Download Multiresistant Acinetobacter baumannii ventriculitis

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Relato de caso
Multiresistant Acinetobacter baumannii ventriculitis
Ventriculite por Acinetobacter baumannii multiresistente
Rafael Augusto Castro Santiago Brandão1;
Moises Heleno Vieira Braga2;
Lucas Alverne Freitas de Albuquerque1;
Paulo Pereira Christo3;
Marcello Penholate Faria4;
Baltazar Leão Reis1.
RESUMO
ABSTRACT
Entre as bactérias Gram-negativas, o Acinetobacter sp
tornou-se um importante patógeno hospitalar, devido ao
aumento do número de cepas multi-resistentes. Esta espécie
é responsável por um número crescente de infecções pósoperatórias caracterizadas por alta mortalidade. A ocorrência
de bactérias Gram-negativas multirresistentes levou a um
aumento no número de infecções do sistema nervoso central.
Em particular, a ocorrência de bactérias resistentes à
cefalosporinas de quarta geração e carbapenênicos resultou
em uma redução significativa de opções terapêuticas para
o tratamento destas infecções. Acinetobacter baumannii
é um importante agente hospitalar e sua resistência aos
antibióticos mais modernos aumenta a cada dia, o que é uma
grave ameaça aos pacientes infectados. Descrevemos um
caso de um paciente submetido a neurocirurgia e colocação
de derivação ventricular externa evoluindo com ventriculite
por Acinetobacter baumannii resistente a cefalosporinas de
quarta geração e meropenem.
Among Gram-negative bacteria, Acinetobacter sp. has
become an important nosocomial pathogen due to the increase
in the number of multiresistant strains, and this species is
responsible for a growing number of postoperative infections
with a high mortality rate. The occurrence of multiresistant
Gram-negative bacteria has led to an increase in the number
of central nervous system infections and the occurrence of
bacteria resistant to fourth-generation cephalosporins and
carbapenems resulted in a significant reduction of therapeutic
options for the treatment of these infections. Acinetobacter
baumannii is an important nosocomial agent and its resistance
to antibiotic has improved over the time and the occurrence of
carbapenems and fourth generation cephalosporins resistant
strains is a serious threaten to infected patients. We describe
a case of a multi-resistant Acinetobacter baumannii resistant
to fourth-generation cephalosporins and meropenem, after a
neurosurgical procedure.
Palavras-chave: Acinetobacter baumannii, Acinetobacter sp,
Infecções por Acinetobacter
Key words: Acinetobacter baumannii, Acinetobacter
sp, Acinetobacter infections Ventriculite causada por
Acinetobacter baumannii multiresistente
1 - Resident of Neurosurgery - Santa Casa de Belo Horizonte, Department of Neurosurgery - Belo Horizonte - MG - Brazil.
2 - Staff Neurosurgeon of Biocor Hospital - Belo Horizonte - MG - Brazil.
3 - Staff Neurologist of Santa Casa de Belo Horizonte - Belo Horizonte - MG - Brazil.
4 - Staff Neurosurgeon of Santa Casa de Belo Horizonte and Life Center Hospital - Belo Horizonte - MG - Brazil.
Recebido em 14 de novembro de 2010, aceito em 03 de setembro de 2011
Brandão RACS, Braga MHV, Albuquerque LAF, Christo PP, Faria MP, Reis BL - Multiresistant Acinetobacter baumannii ventriculitis
J Bras Neurocirurg 23 (2): 172-175, 2012
173
Relato de caso
ABREVIATIONS
EVD - External ventricular drainage
CCT – Cranial computed tomography
CSF – cerebrospinal fluid
CNS - central nervous system
Introduction
Neurosurgical patients have a high risk of developing nosocomial meningitis, with potentially lethal consequences. The widespread use of antibiotics may have altered the epidemiology
of postneurosurgical meningitis in recent years.7 The incidence
of these infections varies and mainly depends on the type of
surgery, use of prophylactic antibiotics , general health of the
patient, and use of drains. The incidence of bacterial meningitis in clean surgeries is 0.6% in the presence of antibiotic
prophylaxis, with this rate reaching 1.9% in the absence of antibiotic prophylaxis.1,6
External ventricular drainage (EVD) is one of the procedures
most widely performed in neurosurgery, presenting a high infection rate of 2 to 33%.1,6 Risk factors for this type of infection
include the duration of EVD, inadequate asepsis during manipulation of drain components, increased intracranial pressure,
and intraventricular hemorrhage.8
Gram-positive bacteria are the most frequent cause of EVD
infection, followed by Gram-negative bacteria.6,8,13 Among
Gram-negative bacteria, Acinetobacter sp. has become an important nosocomial pathogen due to the increase in the number
of multiresistant strains: this species is responsible for a growing number of postoperative infections with a high mortality
rate.3,7,9
During the past three decades, multi-drug-resistant organisms
are a growing concern in intensive care units. Acinetobacter
baumannii is an ubiquitous, gram negative bacteria that can
survive for prolonged periods on environmental surfaces, and
has emerged as an important infectious agent in hospitals worldwide, due to its ability to tolerate desiccation and to accumulate diverse mechanisms of resistance to most antimicrobials,
including aminoglycosides and carbapenems.10
We describe a case of multi-resistant Acinetobacter baumanni
ventriculitis, an important pathogen in infections of intensive
care patients.
