Skip to main page content

• HOME
• Current Issue
• Archive
• Alerts
• About ASM
• Contact us
• Tech Support
• Journals.ASM.org

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Reprints and Permissions Copyright Information Books from ASM Press MicrobeWorld Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Scapellato, P. G. Articles by Bottaro, E. G. Search for Related Content PubMed PubMed Citation Articles by Scapellato, P. G. Articles by Bottaro, E. G.

 Previous Article  |  Next Article 

Journal of Clinical Microbiology, July 2005, p. 3578-3579, Vol. 43, No. 7
0095-1137/05/$08.00+0     doi:10.1128/JCM.43.7.3578-3579.2005
Copyright © 2005, American Society for Microbiology. All Rights Reserved.

LETTER TO THE EDITOR

Meningitis Due to Vancomycin-Resistant Enterococcus faecium Successfully Treated with Combined Intravenous and Intraventricular Chloramphenicol

Top Letter References

 
We report a case of meningitis caused by vancomycin-resistant Enterococcus faecium (VREF) that was succesfully treated with combined intravenous and intraventricular chloramphenicol, as follows. A 46-year-old man suffering from subarachnoid hemorrhage with intraventricular bleeding was admitted to the intensive care unit. On the 9th day, the patient underwent a craneotomy for clipping of an aneurysm. The patient developed a fever 10 days after surgery. Surgical wound tissue and cerebrospinal fluid (CSF) samples were examined, and for both samples, the culture grew E. faecium resistant to vancomycin, ampicillin, and quinolones; the cultured organism was also high-level gentamicin resistant and sensitive to linezolide, chloramphenicol, and quinupristin-dalfopristin.

A toilet of the surgical site was done, and intravenous chloramphenicol was administered (3 g/day). On the 6th day of therapy, VREF was cultured from a sample of CSF obtained by lumbar puncture. On the 12th day of chloramphenicol therapy, we performed an external drainage because of hydrocephalus, VREF was cultured from a surgical sample of CSF, and intraventricular chloramphenicol therapy was initiated (25 mg/day with a temporary occlusion for 60 min of the system after antibiotic instillation). Altogether, the patient completed 47 days of intravenous and 35 days of intraventricular administration of chloramphenicol. The evolution of CSF analysis is shown in Table 1. The patient suffered from a new episode of meningitis due to Providencia stuartii needing treatment with imipenem. Twenty-seven days after chloramphenicol therapy was halted (89th postsurgical day), the patient was discharged from the intensive care unit.

View this table: [in this window] [in a new window]

TABLE 1. Clinical parameters and microbiology of CSFa

VREF isolates have emerged as significant nosocomial pathogens (9). Of the infections caused by VREF, meningitis represents a therapeutic challenge for several reasons, such as limited treatment options because of the frequent multidrug resistance of VREF and difficulty in reaching therapeutic drug concentrations in the CSF. VREF infection is associated with considerable morbidity and mortality. In spite of its increasing importance as a human pathogen, VREF is an unusual etiologic agent of bacterial meningitis. Treatment is a major challenge because these organisms are usually resistant to multiple antibiotics. Therapeutic options include quinupristin-dalfopristin, linezolide, and daptomycin (5); chloramphenicol (5, 10); and investigational agents such as evernimicin (SCH27899 (13), oritavancin (LY333328) (7), dalbavancin (BI397) (1), and tigecycline (2). Meningitis due to VREF has been treated at several centers with various degrees of success. Linezolid and quinupristin-dalfopristin have been shown be useful options for treating this infection (12, 15).

Although chloramphenicol is regarded as bacteriostatic against enterococci, it has a reported clinical efficacy of 53% for treatment of serious VREF infections (6), and successful treatment of meningitis due to VREF was communicated (10). The efficacy of chloramphenicol may be a result of the relatively low plasma drug concentration needed to inhibit susceptible organisms and its excellent diffusion into the CSF, as indicated by the average ratio of CSF:serum chloramphenicol concentration of 0.67 (range, 0.45 to 0.99) (3). In our patient, the initial treatment with intravenous chloramphenicol was unsuccessful, so we decided to begin intraventricular treatment. Intraventricular treatment of meningitis caused by multidrug-resistant bacteria has been reported by other authors (14). Some authors postulated the intrathecal use of chloramphenicol in patients suffering from infected CSF shunts (4, 8, 11), but no experience in treating VREF was communicated. We conclude that in cases of meningitis caused by VREF, intraventricular administration of chloramphenicol could be considered as an alternative treatment.

