Treatment of Infection Caused by Vancomycin-Resistant Enterococci in Extremely Preterm Neonate

Background: Enterococci are facultative anaerobic microorganisms and opportunistic pathogens. Risk factors for enterococcal infection in neonates are prematurity, low birth weight, long-term hospitalization in the neonatal intensive care unit, immaturity of the innate and adaptive immune response, mechanical ventilation and other invasive procedures. Vancomycin-resistant Enterococci has increased significantly over the last two decades as important cause of nosocomial infections. Case description: The preterm male neonate was born by vaginal delivery at 255/7 weeks of gestation with birth weight of 900 g and Apgar score of 2 in the first minute after birth. After initial stabilization in Maternity Hospital, the neonate was admitted to the Institute of Neonatology on the 3rd day of life in severe condition. On the 28th day of life, the neonate developed signs of systemic infection. Complete blood count showed leukocytes of 6300/mm3 and increased concentration of C-reactive protein (90.2 mg/L). Analysis of cerebrospinal fluid obtained by lumbar and ventricular puncture showed pleocytosis, hyperproteinorachia and hypoglycorrhachia. We received a positive result of the tracheal aspirate for Enterococcus faecalis with sensitivity only on linezolid. Because of that, we added linezolid in the therapy. However, Enterococcus faecium grew in the blood and cerebrospinal fluid. In accordance to the antibiogram, the antibiotic therapy was replaced to chloramphenicol. Head ultrasound showed posthemorrhagic ventricular dilatation, increased thickness, irregularity and echogenicity of the ependyma, the presence of intraventricular debris and stranding and fibrin sept formation in left lateral ventricle. During treatment by chloramphenicol the neonate had a mild gray skin color, but count of blood cells, and function of liver and kidneys were normal. After the completion of treatment of neonatal sepsis complicated by meningitis and ventriculitis, ventriculoperitoneal shunt implantation was performed. Conclusion: There is a need for implementation of strategies for control of colonization by vancomycin-resistant Enterococci in pregnant women, as wells as preventive measures in daily work and rational use of antibiotics in the neonatal intensive care unit. Chloramphenicol could be used as a new treatment option for neonatal sepsis caused by vancomycin-resistant Enterococci, especially associated with infection of central nervous system with monitoring complete blood count, liver and kidney function of the neonate.