Case Report
A 62-year-old female patient with no previous comorbidities
presented with a sudden reduction in consciousness level and
signals of increased intracranial pressure: Glasgow Coma Scale was nine. Cranial computed tomography (CT) showed a
fusiform aneurysmal dilatation involving the right vertebral
artery throughout its extension and involving the beginning
of the basilar artery, associated to acute hydrocephalus due to
compression of the fourth ventricle and ischemia in the cerebellar hemisphere (Fig. 1).
Figure 1. CT without contrast, obtained on admission, showing a basilar artery
aneurysm compressing the brainstem.
The patient was submitted to decompressive craniectomy of
the posterior fossa and placement of an external ventricular
drainage (EVD). Intensive care unit was needed, with continuous ventilatory support, analgesia and sedation. Three days
later, the patient developed fever, but CSF was unremarkable.
Chest x-ray diagnosed pneumonia and antibiotic therapy with
vancomycin and cefepime was instituted. Culture of pulmonary secretion collected from the orotracheal tube revealed the
presence of Proteus sp. sensitive to cefepime and meropenem.
The patient remained afebrile for 4 days, when persistent fever returned. The patient presented an allergic reaction to vancomycin, which was replaced by targocid and cefepime was
replaced by meropenem. Fever continued despite antibiotic
therapy, leading us to a new CSF study that was suggestive
of bacterial infection, with pleocytosis (neutrophilic predominance), elevated protein level, low glucose and elevated lactic
acid levels.
A new CT showed ependymal impregnation, characteristic of
ventriculitis. CSF culture revealed infection due to Acinetobacter baumannii, resistant to penicillin, methicillin, tetracycline,
erythromycin, levofloxacin, ciprofloxacin, trimethoprimsulfamethoxazole, ampicillin-sulbactan aminoglycosides,
vancomycin, first, second, third and fourth-generation cephalosporins, meropenem and imipenem and sensitive only to tigecycline. Before the adjustment of the new antibiotic therapy,
the patient presented rapid progressive worsening and developed severe sepsis, dying few hours later.
Brandão RACS, Braga MHV, Albuquerque LAF, Christo PP, Faria MP, Reis BL - Multiresistant Acinetobacter baumannii ventriculitis
J Bras Neurocirurg 23 (2): 172-175, 2012
174
Relato de caso
Discussion
The main pathogens involved in ventriculitis after EVD insertion are Staphylococcus epidermidis (46%), Staphylococcus
aureus (20.4%) and Gram-negative bacteria.1,6,8 The most widely used routine treatment for these patients is a combination
of fourth-generation cephalosporins or carbapenems combined
with vancomycin. Aminoglycosides and quinolones may also
be used depending on the hospital flora and sensitivity of the
bacteria. Third-generation cephalosporins are still widely employed despite the growing number of resistant strains.
