Intraventricular or intrathecal colistin for the treatment of central nervous system infections caused by multidrug-resistant Gram-negative bacteria

Rare post-operative intracranial abscess due to Serratia marcescens: what we can learn from it?

BACKGROUND

Nosocomial infections caused by Serratia marcescens mostly occurred in pediatrics and it was very rarely reported after adult surgery. Here, an intracranial abscess caused by Serratia marcescens was reported. We report a rare case of a postoperative intracranial abscess caused by Serratia marcescens in a 63-year-old male patient with a left parietal mass. The patient underwent resection of the mass on June 1, 2022, and the postoperative pathology revealed an angiomatous meningioma, WHO I. He then experienced recurrent worsening of right limb movements, and repeated cranial CT scans showed oozing blood and obvious low-density shadows around the operation area. Delayed wound healing was considered. Subsequently, a large amount of pus was extracted from the wound. The etiological test showed that Serratia marcescens infection occurred before the removal of the artificial titanium mesh. Antibiotics were initiated based on the results of drug susceptibility tests. At present, the patient is recovering well and is still closely monitored during follow-up.

CONCLUSION

It is rare for Serratia marcescens to cause brain abscesses without any obvious signs of infection. This report provided in detail our experience of a warning postoperative asymptomatic brain abscess caused by an uncommon pathogen.

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.

Pharmacokinetics and pharmacodynamics of peptide antibiotics

Antimicrobial resistance is a major global health challenge. As few new efficacious antibiotics will become available in the near future, peptide antibiotics continue to be major therapeutic options for treating infections caused by multidrug-resistant pathogens. Rational use of antibiotics requires optimisation of the pharmacokinetics and pharmacodynamics for the treatment of different types of infections. Toxicodynamics must also be considered to improve the safety of antibiotic use and, where appropriate, to guide therapeutic drug monitoring. This review focuses on the pharmacokinetics/pharmacodynamics/toxicodynamics of peptide antibiotics against multidrug-resistant Gram-negative and Gram-positive pathogens. Optimising antibiotic exposure at the infection site is essential for improving their efficacy and minimising emergence of resistance.

Intrathecal/Intraventricular Colistin for Antibiotic-Resistant Bacterial CNS Infections in Pediatric Population: A Systematic Review

Central nervous system (CNS) infections constitute a life-threatening condition, especially in children. Treatment limitations exist for drug-resistant CNS bacterial infections. Inadequate CNS penetration and intravenous (IV) antibiotic treatment failure represent a major clinical challenge. However, patients with antibiotic-resistant bacterial CNS infections may benefit from intrathecal (IT) or intraventricular (IVT) colistin. The authors aimed to assess the safety and effectiveness of IT/IVT colistin therapy in the pediatric population, with or without other antibiotics, for the treatment of antibiotic-resistant CNS infections. A comprehensive literature search was conducted using the electronic databases of PubMed, Ovid, and Embase for relevant articles using the following terms: “Colistin”, “CNS infection”, and “Outcome”, as well as their combinations. The retrieved articles were filtered by age (Child), language (English), route of administration (IT/IVT), and species (Humans). The present systematic review comprised 20 articles that included 31 children (19; 61.2% were boys) with multidrug-resistant CNS infection. Their ages ranged from less than one month to 18 years (median: 9 months). Acinetobacter baumannii was the main causative organism in 22 patients (70.9%), and infection occurred mainly after neurosurgical interventions (83.8%). An external ventricular drain was inserted to administer colistin into the ventricular system in 29 cases (93.5%). The median duration for colistin therapy was 18 days. Twenty-three patients (74%) recovered, while five patients (16%) had residual disability, and three patients (10%) died. The authors concluded that IT/IVT colistin therapy is safe and effective as either the primary or adjunct treatment for antibiotic-resistant cases with CNS infection.

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

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.

