Successful treatment of ventriculostomy-associated meningitis caused by multidrug resistant coagulase-negative Staphylococcus epidermidis using low-volume intrathecal daptomycin and loading strategy

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.

Addition of daptomycin for the treatment of pneumococcal meningitis: protocol for the AddaMAP study

BACKGROUND

The leading cause of acute bacterial meningitis in adults is Streptococcus pneumoniae. This infection is associated with high rates of mortality and morbidity related, among other factors, to the excessive host response to the pneumococcal lysis. Experimental in vitro and in vivo data show that the combination of corticosteroids/third-generation cephalosporins and the non-lytic antibiotic, daptomycin, has synergistic effects with (1) a rapid cerebrospinal fluid sterilisation, (2) less brain damages and (3) less loss of cognitive performances. Despite these encouraging results, daptomycin has never been evaluated in adult patients with pneumococcal meningitis.

METHODS AND ANALYSIS

The AddaMAP trial is a phase II, open-label, Simon's two-stage, multicentre trial that has been designed to assess the efficacy and safety of adding daptomycin (10 mg/kg/d for 8 days) to the recommended treatment (corticosteroids+third generation cephalosporin) in adults with confirmed pneumococcal meningitis. The main endpoint is the disability-free survival (defined as modified Rankin Scale mRS≤2) at day 30. Secondary outcomes are overall mortality, disability at D30 and D90 (mRS, Glasgow Coma Scale and Glasgow Outcome Scales, mini-mental score), hearing loss (Hearing Handicap Inventory Test at D30 and D90, routine audiometric test and Hearing-it test at D30), and quality of life (12-item Short Form Survey and WHO QOL BREF). Seventy-two analysable patients are required.

ETHICS AND DISSEMINATION

The study protocol was approved by the Institutional Review Board of the IDF 1 of the ethics committee on 16 January 2018, and authorisation was obtained from the Agence Nationale de Securité des Médicaments et des Produits de Santé on 22 September 2017. The results will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03480191.

Daptomycin for the treatment of acute bacterial meningitis: a narrative review

BACKGROUND

There is a growing interest in the utilization of daptomycin for the treatment of multi-drug resistant, Gram-positive infections. Pharmacokinetic studies suggest that daptomycin could penetrate into the cerebrospinal fluid, albeit to a small extent. The objective of this review was to evaluate the available clinical evidence for daptomycin use in acute bacterial meningitis of both pediatric and adult patients.

METHODS

Electronic databases were searched up to June 2022 for studies published on the topic. The inclusion criteria were met if the study reported the use of intravenous daptomycin (more than a single dose) for the treatment of diagnosed acute bacterial meningitis.

RESULTS

A total of 21 case reports were identified that met the inclusion criteria. These suggest that daptomycin could be safe and effective alternative in achieving clinical cure of meningitis. In these studies, daptomycin was used in the event of treatment failure, patient intolerance, or bacterial resistance to first-line agents.

CONCLUSIONS

Daptomycin has potential to be an alternative to standard care for meningitis caused by Gram-positive bacteria in the future; however, more robust research is required to establish an optimal dosing regimen, duration of therapy, and place in therapy for the management of meningitis.

Current Perspectives on the Diagnosis and Management of Healthcare-Associated Ventriculitis and Meningitis

