Successful Treatment of a Patient with Ventriculoperitoneal Shunt-Associated Meningitis Caused by Extended-Spectrum <i>β</i>-Lactamase-Producing <i>Klebsiella pneumoniae</i>

Abstract

Bacterial meningitis is responsible for significant morbidity and mortality worldwide, despite that modern antibiotics effectively penetrate cerebrospinal fluid to eradicate bacteria. A clinical suspicion of bacterial meningitis should be recognized early for the rapid diagnostic workup. Bacterial meningitis associated with ventriculoperitoneal shunt (VPS) is not uncommon and infrequently presents as abdominal symptoms and signs. Infections of the central nervous system caused by extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-KP) are extremely rare, and such multiple drug-resistant pathogens frequently cause inappropriate treatments and mortality. β -Lactamases are bacterial enzymes that inactivate β-lactam antimicrobial agents. The increased prevalence of ESBL-producing organism infections has become a worldwide problem. Timely and appropriate treatment is important to reduce mortality and morbidity of infections caused by ESBL-producing organisms. Here, we report a 61-year-old male patient who underwent VPS implantation for consequent hydrocephalus following spontaneous intracranial hemorrhage six months before this presentation. He was admitted for intermittent fever and right lower quadrant abdominal pain, and he was initially managed as acute appendicitis with its typical presentation. Finally, he was diagnosed VPS-associated meningitis caused by ESBL-KP. This patient was successfully treated with the combination of meropenem, a carbapenem antibiotic that is the drug of choice for treating ESBL-producing organisms, and high-dose fosfomycin, a phosphonic acid derivative antibiotic that is effective in treating some drug-resistant pathogens. In the present report, we emphasize the clinical presentations of catheter-related meningitis and risk factors for infections caused by ESBL-producing pathogens. Antibiotic combination therapy can provide synergistic effect and maximize anti-bacterial activity in ESBL-KP meningitis.

Physiologically based pharmacokinetic‐pharmacodynamic evaluation of meropenem plus fosfomycin in paediatrics

“…The same antimicrobial combination consisting of 8 g fosfomycin q8h and 1 g meropenem q8h successfully treated a 61‐year‐old patient with ventriculoperitoneal shunt‐associated meningitis due to an extended‐spectrum β‐lactamase‐producing K. pneumoniae. 54 In a clinical study, 15 patients with pulmonary exacerbation due to cystic fibrosis colonized by multidrug‐resistant P. aeruginosa were treated with 5 g q8h fosfomycin in combination with other antimicrobials in pairs, including meropenem, and demonstrated clinical improvements in 14 of the 15 patients 55 …”

Migration of the distal catheter of the ventriculoperitoneal shunt in hydrocephalus

“…The risk of intracranial infection was greater when the catheter penetrated the colon. This could be attributed to the retrograde ascent of pathogenic bacteria (e.g., fecal coliform bacteria) within the colic mucosa from the distal catheter (Knuth et al, ; Tseng et al, ). Another frequent, albeit less serious, abdominal complication is the formation of CSF pseudocysts, which were observed in all cases of liver penetration.…”

Faecal carriage of ESBL and plasmid-mediated AmpC β-lactamase genes in <i>Klebsiella</i> spp. and <i>Shigella</i> spp. isolated from inpatient and outpatient carriers in Tabriz, Iran.

“…Resistance to broad spectrum β-lactams, mediated by extended spectrum β-lactamase (ESBL), and AmpC beta-lactamases (AmpC) are an increasing concern around the world (1). These enzymes often cause improper treatments with increased infections and mortality, medical expenses and prolonged hospital stays (2). Strains that have such genes are typically resistant to several antimicrobial agents and can challenge treatment, as therapeutic options are few.…”