The Use of Colistin for the Treatment of Multidrug-resistant Gram-negative Infections in Neonates and Infants: A Review of the Literature

In this review, we report the available data regarding efficacy, safety and pharmacokinetics of colistin in the treatment of multidrug-resistant Gram-negative bacteria in neonates and infants. Seventeen clinical studies, involving 312 patients, and 3 pharmacokinetics studies were identified. Blood stream infection was the most common source of infection, followed by pneumonia and meningitis/ventriculitis. In most cases, colistin was administered in association with other antibiotics. The most common route of administration was intravenous, with colistimethate doses ranging from 25,000 to 225,000 IU/kg/day divided into 2 or 3 doses. A recent pharmacokinetic study suggested that the appropriate intravenous dose should be >150,000 IU/kg/day. Microbiologic cure was obtained in 94.2% of patients and survival was 76.6%. The combination of intraventricular and intravenous colistin should be used in meningitis/ventriculitis. Nebulized colistin should be used as adjunctive treatment, but not as monotherapy. Nephrotoxicity and apnea were reported in 5.8% and 3.9% of patients respectively.The use of colistin for multidrug-resistant Gram-negative infections in neonates and infants is effective and safe, but the quality of studies is moderate. The optimal intravenous dose should be higher than that indicated in most reports.

Epidemiology and Treatment of Multidrug-Resistant and Extensively Drug-Resistant Pseudomonas aeruginosa Infections

In recent years, the worldwide spread of the so-called high-risk clones of multidrug-resistant or extensively drug-resistant (MDR/XDR) Pseudomonas aeruginosa has become a public health threat. This article reviews their mechanisms of resistance, epidemiology, and clinical impact and current and upcoming therapeutic options. In vitro and in vivo treatment studies and pharmacokinetic and pharmacodynamic (PK/PD) models are discussed. Polymyxins are reviewed as an important therapeutic option, outlining dosage, pharmacokinetics and pharmacodynamics, and their clinical efficacy against MDR/XDR P. aeruginosa infections. Their narrow therapeutic window and potential for combination therapy are also discussed. Other "old" antimicrobials, such as certain β-lactams, aminoglycosides, and fosfomycin, are reviewed here. New antipseudomonals, as well as those in the pipeline, are also reviewed. Ceftolozane-tazobactam has clinical activity against a significant percentage of MDR/XDR P. aeruginosa strains, and its microbiological and clinical data, as well as recommendations for improving its use against these bacteria, are described, as are those for ceftazidime-avibactam, which has better activity against MDR/XDR P. aeruginosa, especially strains with certain specific mechanisms of resistance. A section is devoted to reviewing upcoming active drugs such as imipenem-relebactam, cefepime-zidebactam, cefiderocol, and murepavadin. Finally, other therapeutic strategies, such as use of vaccines, antibodies, bacteriocins, anti-quorum sensing, and bacteriophages, are described as future options.

Colistin for Treatment of Multidrug Resistant Central Nervous System Infection: A Triple Route Therapy!

How to cite this article: Shukla RK, Kapoor I, Mahajan C, Prabhakar H. Colistin for Treatment of Multidrug Resistant Central Nervous System Infection: A Triple Route Therapy!. Indian J Crit Care Med 2019;23(6):287.

Clinical Use of Colistin in Biofilm-Associated Infections

Biofilm is an adaptive bacterial strategy whereby microorganisms become encased in a complex glycoproteic matrix. The low concentration of oxygen and nutrients in this environment leads to heterogeneous phenotypic changes in the bacteria, with antimicrobial tolerance being of paramount importance. As with other antibiotics, the activity of colistin is impaired by biofilm-embedded bacteria. Therefore, the recommendation for administering high doses in combination with a second drug, indicated for planktonic infections, remains valid in this setting. Notably, colistin has activity against metabolically inactive biofilm-embedded cells located in the inner layers of the biofilm structure. This is opposite and complementary to the activity of other antimicrobials that are able to kill metabolically active cells in the outer layers of the biofilm. Several experimental models have shown a higher activity of colistin when used in combination with other agents, and have reported that this can avoid the emergence of colistin-resistant subpopulations. Most experience of colistin in biofilm-associated infections comes from patients with cystic fibrosis, where the use of nebulized colistin allows high concentrations to reach the site of the infection. However, limited clinical experience is available in other scenarios, such as osteoarticular infections or device-related central nervous system infections caused by multi-drug resistant microorganisms. In the latter scenario, the use of intraventricular or intrathecal colistin also permits high local concentrations and good clinical results. Overall, the efficacy of intravenous colistin seems to be poor, but its association with a second antimicrobial significantly increases the response rate. Given its activity against inner bioflm-embedded cells, its possible role in combination with other antibiotics, beyond last-line therapy situations, should be further explored.

