Year : 2012 | Volume
: 5 | Issue : 4 | Page : 373--375
Recurrent shunt associated ventriculitis caused by methicillin-resistant Staphylococcus aureus: Case with fatal outcome despite linezolid therapy
Sadia Khan1, Sujatha Sistla1, VR Roopesh Kumar2, N Srinivas Acharya1, Subhash C Parija1,
1 Department of Microbiology, JIPMER, Puducherry, India
2 Department of Neurosurgery, JIPMER, Puducherry, India
Department of Microbiology, Amrita Institute of Medical Sciences, Kochi - 682 041
Ventriculoperitoneal shunt-associated ventriculitis is a serious though under-reported nosocomial complication of neurocritical settings. The treatment of CNS Methicillin-resistant Staphylococcus aureus (MRSA) infections is usually successful with vancomycin or linezolid. Here, we report a case of ventriculitis due to MRSA following a shunt infection, which did not show clinical response to linezolid therapy. With the increasing use of invasive procedures, nosocomial infections have increased exponentially. Exercising extreme care in such CNS procedures becomes very important.
|How to cite this article:|
Khan S, Sistla S, Roopesh Kumar V R, Acharya N S, Parija SC. Recurrent shunt associated ventriculitis caused by methicillin-resistant Staphylococcus aureus: Case with fatal outcome despite linezolid therapy.Ann Trop Med Public Health 2012;5:373-375
|How to cite this URL:|
Khan S, Sistla S, Roopesh Kumar V R, Acharya N S, Parija SC. Recurrent shunt associated ventriculitis caused by methicillin-resistant Staphylococcus aureus: Case with fatal outcome despite linezolid therapy. Ann Trop Med Public Health [serial online] 2012 [cited 2021 Jan 24 ];5:373-375
Available from: https://www.atmph.org/text.asp?2012/5/4/373/102064
Ventriculoperitoneal shunts are often necessary in neurosurgical intensive care patients. Shunt-related ventriculitis is a serious nosocomial complication in neurocritical settings, and infection rates ranging from 5-20% have been reported.  The causative organisms frequently implicated are Staphylococci, particularly Coagulase Negative Staphylococcus (CoNS), followed by gram-negative bacteria.  The factors predisposing to such infections may range from non-adherence to rigid insertion and maintenance protocols, leakage of CSF, and frequent shunt manipulations. Diagnostic difficulties arise due to the mild inflammatory response produced by the most common causative agent, Staphylococci. Clear cut clinical signs of severe CNS infection are often absent.
With the changing nosocomial flora, the causes of nosocomial infections have also undergone a paradigm shift. Here, we report a case of methicillin-resistant Staphylococcus aureus-associated ventriculitis and the failure of therapy with linezolid.
A 60-year-old male presented to the neurosurgery casualty with head injury after a road traffic accident. The patient was unconscious and had bleeding from the ear and nose. On examination, his pulse rate was 70/minute, blood pressure was 140/90, and the Glasgow Coma Scale was calculated to be 11 (E4M6V1). The CT scan confirmed a temporal contusion with mass effect. Emergency surgical evacuation was done. Post-operatively, the patient showed gradual improvement and could ambulate with assistance. He was discharged from the hospital in a month.
A month later, he presented with weakness of lower limbs and difficulty in walking. A CT scan done at that time showed communicating hydrocephalus, which was a delayed sequela to head injury. Emergency surgery was done, and right ventriculoperitoneal shunt was placed. The patient improved following surgery. However, he developed a CSF leak from the cranial wound on the 5 th post-operative day, which was sutured. On the 8 th post-operative day, he complained of high grade fever. A culture of the shunt tap showed pus cells, and MRSA was grown in pyogenic culture. Following this, an external ventricular drainage was done, and the patient was started on inj vancomycin 1 gm iv 8 hrly. The fever subsided, and a repeat culture of the shunt tap was reported as sterile.
However, 2 weeks later, the patient had high grade fever again. Subsequent two cultures grew MRSA sensitive to gentamicin, vancomycin, and linezolid. The shunt was removed and sent for pyogenic culture. Methicillin resistant Staphylococcus aureus with a similar sensitivity pattern was isolated from the shunt. MIC of vancomycin was determined by broth microdilution as recommended by CLSI. Concentrations of 0.5 to 32ug/ml were tested and read manually after 24hrs of incubation. The MIC for Vancomycin in this case was < 0.5 ug/ml. Tab linezolid 600 mg bd was started as the serum creatinine levels had shot up to 2.2 mg/dl. The blood culture was sterile. The patient continued to have high grade fever. A CT repeated at this stage showed hydrocephalus without mass effect. The patient was planned for theco-peritoneal shunt. However, the patient deteriorated rapidly with absent eye opening and no motor response. The patient did not respond to linezolid therapy and expired.
Ventriculitis can be caused by trauma, invasive procedures like shunt insertion in immunocompromised hosts, following rupture of abscess or as a complication following intraventricular surgery, intrathecal chemotherapy, or meningitis. Ventricular catheter-related ventriculitis has an incidence variable from 5-22%. , However, rates higher than 10% should initiate a thorough examination of institutional protocols. The most common cause of pyogenic ventriculitis is gram- negative rods. Shunt-related ventriculitis, on the other hand, show gram-positive cocci of the normal skin flora as the most common cause.  The dearth of literature on pyogenic ventriculitis and the presence of few case reports on ventriculitis due to MRSA prompted us to report this case. 
