Successful treatment of vancomycin-resistant enterococcal infection of an external ventricular drain with 2 weeks of intravenous linezolid

Abstract

Hydrocephalus is a common condition worldwide, and is frequently managed by diversion of cerebrospinal fluid (CSF), either externally with a drain or internally with a shunt. An external ventricular drain (EVD) can be an essential treatment modality, but is associated with a risk of infection, most commonly caused by Staphylococcal species, which can result in meningitis or ventriculitis and a delay in the definitive management of the hydrocephalus. Here, we report the case of a patient who required an EVD to manage post-operative hydrocephalus following a craniotomy and microvascular decompression for trigeminal neuralgia. He subsequently developed EVD-associated infection with a vancomycin-resistant Enterococcus faecium (VRE), which was treated successfully with a 2-week course of intravenous linezolid monotherapy. The authors believe this to be the only described case of successful treatment within this time frame of a CSF VRE infection associated with indwelling foreign material.

A Difficult Case of Ventriculitis in a 40-Year-Old Woman with Acute Myeloid Leukemia

“…Enterococcal meningitis is uncommon and linked with a high death rate [22][23][24]. The risk factors for developing post-neurosurgical infections vary depending on the surgical procedure used and include multiple EVDs, longer drainage duration, higher frequency of CSF sampling, prior brain surgery, lower Glasgow coma scale (GCS), and insertion site dehiscence [4].…”

“…Only a few cases of vancomycin-resistant enterococcal meningitis/ventriculitis have been described in the literature. There are limited therapeutic options for device-associated vancomycin-resistant CNS infections, and the optimal treatment has yet to be discovered [22][23][24][25][26][27]. An antibiotic's entrance into the CSF is determined by the drug's physicochemical qualities, alongside host variables such as the patient's age, CSF flow and volume, plasma albumin, and polymorphisms in genes that encode transport proteins [22].…”

“…Broad-spectrum antibiotics with great action against anaerobes but low activity against enterococci may enhance the colonization of the gastrointestinal tract with VRE [23][24][25][26].…”

“…Prior to the development of bacteremia and the discovery of vancomycin-resistant E. faecium in the CSF, our patient had received therapy with piperacillin/tazobactam, meropenem, and levofloxacin, which may have impacted the development of VRE. Due to the limited CNS penetration and reports of treatment failure, monotherapy is not recommended for VRE meningitis [22][23][24][25][26]. Because of its better penetration into the CNS compared to other treatments, linezolid is frequently regarded as the treatment of choice for individuals with VRE meningitis, if they are susceptible.…”