidrug-resistant A. baumannii meningitis/ventriculitis treated with CVI and/or IVT tigecycline, and any relevant complications were not observed.

Conclusions: CVI and IVT tigecycline and IVT colistin could be considered as the first-line therapy in patients with ventricular infections from MDR/extreme drug-resistant A. baumannii. However, more studies should be conducted to confirm our observation.

Tigecycline in the treatment of multidrug-resistant Acinetobacter baumannii meningitis: Results of the Ege study

OBJECTIVES

In this study we retrospectively reviewed A. baumannii meningitis cases treated with tigecycline including regimens and evaluated the efficacy of tigecycline in the therapy.

PATIENTS AND METHODS

Study was performed in seven tertiary-care educational hospitals from five cities of Turkey and one center from France. We extracted data and outcomes of all adult (aged >18) patients with culture proven A. baumannii meningitis treated with tigecycline including antibiotic therapy until April 2016.

RESULTS

A total of 23 patients (15 male and eight female) fulfilled our inclusion criteria. All Acinetobacter strains were carbapenem-resistant and susceptible to tigecycline. Six cases received tigecycline monotherapy while 17 received tigecycline including combination therapy (10 with colistin, 4 with netilmicin, 3 with amikacin, 4 with meropenem). Seven of 23 cases (30%) died during the tigecycline including therapy (1 in monotherapy, 4 in colistin, 2 in netilmicin, 1 amikacin, one case received tigecycline + netilmicin followed by tigecycline + colistin). Hence, overall end of treatment (EOT) success was 70%. However, since further 27% died due to additional nosocomial infections, overall clinical success (relieved symptoms at the EOT and one-month post-therapy survival without any relapse or reinfection) decreased to 43%.

CONCLUSION

We conclude that tigecycline may be an alternative in the salvage treatment of nosocomial multidrug-resistant Acinetobacter spp. meningitis. Acinetobacter spp. Meningitis.