Ventriculitis or post-neurosurgical meningitis or healthcare-associated ventriculitis and meningitis (VM) is a severe infection that complicates central nervous system operations or is related to the use of neurosurgical devices or drainage catheters. It can further deteriorate patients who have already presented significant neurologic injury and is associated with high morbidity, mortality, and poor functional outcome. VM can be difficult to distinguish from aseptic meningitis, inflammation that follows hemorrhagic strokes and neurosurgical operations. The associated microorganisms can be either skin flora or nosocomial pathogens, most commonly, Gram-negative bacteria. Classical microbiology can fail to isolate the culprit pathogen. Novel cerebrospinal fluid (CSF) biomarkers and molecular microbiology can fill the diagnostic gap and expedite pathogen identification and treatment. The pathogens may demonstrate significant resistant patterns and their antibiotic treatment can be difficult, as many important drug classes, including the beta-lactams and the glycopeptides, hardly penetrate to the CSF, and do not achieve therapeutic levels at the site of the infection. Treatment modifications, such as higher daily dose and prolonged or continuous administration, might increase antibiotic levels in the site of infection and facilitate pathogens clearance. However, in the case of therapeutic failure or infection due to difficult-to-treat bacteria, the direct antibiotic instillation into the CSF, in addition to the intravenous antibiotic delivery, may help in the resolution of infection. However, intraventricular antibiotic therapy may result in aseptic meningitis and seizures, concerning the administration of aminoglycosides, polymyxins, and vancomycin. Meanwhile, bacteria form biofilms on the catheter or the device that should routinely be removed. Novel neurosurgical treatment modalities comprise endoscopic evacuation of debris and irrigation of the ventricles. VM prevention includes perioperative antibiotics, antimicrobial impregnated catheters, and the implementation of standardized protocols, regarding catheter insertion and manipulation.

Antimicrobial use in central nervous system infections

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.

Use of Intraventricular Medications in Critically Ill Patients: A Systematic Review

New evidence and increased use of intracranial devices have increased the frequency of intraventricular (IVT) medication administration in the neurologic intensive care unit. Significant benefits and risks are associated with administration of medications directly into the central nervous system. This review summarizes important literature, along with key information for clinicians regarding the administration, dosing, monitoring, and adverse effects related to IVT medication usage. Multiple medications have supporting literature for their use in critically ill patients including amphotericin B, aminoglycosides, colistimethate, daptomycin, quinupristin/dalfopristin, vancomycin, alteplase, and nicardipine. Sterile preparation and delivery, along with different types of devices that support medication administration, are also reviewed. One randomized, placebo-controlled trial of alteplase demonstrated decreased mortality but no change in good functional outcome. Other reports of IVT medication use are mainly limited to case reports and retrospective case series. There is a need for increased research on the topic; however, several practical barriers decrease the likelihood of a large, placebo-controlled, prospective study for most indications. Providers should consider implementing protocols to maximize safety of IVT medication delivery to ensure optimal patient outcomes.

Coagulase-negative staphylococci (CoNS) meningitis: a narrative review of the literature from 2000 to 2020

Coagulase-negative staphylococci (CoNS) are recognized as comprising the main part of human normal microbiota and are rarely associated with severe and intensive infections. However, these organisms can cause a number of infections in humans, especially immunocompromised patients and neonates. Bacterial meningitis, as an important and acute infection in the central nervous system, is still a major global health challenge and a serious infectious disease, causing a high rate of mortality and morbidity. CoNS as causative agents of meningitis are generally related to trauma or direct implantation of foreign bodies and the presence of a cerebrospinal fluid shunt. Numerous epidemiologic and clinical studies have shown that different CoNS isolates such as Staphylococcus capitis, Staphylococcus lugdunensis, Staphylococcus hominis, Staphylococcus epidermidis, Staphylococcus schleiferi, Staphylococcus saprophyticus, Staphylococcus warneri and Staphylococcus haemolyticus are more frequently associated with meningitis. This study attempts to determine the role of CoNS in meningitis and reviews the reported cases of meningitis induced by CoNS from the year 2000 to 2020 in the literature.

Post-Traumatic Meningitis Is a Diagnostic Challenging Time: A Systematic Review Focusing on Clinical and Pathological Features

Post-traumatic meningitis is a dreadful condition that presents additional challenges, in terms of both diagnosis and management, when compared with community-acquired cases. Post-traumatic meningitis refers to a meningeal infection causally related to a cranio-cerebral trauma, regardless of temporal proximity. The PICO (participants, intervention, control, and outcomes) question was as follows: "Is there an association between traumatic brain injury and post-traumatic meningitis?" The present systematic review was carried out according to the Preferred Reporting Items for Systematic Review (PRISMA) standards. Studies examining post-traumatic meningitis, paying particular attention to victims of traumatic brain injury, were included. Post-traumatic meningitis represents a high mortality disease. Diagnosis may be difficult both because clinical signs are nonspecific and blurred and because of the lack of pathognomonic laboratory markers. Moreover, these markers increase with a rather long latency, thus not allowing a prompt diagnosis, which could improve patients' outcome. Among all the detectable clinical signs, the appearance of cranial cerebrospinal fluid (CSF) leakage (manifesting as rhinorrhea or otorrhea) should always arouse suspicion of meningitis. On one hand, microbiological exams on cerebrospinal fluid (CSF), which represent the gold standard for the diagnosis, require days to get reliable results. On the other hand, radiological exams, especially CT of the brain, could represent an alternative for early diagnosis. An update on these issues is certainly of interest to focus on possible predictors of survival and useful tools for prompt diagnosis.

