<i>Enterococcus faecium</i> meningitis: A challenging pathogen in the central nervous system

Enterococcus faecium meningitis is typically linked to procedures, devices, or severe immunosuppression. This report discusses a 66-year-old man with chronic obstructive pulmonary disease (COPD) who developed E. faecium meningitis without conventional risk factors, suggesting a shift in regional microbiological trends. The patient was previously hospitalized for an acute COPD exacerbation and developed a catheter-associated urinary tract infection with vancomycin- and linezolid-sensitive E. faecium . Despite linezolid, he experienced persistent headaches and altered sensorium following discharge. On readmission, he exhibited drowsiness, neck stiffness, and a positive Kernig’s sign. Cerebrospinal fluid (CSF) analysis suggested bacterial meningitis, with E. faecium resistant to ampicillin but sensitive to vancomycin and linezolid in culture. Magnetic resonance imaging suggested ventriculitis. Initial empirical treatment was modified to vancomycin, based on the sensitivity report, with the addition of linezolid when the second CSF culture showed persistent infection. Meningitis resolved with CSF clearance and a negative brain computed tomography scan. He was shifted out of the intensive care unit, but developed nosocomial pneumonia and died. The increasing pathogenicity of E. faecium in patients with chronic medical conditions or prior antibiotic use, as observed in this case, is concerning. Gut dysbiosis from antibiotic exposure and COPD may have facilitated colonization by this organism. Linezolid serves as a vital adjunct to vancomycin. This case underscores the need for due vigilance by clinicians while treating E. faecium infections.