Multidrug-resistant ventriculitis: Diagnostic and therapeutic challenges

Chronic meningitis is defined as inflammation of the meninges, with signs and symptoms persisting for at least 4 weeks without alleviation. Etiologies include inadvertent use of antibiotics, ventriculoperitoneal (VP) shunt infection and neoplasm. The incidence of shunt infection is about 2–27% in hydrocephalus cases. Gram-negative bacilli are responsible for 7–27.5% of all VP shunt infections. Here, we are reporting one such case which presented with chronic multidrug-resistant (MDR) meningitis secondary to VP shunt infection. A 7-year-old child with spastic quadriplegic cerebral palsy and hydrocephalus with VP shunt in situ presented following per rectal extrusion of shunt. Distal end was resected and proximal end was externalized to facilitate cerebrospinal fluid (CSF) drainage. CSF culture showed growth of Klebsiella oxytoca sensitive to intravenous (IV) meropenem. The child was readmitted 15 days later with fever and lethargy. Computed tomography brain showed features suggestive of ventriculitis. CSF culture on this occasion was positive for Enterococcus faecalis ; hence, vancomycin was commenced. Studies show that in addition to antibiotic treatment, removing the VP shunt temporarily is the most effective approach to eliminating shunt infection. Hence VP shunt was removed and an external ventricular drain (EVD) was inserted. Repeat CSF culture done a week later showed Pseudomonas aeruginosa and K. oxytoca growth resistant to carbapenems. Antimicrobial resistance testing done showed New Delhi metalloproteinase variant. Hence, IV ceftazidime/avibactam, aztreonam was commenced .Studies show that with intraventricular antibiotic therapy using vancomycin and aminoglycosides, CSF sterilisation was achieved in 88.4%. In our case, both vancomycin and amikacin were administered intraventricularly along with the removal of VP shunt and placing an EVD as a temporary measure. IV and intraventricular antibiotics were continued for 3 weeks till 3 consecutive CSF cultures were sterile. The child underwent removal of EVD and programmable VP shunt insertion on the opposite side. The child was discharged with IV antibiotics for a week, and resulted in successful recovery. Chronic MDR meningitis poses a challenge to clinicians diagnostically and therapeutically. Children with MDR ventriculitis secondary to VP shunt infection require prolonged IV and intraventricular antibiotics as well as long-term hospital stay. Removal of VP shunt with temporary EVD insertion is crucial in treatment. Re-insertion of VP shunt can be performed once CSF culture is sterile. Long-term follow-up of these children is recommended due to the risk of recurrent ventriculitis.