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.

Acute myeloid leukemia with central nervous system extension and subdural seeding of vancomycin-resistant Enterococcus faecium after bilateral subdural hematomas treated with subdural daptomycin administration

Background:

We present a rare case of comorbid relapsed acute myeloid leukemia (AML) with the involvement of the central nervous system (CNS) and subdural seeding of vancomycin-resistant Enterococcusfaecium (VRE). The safety profile, treatment approach with pharmacokinetic considerations, and evaluation of success for bilateral subdural administration of daptomycin after subdural hematoma (SDH) are assessed.

Case Description:

A 45-year-old male with a history of AML who underwent chemotherapy (induction with 7 + 3) was admitted to oncology with relapsed AML confirmed by bone marrow biopsy, complicated by neutropenic fever and VRE bacteremia. After acute neurological changes with image confirmation of mixed- density bilateral SDHs secondary to thrombocytopenia, the patient was admitted to the neurosurgery unit and underwent bilateral burr hole craniotomies for subdural evacuation with the placement of the left and right subdural drains. Culture of the subdural specimen confirmed VRE seeding of the subdural space. The patient received the first dose of daptomycin into the bilateral subdural spaces 2 days after evacuation and was noted to have acute improvement on neurological examination, followed by a second administration to the left subdural space 5 days after evacuation with bilateral drains pulled thereafter.

Conclusion:

In this patient, the complication of relapsed AML may have contributed to the rare extension of VRE into the CNS space. Screening for patients at risk of AML with CNS involvement and addressing coagulopathy and risk of infection may help mitigate morbidity. Bilateral administration of subdural daptomycin bolus into the subdural space was tolerated and possibly contributed to the patient’s neurological improvement during an extended hospital course.

La pharmacologie des antibiotiques dans le liquide cérébrospinal

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.

Novel and preclinical treatment strategies in pneumococcal meningitis

PURPOSE OF REVIEW

Pneumococcal meningitis is the most frequent form of bacterial meningitis in Europe and the United States. Although early antimicrobial and adjuvant therapy with dexamethasone have helped to improve disease outcome in adults, mortality and morbidity rates remain unsatisfactorily high, emphasizing the need for additional treatment options. Promising targets for adjuvant therapy have been identified recently and will be the focus of this review.

RECENT FINDINGS

Brain disease in pneumococcal meningitis is caused by direct bacterial toxicity and excessive meningeal inflammation. Accordingly, promising targets for adjuvant therapy comprise limiting the release of toxic bacterial products and suppressing inflammation in a way that maximally protects against tissue injury without hampering pathogen eradication by antibiotics. Among the agents tested so far in experimental models, complement inhibitors, matrix-metalloproteinase inhibitors, and nonbacteriolytic antibiotics or a combination of the above have the potential to more efficiently protect the brain either alone (e.g., in children and outside the high-income settings) or in addition to adjuvant dexamethasone. Additionally, new protein-based pneumococcal vaccines are being developed that promise to improve disease prevention, namely by addressing the increasing problem of serotype replacement seen with pneumococcal conjugate vaccines.

SUMMARY

Pneumococcal meningitis remains a life-threatening disease requiring early antibiotic and targeted anti-inflammatory therapy. New adjuvant therapies showed promising results in animal models but need systematic clinical testing.

Intravenous and Intraventricular Daptomycin Plus Intravenous Linezolid Treatment of an Infant with Vancomycin-Resistant Enterococci-Induced Ventriculoperitoneal Shunt Infection

BACKGROUND

The rate of ventriculoperitoneal (VP) shunt infection is reported between 3% and 20%. Vancomycin-resistant enterococci (VRE) are increasingly prevalent nosocomial pathogens worldwide, and they rarely cause infections to the central nervous system. Daptomycin is a cyclic lipopeptide effective antibiotic because of its rapid bactericidal effect. It is a life-saving treatment option for meningitis, bacteremia, sepsis, endocarditis, and urinary system infections caused by VRE.