Top Letter References

 

1
1. Anderegg, T. R., D. J. Biedenbach, R. N. Jones, and Quality Control Working Group. 2003. Initial quality control evaluations for susceptibility testing of dalbavancin (BI397), an investigational glycopeptide with potent gram-positive activity. J. Clin. Microbiol. 41:2795-2796.[Free Full Text]
2
2. Cercenado, E., S. Cercenado, J. A. Gomez, and E. Bouza. 2003. In vitro activity of tigecycline (GAR-936), a novel glycylcycline, against vancomycin-resistant enterococci and staphylococci with diminished susceptibility to glycopeptides. J. Antimicrob. Chemother. 52:138-139.[Free Full Text]
3
3. Friedman, C. A., F. C. Lovejoy, and A. L. Smith. 1979. Chloramphenicol disposition in infants and children. J. Pediatr. 95:1071-1077.[Medline]
4
4. Kaufman, B. A. 1997. Infections of cerebrospinal fluid shunts, p. 555-577. In W. M. Scheld, R. J. Whitley, and D. T. Durak (ed.), Infections of the central nervous system, 2nd ed. Lippincott-Raven, Philadelphia, Pa.
5
5. Kaye, K. S., J. J. Engemann, H. S. Faimow, and E. Abrutyn. 2004. Pathogens resistant to antimicrobial agents: epidemiology, molecular mechanisms and clinical management. Infect. Dis. Clin. North Am. 18:467-511.[Medline]
6
6. Lautenbach, E., M. G. Schuster, W. B. Bilker, and P. J. Brennan. 1998. The role of chloramphenicol in the treatment of bloodstream infection due to vancomycin-resistant Enterococcus. Clin. Infect. Dis. 27:1259-1265.[Medline]
7
7. Lefort, A., A. Saleh-Mghir, L. Garry, C. Carbon, and B. Fantin. 2000. Activity of LY333328 combined with gentamicin in vitro and in rabbit experimental endocarditis due to vancomycin-susceptible or -resistant Enterococcus faecalis. Antimicrob. Agents Chemother. 44:3017-3021.[Abstract/Free Full Text]
8
8. McLaurin, R. L. 1973. Infected cerebrospinal fluid shunts. Surg. Neurol. 1:191-195.[Medline]
9
9. National Nosocomial Infection Surveillance System. 1996. National Nosocomial Infection Surveillance (NISS) report: data summary from October 1986-April 1996, issued May 1996. Am. J. Infect. Control 24:380-388.[CrossRef][Medline]
10
10. Pérez Mato, S., S. Robinson, and R. E. Bégué. 1999. Vancomycin-resistant Enterococcus faecium meningitis successfully treated with chloramphenicol. Pediatr. Infect. Dis. J. 18:483-484.[Medline]
11
11. Salomon, J. H. 1978. Intraventricular chloramphenicol. Child's Brain 4:114-119.[Medline]
12
12. Shaikh, Z. H., C. A. Peloquin, and C. D. Ericson. 2001. Successful treatment of vancomycin-resistant Enterococcus faecium meningitis with linezolid: case report and literature review. Scand. J. Infect. Dis. 33:375-379.[CrossRef][Medline]
13
13. Souli, M., C. Thauvin-Eliopoulos, and G. M. Eliopoulos. 2000. In vivo ac-tivities of evernimicin (SCH 27899) against vancomycin-susceptible and vancomycin-resistant enterococci in experimental endocarditis. Antimicrob. Agents Chemother. 44:2733-2739.[Abstract/Free Full Text]
14
14. Vasen, W., P. Desmery, S. Ilutovicch, and A. Di Martino. 2000. Intrathecal use of colistin. J. Clin. Microbiol. 38:3523.[Free Full Text]
15
15. Williamson, J. C., S. S. Glazier, J. E. Peacock Jr. 2002. Successful treatment of ventriculostomy-related meningitis caused by vancomycin-resistant Enterococcus with intravenous and intraventricular quinupristin/dalfopristin. Clin. Neurol. Neurosurg. 104:54-56.[CrossRef][Medline]

						Pablo Gustavo Scapellato* Servicio de Infectología Hospital Donación F. Santojanni Pilar 950 Buenos Aires (1408, INH), Argentina Cecilia Ormazabal Servicio de Bacteriología Hospital Donación F. Santojanni Pilar 950 Buenos Aires (1408, INH), Argentina José Luis Scapellato Unidad de Terapia Intensiva Hospital Donación F. Santojanni Pilar 950 Buenos Aires (1408, INH), Argentina Edgardo Gabriel Bottaro María Teresa Rodríguez Brieschke Gabriela Inés Vidal Servicio de Infectologìa Hospital Donación F. Santojanni Pilar 950 Buenos Aires (1408, INH), Argentina
						* Phone: 011-4630-5772,Fax: 011-4630-5773,E-mail: pscapel{at}intramed.net

---

Journal of Clinical Microbiology, July 2005, p. 3578-3579, Vol. 43, No. 7
0095-1137/05/$08.00+0     doi:10.1128/JCM.43.7.3578-3579.2005
Copyright © 2005, American Society for Microbiology. All Rights Reserved.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Reprints and Permissions Copyright Information Books from ASM Press MicrobeWorld Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Scapellato, P. G. Articles by Bottaro, E. G. Search for Related Content PubMed PubMed Citation Articles by Scapellato, P. G. Articles by Bottaro, E. G.