Multidrug-resistant Acinetobacter baumannii (MDRAB) has emerged as an increasingly important pathogen that causes nosocomial meningitis. However, MDRAB-associated nosocomial meningitis is rarely reported in children.

We report the case of a 1-year-old girl with a choroid plexus papilloma, who developed postoperative nosocomial meningitis due to MDRAB. The bacterial strain was sensitive only to tigecycline and colistin, and showed varying degrees of resistance to penicillin, amikacin, ceftriaxone, cefixime, cefotaxime, ciprofloxacin, levofloxacin, gentamicin, meropenem, imipenem, and tobramycin. She was cured with intravenous doxycycline and intraventricular gentamicin treatment.

Doxycycline and gentamicin were shown to be effective and safe in the treatment of a pediatric case of MDRAB meningitis.

Acinetobacter baumannii (A. baumannii) is a Gram-negative bacterium that causes various nosocomial infections[1,2]. Postoperative nosocomial meningitis due to A. baumannii is rarely reported in children. Treatment of A. baumannii infection is of concern due to the increasing prevalence of multidrug resistance[3]. In this report, we present the case of a child who developed post-neurosurgical meningitis due to multidrug-resistant A. baumannii (MDRAB). The child was successfully treated with intravenous doxycycline and intraventricular gentamicin administration. This report also presents a systematic literature review concerning MDRAB-associated nosocomial meningitis in children.

Postoperative MDRAB meningitis.

As colistin has severe side effects in children, the patient was started on tigecycline (2 mg/kg/d divided q12h). After 12 d of antibiotic therapy with tigecycline, the patient still had a fever. The CSF culture was positive for MDRAB. Doxycycline is known to be active against MDRAB and was administered to the patient following the failure of tigecycline (4 mg/kg/d divided q12h) and intraventricular gentamicin (2 mg/d, once daily) was administered. The patient became afebrile 6 d later. After 17 d, the CSF was found to be sterile. Doxycycline and gentamicin were administered for 8 wk. The clinical course of the patient is shown in Figure 2.

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Figure 2 Clinical course of a 1-year-old patient with multidrug-resistant Acinetobacter baumannii meningitis. CTRX: Ceftriaxone (Rocephin); MEPM: Meropenem; VAN: Vancomycin; TGC: Tigecycline; DO: Doxycycline; GM: Gentamicin; WBC: White blood cell; CRP: C-reactive protein; CSF: Cerebrospinal fluid; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BUN: Blood urea nitrogen; Cr: Creatinine.

There were no serious side effects of doxycycline and gentamicin treatment. The patient is now healthy and is receiving scheduled follow-up and her CT examination results remained normal at the subsequent two-year follow-up (Figure 1).

MDRAB is a troublesome pathogen in healthcare institutions owing to multidrug resistance, which is a threat to the current antibiotic era[4]. Nosocomial meningitis due to MDRAB is fatal and its treatment is challenging because of the low blood-brain barrier permeability of antibiotic drugs[5,6]. Thus, the choice of antibiotics is critical to the treatment of nosocomial MDRAB meningitis. It is also important to analyze the blood and CSF cultures before treatment initiation to avoid inappropriate antibiotic use. In the present case, CSF culture showed the presence of MDRAB that was sensitive only to tigecycline and colistin.

In the past, colistin had been used successfully against Gram-negative bacteria; however, its prescription decreased due to nephrotoxicity[7]. Tigecycline is a broad-spectrum bacteriostatic compound of glycylcyclines, which is active against several multidrug-resistant pathogens as well as MDRAB[8]. In our case, tigecycline was initially administered intravenously, but the patient did not respond to the treatment and continued to manifest typical signs of meningitis. The possible explanation of the therapeutic failure of intravenous tigecycline treatment could be attributed to its poor ability to penetrate through the blood-brain barrier. Thus, a combination of intravenous and intraventricular (IVT) antibiotic administration may be a therapeutic option to ensure sterilization of the CSF. Both doxycycline and tigecycline belong to the tetracycline class of antibiotics. Doxycycline was administered following the failure of tigecycline, known to be active against MDRAB. In our case, doxycycline was effective in the treatment of the CNS infection, which may be explained by an increased doxycycline distribution in the CNS owing to the disruption of the blood-brain barrier, in inflammatory diseases like meningitis. However, further pharmacological studies are needed to confirm this observation. Moreover, the intraventricular gentamicin administration could effectively sterilize the CSF.

MDRAB has emerged as an increasingly important pathogen often associated with post-neurosurgical meningitis[9]. In the literature, the number of pediatric cases with MDRAB meningitis is low. Data regarding the clinical characteristics, therapy, and treatment outcomes in pediatric cases are summarized in Table 1[10-15]. Since active antibiotics including tigecycline and colistin diffuse poorly to the central nervous system, it is a challenge to treat patients via intravenous administration of these drugs. The IVT administration of these antibiotics is currently the only treatment option for MDRAB meningitis.

In conclusion, this case suggests that the combination of intravenous doxycycline and intraventricular gentamicin administration may be a potentially effective and safe therapeutic option for the treatment of childhood MDRAB meningitis.