CASE DESCRIPTION

Here, we present a 2.5-month-old infant boy with a ventriculoperitoneal shunt infection caused by vancomycin-resistant Enterococcus faecium. This is the first report of a pediatric VP shunt infection caused by VRE and treated with a combination of intravenous (IV) linezolid IV and intraventricular (IVT) daptomycin.

CONCLUSION

The patient was admitted to the medical center with umbilical discharge, and shunt revision was applied with the thought of shunt dysfunction. Intermittent umbilical cerebrospinal fluid (CSF) leakage continued, and the patient experienced a fever 2 weeks after the operation. VRE growth in his CSF culture was treated by meropenem and linezolid. Upon continuation of the growth afterwards, the patient was referred to our hospital and underwent extraventricular drainage, and IV linezolid, IV daptomycin (8 mg/kg per day), and IVT daptomycin (2.5 mg/kg per day) was scheduled as treatment. On the fifth day of treatment, there was no growth in the culture, and no side effects were observed during the treatment. A VP shunt was placed in the patient for the 15 days of IV daptomycin plus IVT treatment, and 36 days of linezolid. No infection was observed in the 8-month follow-up period.

Considerations about the Use of a Loading Dose of Daptomycin in a Neutropenic Murine Thigh Infection Model with Methicillin-Resistant Staphylococcus aureus Infection

Previous clinical studies have showed the clinical benefits of the initiation of treatment with a daptomycin (DAP) loading dose, but only a few studies have evaluated its antimicrobial benefits. We evaluated the efficacy of a DAP loading dose against methicillin-resistant Staphylococcus aureus (MRSA) infections in a neutropenic murine thigh infection model. Three MRSA isolates (DAP MIC: 0.5, 1, and 2 mg/L) were tested. Four DAP regimens simulating human concentration-time profiles, i.e., (i) day 1: 8 mg/kg and day 2: 6 mg/kg, (ii) days 1 and 2: 6 mg/kg/day, (iii) day 1: 8 mg/kg and day 2: 4 mg/kg, and (iv) days 1 and 2: 4 mg/kg/day, were administered to the mice. Efficacy was calculated as the change in bacterial density. DAP loading-dose regimen iii showed greater antimicrobial activity against MRSA with MIC 1 mg/L than nonloading regimen iv (-3.10 ± 0.63 vs. -0.71 ± 0.34 log10 CFU; p < 0.01). Loading-dose regimen iii achieved greater log10 CFU changes than nonloading regimen ii, while the total DAP dose for 2 days was the same (-3.10 ± 0.63 vs. -1.46 ± 0.48 log10 CFU; p < 0.05). DAP loading-dose regimen iii showed enhanced antimicrobial activity against MRSA with DAP MIC 0.5 mg/L when compared with nonloading regimen iv. However, loading-dose regimens i and iii did not reduce bacterial density for MRSA with DAP MIC 2 mg/L. Our data suggest that a DAP loading-dose regimen would be an advantageous procedure for patients infected with MRSA with DAP MIC ≤1 mg/L.

Intrathecal/Intraventricular Linezolid in Multidrug-Resistant Enterococcus faecalis Ventriculitis

Background The use of intrathecal antibiotic therapy for the treatment of ventriculitis and/or meningitis has demonstrated efficacy especially when sterilization of the cerebrospinal fluid is not possible with intravenous antibiotics alone. Case Description We describe the successful treatment of Enterococcus faecalis ventriculitis utilizing intrathecal linezolid in a 32-year-old female patient with severe allergy to vancomycin, prohibitive bacterial susceptibilities, and failure of previous attempts to sterilize the cerebrospinal fluid despite multimodal treatment. Conclusion Intrathecal linezolid is a useful treatment in the setting of multidrug-resistant bacterial ventriculitis. We present a useful dosing regimen for the administration of intrathecal linezolid.