The spread of multiresistant Gram-negative bacteria has led to
an increase in the number of CNS infections caused by these
bacteria. In this respect, the occurrence of bacteria resistant to
fourth-generation cephalosporins and carbapenems results in a
significant reduction of therapeutic options for the treatment of
these infections.3
Acinetobacter spp. are non-fermentative, aerobic, gram-negative coccobacilli widely distributed in soil and water. Acinetobacter baumannii, main representative bacteria of the group,
can cause various types of nosocomial infections. Recently
published data from the National Nosocomial Infections Surveillance System regarding ICU patients across the USA show
that in 2003 A. baumanii was responsible for 6.9% of pneumonia, 2.4% of bloodstream infections, 2.1% of surgical site
infections and 1.6% of urinary tract infections.4,7
CNS infections due to A. baumannii after neurosurgical procedures are rare but with a high mortality rate (20-27%),15
normally progressing to sepsis. Risk factors for nosocomial A.
baumannii meningitis are associated with emergency neurosurgical procedures and more than 5 days of EVD, both present in our patient.15
A. baumannii are highly resistant to quinolones and third-generation cephalosporins, but respond well to antibiotic therapy
with fourth-generation cephalosporins and carbapenems. Recent studies have shown that the occurrence of Acinetobacter
strains resistant to these antibiotics is becoming a great therapeutic challenge. A multicenter study (MYSTIC Program)
conducted between 1997 and 2000 and involving 37 European
hospitals has shown a sensitivity of Acinetobacter baumannii
to imipenem ranging from 93 to 100% at most hospitals studied compared to a rate of 62-66% reported for Turkish hospitals.14 Two other studies evaluating patients with meningitis
caused by Acinetobacter found no resistance to carbapenems,
with the sensitivity to these drugs ranging from 92 to 100%,
but showed a high resistance to other antibiotics, including cephalosporins.2,5 Another series involving 35 patients evaluated
after neurosurgery reported a sensitivity to imipenem, meropenem and cefepime of 55.2%, 55.2% and 37.9%, respectively.9
The presence of multiresistance and the poor penetration of
many drugs through the blood–brain barrier have forced the
use of topical therapies, initially with aminoglycosides and
more recently the use of intraventricular and intrathecal colistin. Colistin is a polymyxin used successfully against Gramnegative bacteria in the past and abandoned because of reported toxicity, mainly nephrotoxicity.11 They have shown good
results in selected cases.11,12
Colonization of the EVS with Acinetobacter sp. was considered as the source of the infection in the patient. The organism’s
ability to tolerate desiccation and to accumulate diverse mechanisms of resistance favors its long-term persistence in
ICUs, where skin carriage may persist for weeks/months and
the Acinetobacter-colonized hands of the staff may be responsible for patient-to-patient spread. Environmental contamination and contamination of medical equipment may also play an
important role in the transmission of A. baumannii in healthcare institutions.7
One of the major treatment difficulties is the late identification
of the pathogen which normally takes about 72 hours to be
identified by culture, as was the case of the present patient, in
which the delay in the bacterial identification led to late proper treatment, with a consequent unfavorable prognosis. Empirical treatment with carbapenems and vancomycin, normally
used in most hospitals, is usually ineffective and compromises
the treatment of patients infected with a highly virulent bacterium. Although Gram staining is a useful tool , suggestive of
the germ type , only culture permits the exact identification of
the microorganism and the eligible antibiotic. In addition to
therapeutic improvement, advances in diagnostic work-up are
important since only early identification of the involved pathogen permits planning and application of an effective treatment ,
which can be either intravenous , intrathecal or intraventricular.
Conclusion
Gram-negative bacteria are important pathogens of postoperative infections in patients submitted to neurosurgical procedures. The occurrence of bacteria resistant to fourth-generation
cephalosporins and carbapenems, including Acinetobacter
spp., impairs the prognosis of these patients. In addition to the
need for new antibiotics and therapeutic modalities, new tools
for the early identification of these pathogens are necessary in
order to quickly initiate treatment and thus improve the final
prognosis of the patient.
Brandão RACS, Braga MHV, Albuquerque LAF, Christo PP, Faria MP, Reis BL - Multiresistant Acinetobacter baumannii ventriculitis
J Bras Neurocirurg 23 (2): 172-175, 2012
175
Relato de caso
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Corresponding Author
Rafael Augusto Castro Santiago Brandão
Address: Rua Genebra 936, Nova Suíça, City:
Belo Horizonte, State: Minas Gerais
Country: Brazil postal code: 30480510
Phone: +55 31 91197552/ +55 31 33343824
Email: [email protected]
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and literature review. J Hosp Infect 2009;71:176–80.
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Brandão RACS, Braga MHV, Albuquerque LAF, Christo PP, Faria MP, Reis BL - Multiresistant Acinetobacter baumannii ventriculitis
J Bras Neurocirurg 23 (2): 172-175, 2012