Methicillin-resistant Staphylococcus aureus has emerged as a nosocomial pathogen associated with increasing number of large hospital outbreaks. In tertiary care hospitals in India, the incidence of MRSA infections may range from 35-42%.  These infections have a higher incidence in surgical and intensive care units where antibiotic usage is maximum. Occurrence of neurosurgical MRSA infections has been reported to be around 26%.
In this case, the patient showed a nosocomial shunt infection with MRSA. Most shunt infections associated with VP shunts occur within the first two months of surgery.  The patient mentioned in this case was infected within 8 days of insertion of the VP shunt. Although an early diagnosis of MRSA could be made and the patient showed good clinical and microbiological response with intravenous vancomycin, recurrence of symptoms was seen after 2 weeks. The probable reason of recurrence is a weak and unpredictable penetration of the CSF by vancomycin. Continuous intravenous vancomycin along with intrathecal administration has been recommended to overcome this limitation.  Due to increasing urea levels in the blood, indicating a compromised kidney function, the patient had to be started on oral linezolid. Linezolid, in comparison to other anti-MRSA agents, has 100% bioavailability when administered orally.  However, clinical failure in this case can be attributed to persistence of the shunt as an avascular nidus of infection. Due to inflammatory reactions in the CNS of the patient, linezolid's inability to maintain a constant level in the CSF cannot be ruled out. Descriptions of intrathecal therapy of linezolid and teicoplanin are available in the literature. ,, Their utility as a last resort in cases of failure of systemic therapy has been described.
Highly invasive procedures increase the risk of MRSA infections. Failure to identify and treat these can have disastrous consequences for the patient with CNS infection. Extreme care must be practiced in all CNS-invasive procedures.
The scant literature available on ventriculitis makes documentation of its frequency difficult. It probably leads to a misidentification of the entity. Prospective studies are needed to establish the incidence and treatment outcome of ventriculitis. 
|1||Beer R, Lackner P, Pfausler B, Schmutzhard E. Nosocomial ventriculitis and meningitis in neurocritical care patients. J Neurol 2008;255:1617-24.|
|2||Schoenbaum SC, Gardner P, Shillito J. Infections of cerebrospinal fluid shunts: Epidemiology, clinical manifestations, and therapy. J Infect Dis 1975;131:543-52.|
|3||Bhatnagar V, Mitra DK, Upadhyaya P. Shunt related infections in hydrocephalic children. Indian Pediatr 1986;23:255-7.|
|4||Lozier AP, Sciacca RR, Romagnoli MF, Connolly ES Jr. Ventriculostomy-related infections: A critical review of the literature. Neurosurgery 2002;51:170-81.|
|5||Pfausler B, Spiss H, Beer R, Kampl A, Engelhardt K, Schober M, et al. Treatment of staphylococcal ventriculitis associated with external cerebrospinal fluid drains: A prospective randomized trial of intravenous compared with intraventricular vancomycin therapy. J Neurosurg 2003;98:1040-4.|
|6||Venditti M, Micozzi A, Serra P, Buniva G, Palma L, Martino P. Intraventricular administration of Teicoplanin in shunt associated ventriculitis caused by Methicillin resistant Staphylococcus aureus. J Antimicrob Chemother 1988;21:513-5.|
|7||Tyagi A, Kapil A, Singh P. Incidence of Methicillin Resistant Staphylococcus aureus (MRSA) in Pus Samples at a Tertiary Care Hospital, AIIMS, New Delhi. J Indian Acad Clin Med 2008;9:33-5.|
|8||Chadwick EG, Yogev R, Shulman ST, Weinfeld RE, Patel IH. Single-dose ceftriaxone pharmacokinetics in pediatric patients with central nervous system infections. J Pediatr 1983;102:134-7.|
|9||Spanu T, Romano L, D'Inzeo T, Masucci L, Albanese A, Papacci F, et al. Recurrent ventriculoperitoneal shunt infection caused by small-colony variants of Staphylococcus aureus. Clin Infect Dis 2005;41:e48- 52.|
|10||Welshman IR, Sisson TA, Jungbluth GL, Stalker DJ, Hopkins NK. Linezolid absolute bioavailability and the effect of food on oral bioavailability. Biopharm Drug Dispos 2001;22:91-7.|
|11||Cruciani M, Navarra A, Di PG, Andreoni M, Danzi MC, Concia E, et al. Evaluation of intraventricular teicoplanin for the treatment of neurosurgical shunt infections. Clin Infect Dis 1992;15:285-9.|
|12||Spanu T, Rigante D, Tamburrini G, Fiori B, D'Inzeo T, Posteraro B, et al. Ventriculitis due to Staphylococcus lugdunensis: Two case reports. J Med Case Rep 2008;2:267.|
|13||Ntziora F, Falagas ME. Linezolid for the treatment of patients with central nervous system infection. Ann Pharmacother 2007;41:296- 308.|
|14||Agrawal A, Cincu R, Timothy J. Current concepts and approach to Ventriculitis. Infect Dis Clin Pract 2008;16:100-4.|