Efficacy of intraventricular amikacin treatment in pan-resistant Pseudomonas aeruginosa postsurgical meningitis

Background

We describe a case of pan-resistant Pseudomonas aeruginosa postsurgical meningitis associated with the presence of an external ventricular device. We changed therapy twice; finally, by using amikacin and a continuous infusion of cefepime, we obtained clinical improvement.

Case presentation

A female patient, who underwent surgery for a cavernous angioma, presented with meningitis. Cerebrospinal fluid culture revealed a multidrug-resistant Pseudomonas aeruginosa, initially sensitive only to colistin. We successfully used intrathecal amikacin and intravenous cefepime continuous infusion plus intravenous amikacin after two previous ineffective therapeutic approaches.

Conclusion

The evaluation of the antibiotic concentration and the bactericidal activity in cerebrospinal fluid may contribute to the choice of the drug in cases of multidrug-resistant meningitis.

Best practices for the use of intracerebroventricular drug delivery devices

For decades, intracerebroventricular (ICV), or intraventricular, devices have been used in the treatment of a broad range of pediatric and adult central nervous system (CNS) disorders. Due to the limited permeability of the blood brain barrier, diseases with CNS involvement may require direct administration of drugs into the brain to achieve full therapeutic effect. A recent comprehensive literature review on the clinical use and complications of ICV drug delivery revealed that device-associated complication rates are variable, and may be as high as 33% for non-infectious complications and 27% for infectious complications. The variability in reported safety outcomes may be driven by a lack of consensus on best practices of device use. Numerous studies have demonstrated that employing strict aseptic techniques and following stringent protocols can dramatically reduce complications. Key practices to be considered in facilitating the safe, long-term use of these devices are presented.

Therapeutic drug monitoring for colistin therapy in severe multi-resistant Acinetobacter intracerebral abscess: A single case study with high-dose colistin and review of literature

Objectives:

Intracranial infections due to multidrug- resistant (MDR) gram-negative pathogens are associated with increased morbidity and mortality. As therapeutic options are limited and systemic drug penetration into the infection focus is difficult, intraventricular therapy has been described.

Methods:

We report on a patient with intracranial abscess caused by MDR Acinetobacter baumannii.

Results:

He was treated with high doses of intravenous and intraventricular colistin resulting in microbiological clearance and clinical cure. Therapy was controlled by therapeutic drug monitoring (TDM) of serum and liquor colistin levels. About 100 cases with intraventricular or intrathecal colistin are reported in literature but data on TDM are sparse.

Conclusions:

This is one of the first cases providing data on TDM for locally administered high dose colistin therapy for the treatment of intracranial abscess formations. Based on these findings, increasing the intraventricular application interval paralleled with intravenous colistin could possibly be sufficient to achieve appropriate therapeutic drug levels. Further studies are needed to support alternative dosing strategies in similar cases.

Intracerebroventricular Delivery as a Safe, Long-Term Route of Drug Administration

Intrathecal delivery methods have been used for many decades to treat a broad range of central nervous system disorders. A literature review demonstrated that intracerebroventricular route is an established and well-tolerated method for prolonged central nervous system drug delivery in pediatric and adult populations. Intracerebroventricular devices were present in patients from one to 7156 days. The number of punctures per device ranged from 2 to 280. Noninfectious complication rates per patient (range, 1.0% to 33.0%) were similar to infectious complication rates (0.0% to 27.0%). Clinician experience and training and the use of strict aseptic techniques have been shown to reduce the frequency of complications.