Journal Article

Multidrug-resistant Klebsiella oxytoca ventriculitis, successfully treated with intraventricular tigecycline: A case report

Pérez-Neri, Iván, Angeles-Morales, Verónica, Cárdenas, Graciela, Soto-Hernández, José Luis, Barradas, Victor Alcocer, Soto-Ramírez, Adán

2020

Overview

•Ventriculitis by gram negative bacteria is a serious disease with high mortality.•Treatment is limited by poor penetration of several antibiotics into CSF.•Tigecycline is a derivative of minocycline with a wide spectrum of activity.•5 mg of intraventricular tigecycline produced CSF therapeutic levels for 6 h.•Intraventricular tigecycline may be effective in refractory cases ventriculitis. A 38-year-old male presented to the hospital with headache, fever, and meningeal signs. He had undergone a surgical review of a ventriculoperitoneal shunt system one month earlier. A head computed tomography scan showed hydrocephalus. His medical history included a human immunodeficiency virus infection identified four years before and resolved cryptococcal meningitis, which had necessitated the implantation of the shunt system. Ventricular cerebrospinal fluid (CSF) was obtained, which showed inflammation and, in culture, grew a Gram-negative bacillus identified as multidrug-resistant Klebsiella oxytoca. The shunt was removed and a ventricular drain was installed. Treatment with meropenem and amikacin was established without a response; the CSF white blood cell count continued to increase, with cultures remaining positive. The patient's clinical condition deteriorated to stupor. With informed consent, intraventricular (ITV) treatment with tigecycline was initiated at a dose of 5 mg every 24 h and, three days later, the CSF cultures were negativized. Tigecycline levels in the CSF were quantified by liquid chromatography with ultraviolet detection and showed peak concentrations achieved at two hours after the dose of between 178 and 310 μg/mL. After 11 days of treatment with ITV tigecycline and eight negative CSF cultures, a new CSF shunt was installed. During follow-up review 10 months later, the patient reported he was working. The dose of tigecycline used in this study produced levels 15 to 20 times the minimum inhibitory concentration of the bacteria for up to six hours with adequate tolerance.

• Publisher: Elsevier B.V,Elsevier Limited
• Subject: Adult / Amikacin / Anti-bacterial agents / Anti-Bacterial Agents - cerebrospinal fluid / Anti-Bacterial Agents - therapeutic use / Anti-HIV Agents - therapeutic use / Antibiotics / Case reports / Cell culture / Cerebral ventriculitis / Cerebral Ventriculitis - complications / Cerebral Ventriculitis - diagnosis / Cerebral Ventriculitis - drug therapy / Cerebral Ventriculitis - microbiology / Cerebrospinal fluid / Chromatography liquid / Computed tomography / Drug dosages / Drug resistance / Drug Resistance, Multiple, Bacterial / Drug resistant multiple / Efavirenz, Emtricitabine, Tenofovir Disoproxil Fumarate Drug Combination - therapeutic use / Fever / Gram-positive bacteria / Headache / HIV / HIV Infections - complications / HIV Infections - drug therapy / Human immunodeficiency virus / Humans / Hydrocephalus / Informed consent / Injections intraventricular / Klebsiella Infections - complications / Klebsiella Infections - diagnosis / Klebsiella Infections - drug therapy / Klebsiella Infections - microbiology / Klebsiella oxytoca / Klebsiella oxytoca - isolation & purification / Klebsiella oxytoca - physiology / Liquid chromatography / Male / Meningitis / Meropenem / Microbial Sensitivity Tests / Minimum inhibitory concentration / Multidrug resistance / Multidrug resistant organisms / Neurology / Neurosurgery / Nosocomial infections / Patients / Surgical Wound Infection - complications / Surgical Wound Infection - diagnosis / Surgical Wound Infection - drug therapy / Surgical Wound Infection - microbiology / Tigecycline / Tigecycline - cerebrospinal fluid / Tigecycline - therapeutic use / Ventricle / Ventriculitis / Ventriculoperitoneal Shunt