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Berksu Curebal, Nazan Dalgic and Banu Bayraktar

Ventriculoperitoneal (VP) shunt infections are seen in 3%–17% of patients with VP shunts. These infections may cause severe morbidity and mortality. Staphylococci are the most common cause of CSF shunt-associated infections, although gram-negative bacteria (especially multidrug-resistant [MDR] and extensive drug–resistant [XDR] bacteria) also play an important role. Due to increased antibiotic resistance, sometimes off-label usage of antibiotics is considered. Tigecycline is one of these antibiotics. It should not be used unless there are no other antibiotic treatment options available, especially in children. It belongs to the glycylcycline class of antibiotic agents and inhibits protein translation in bacteria by binding to the 30S ribosomal subunit. The authors describe the case of a patient who had an XDR Klebsiella pneumoniae–positive VP shunt infection. After removal of his VP shunt, an external ventricular drain was inserted, and the patient was treated with a combination of intravenous (1.2 mg/kg/day) and intraventricular (4 mg/day) tigecycline in addition to his meropenem (120 mg/kg/day) treatment. On the 7th day of the combined therapy, his CSF culture was sterile. Because tigecycline distribution into the tissues is not sufficient with intravenous administration, combining it with intraventricular infusion can provide new treatment methods. However, further studies are needed for its use as a treatment method in children.

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Berksu Curebal, Nazan Dalgic and Banu Bayraktar

Ventriculoperitoneal (VP) shunt infections are seen in 3%–17% of patients with VP shunts. These infections may cause severe morbidity and mortality. Staphylococci are the most common cause of CSF shunt-associated infections, although gram-negative bacteria (especially multidrug-resistant [MDR] and extensive drug–resistant [XDR] bacteria) also play an important role. Due to increased antibiotic resistance, sometimes off-label usage of antibiotics is considered. Tigecycline is one of these antibiotics. It should not be used unless there are no other antibiotic treatment options available, especially in children. It belongs to the glycylcycline class of antibiotic agents and inhibits protein translation in bacteria by binding to the 30S ribosomal subunit. The authors describe the case of a patient who had an XDR Klebsiella pneumoniae–positive VP shunt infection. After removal of his VP shunt, an external ventricular drain was inserted, and the patient was treated with a combination of intravenous (1.2 mg/kg/day) and intraventricular (4 mg/day) tigecycline in addition to his meropenem (120 mg/kg/day) treatment. On the 7th day of the combined therapy, his CSF culture was sterile. Because tigecycline distribution into the tissues is not sufficient with intravenous administration, combining it with intraventricular infusion can provide new treatment methods. However, further studies are needed for its use as a treatment method in children.

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Adem Yılmaz, Nazan Dalgic, Murat Müslüman, Mesut Sancar, Ibrahim Çolak and Yunus Aydın

Object

The emergence of multidrug-resistant bacteria as a cause of ventriculoperitoneal (VP) shunt infection is a disconcerting phenomenon that often requires the use of alternative antimicrobial agents due to resistance against commonly used medications. Linezolid, a member of a new class of antimicrobial agents, has good activity against virtually all important gram-positive pathogens, including multidrug-resistant gram-positive pathogens. The object of this article is to report a single-center experience with linezolid treatment in 6 young patients with VP shunt infections caused by drug-resistant strains.

Methods

The authors reviewed the records of 6 pediatric patients who developed VP shunt infection and in whom initial antimicrobial treatment regimens, including vancomycin, either failed or were associated with vancomycin-resistant enterococcus. All 6 patients were treated at their hospital between July 1, 2008, and June 29, 2009. The patients' demographic and clinical characteristics, underlying diseases, clinical manifestations, laboratory results, and various treatment modalities used before linezolid therapy were evaluated.

Results

The 6 patients included were 2 boys and 4 girls with a mean (± SD) age of 11.83 ± 12 months (range 4–36 months). Five patients had acquired an infection within 4 months (mean 7.50 ± 13.51 months, range 1–35 months) after shunt insertion. Four patients were treated with external ventricular drainage. Two patients' parents refused to allow shunt removal and placement of an external ventricular drain. The CSF was clear of bacterial growth within a mean of 3.67 ± 1.36 days (range 2–6 days) after initiation of linezolid treatment. The mean duration of linezolid treatment was 18.17 ± 3.31 days (range 14–21 days). Microbiological clearance of CSF and clinical cure were achieved in all patients. No laboratory or clinical side effects were observed during the treatment period. The mean length of hospital stay was 22.8 ± 4.96 days (range 17–28 days).

Conclusions

Linezolid could be an appropriate treatment alternative in children with ventriculostomy-related CSF infections caused by drug-resistant strains, including cases in which shunt removal is not an option. Well-designed prospective studies providing additional information on linezolid levels in plasma and CSF are necessary to confirm the authors' observations.