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Is First-Line Vancomycin Still the Best Option to Treat Staphylococcus Health Care-Associated Meningitis?
Roman Mounier1, David Lobo1, Anne Hulin2
1Anaesthesia and Surgical Intensive Care Unit Department, Henri Mondor University Hospital of Paris-Paris XII School of Medicine, Creteil, France.
Background:
Cerebrospinal fluid (CSF) penetration of vancomycin through the blood-brain barrier is poor but important inflammation improved it. Hence, vancomycin is recommended for the treatment of community meningitis. However, what about mild inflammatory health care-associated meningitis? The aim of this study was to evaluate the impact of vancomycin diffusion on CSF in Staphylococcus epidermidis health care-associated meningitis.
Case Description:
This was a retrospective study of all consecutive patients with S. epidermidis CSF shunt-associated infection, which was treated by continuous intravenous vancomycin after standard of care (60 mg/kg/d after a loading dose of 15 mg/kg). Patient outcome, CSF protein level, and vancomycin concentration in CSF and serum were assessed. We report 6 consecutives cases. Clinical and biologic manifestations were of mild intensity. Meningeal permeability was moderately altered with low CSF protein levels. Despite appropriate vancomycin dosage resulting in high serum concentrations, CSF remained below the S. epidermidis minimal inhibitory concentration.
Conclusions:
We propose to reassess vancomycin use as first-line therapy when meningeal inflammation is mild-to-moderate in favor of antibiotics, which have a better CSF penetration.
Insights
Vancomycin shows poor cerebrospinal fluid (CSF) penetration for healthcare-associated meningitis, even with inflammation. Alternative antibiotics are recommended for mild-to-moderate meningeal inflammation.
Area of Science:
- Neuroscience
- Infectious Diseases
- Pharmacology
Background:
- Vancomycin is recommended for community meningitis due to improved CSF penetration with inflammation.
- Healthcare-associated meningitis presents a unique challenge regarding antibiotic efficacy.
- The study investigates vancomycin's CSF diffusion in Staphylococcus epidermidis meningitis.
Observation:
- A retrospective study analyzed patients with S. epidermidis CSF shunt-associated infection treated with continuous IV vancomycin.
- Patients presented with mild clinical and biological manifestations and moderate meningeal permeability.
- Low CSF protein levels were observed, indicating limited inflammation.
Findings:
- Despite high serum vancomycin concentrations, CSF levels remained below the minimal inhibitory concentration for S. epidermidis.
- Vancomycin diffusion into the CSF was inadequate for effective treatment in this cohort.
- The standard vancomycin dosage did not achieve therapeutic concentrations in the CSF.
Implications:
- Reassessing vancomycin as a first-line therapy for mild-to-moderate meningeal inflammation is suggested.
- Antibiotics with better CSF penetration may be more suitable for healthcare-associated meningitis.
- This study highlights the importance of considering CSF penetration in antibiotic selection for meningitis.
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