A Man With Resistant Meningitis After Neurosurgery

Key TakeawaysA 27-year-old man developed postoperative meningitis caused by multidrug-resistant Acinetobacter baumannii, which was susceptible only to colistin. Colistin treatment initially improved his neurologic status and sterilized the cerebrospinal fluid, but he later developed severe respiratory complications and refractory septic shock. The case highlights the challenges of treating multidrug-resistant hospital-acquired infections and the importance of infection prevention.The case report by pathologist Inssaf Haddi and colleagues at the Cadi Ayyad University in Marrakesh, Morocco, underscores the need for infection prevention measures in hospitals.The Patient and His Medical HistoryThe patient presented to a hospital in Marrakesh, Morocco, 3 weeks after surgical treatment for a craniopharyngioma, with suspected postoperative meningitis. He reported no fever or runny nose. A known preexisting condition was anterior hypophyseal insufficiency.The patient’s medication, family, social, substance use, travel, and allergy histories were unremarkable.FindingsUpon admission, the patient’s vital signs were measured. Respiratory and heart rates, blood pressure, oxygen saturation on room air, and body temperature were within their respective normal ranges.Inspection, auscultation, palpation, and percussion of the patient’s body confirmed the information provided in the medical history.A CT scan of the head revealed no intracranial abnormalities.A lumbar puncture revealed cloudy cerebrospinal fluid with 5760 leukocytes/mm3, 5.7 g/L protein, and 0.05 g/L glucose. The blood glucose concentration was 116 mg/dL, and the C-reactive protein level was 227.8 mg/L.DiagnosisGram stain revealed gram-negative coccobacilli and signs of a marked inflammatory reaction in the cerebrospinal fluid. A cerebrospinal fluid culture identified A baumannii. Susceptibility testing showed that the bacterium was susceptible only to colistin.Antibiotic therapy with intravenous and intrathecal colistin (9,000,000 IU daily for 18 days) was initiated and led to rapid neurologic improvement. Fifteen days after the start of antibiotic therapy, the cerebrospinal fluid became sterile. Low-molecular-weight heparin was added at a therapeutic dose. Subsequently, direct oral anticoagulants were administered. Levothyroxine and hydrocortisone were administered to treat anterior pituitary insufficiency.Despite this therapy, the patient developed respiratory arrest and had to be intubated, mechanically ventilated, and sedated. During mechanical ventilation, he developed methicillin-resistant Staphylococcus aureus-associated pneumonia and acute respiratory failure. Septic shock, which could not be treated even with high-dose noradrenaline, led to the patient’s death 1 month after admission.Discussion“This case report illustrates the complexity of managing postoperative nosocomial meningitis, particularly given the poor diffusion of antibiotics in the CSF,” wrote the authors of the case report. Early diagnosis, adequate antibiotic therapy, good antimicrobial stewardship, and rigorous infection prevention measures for patients at risk for multidrug-resistant bacterial infections are of critical importance.This story was translated from Univadis Germany, part of the Medscape Professional Network.