Tigecycline Therapy in an Infant for Ventriculoperitoneal Shunt Meningitis

Abstract

Shunt infections are seen in 3% to 20% of patients who have cerebrospinal fluid (CSF) shunts. Although the staphylococcal species are the most common cause of shunt-related infections, Gram-negative bacteria are increasingly reported with higher mortality rates. Tigecycline, a glycylcycline, is not approved for children. But in the era of nosocomial infections due to multidrug-resistant pathogens, it can be the life-saving option. We report an infant with ventriculoperitoneal shunt-related meningitis treated with a tigecycline combination regimen. A 5-month-old boy who had a ventriculoperitoneal shunt was admitted with meningitis. Extended spectrum β-lactamase-producing Klebsiella pneumoniae grew in the CSF. At the end of the fourth week of intravenous meropenem plus gentamicin therapy, carbapenem-resistant K pneumoniae grew in the CSF (mean inhibitory concentration value for meropenem >4 μg/mL, by E-test). The infected shunt was removed, and an external ventricular drainage catheter was inserted. With permission, intravenous tigecycline (1.2 mg/kg per dose twice a day) and intrathecal amikacin were added to the meropenem. Intrathecal amikacin could be given for only 7 days. On the sixth day of tigecycline treatment, the CSF was sterilized. Antibiotic therapy was given and consisted of a total of 60 days of meropenem and 20 days of tigecycline therapy. Because no available efficacy and safety data from randomized-controlled studies exist, tigecycline must be used only as salvage therapy, in combination with other drugs, for critically ill children who have no alternative treatment options.

Tigecycline salvage therapy for critically ill children with multidrug-resistant/extensively drug-resistant infections after surgery

“…Penetration of tigecycline into the cerebrospinal fluid of patients with uninflamed meninges is minimal and far below the typical minimum inhibitory concentration (MIC) of tigecycline against A. baumannii (Rodvold et al, 2006). Despite low cerebrospinal fluid concentrations of tigecycline relative to the MIC, there are case reports describing successful treatment of MDR meningitis in children (Jaspan et al, 2010;Emiroglu et al, 2017). Colistin or polymyxin B may be needed to treat meningitis due to MDR A. baumannii (Karaiskos et al, 2013).…”

Tigecycline Use in Neonates: 5-Year Experience of a Tertiary Center

“…Almost all of the available data regarding the use of tigecycline in infants and children younger than 8 years derive from small case series collected retrospectively. [3][4][5][6][7]10 Although optimal dosage has not been defined, the usual dose reported in different case series ranged from 1 to 2 mg/kg every 12 hours. 1 In a case report of 12-month old liver transplant recipient with XDR Acinetobacter baumannii bacteremia, it was found that a dose of 1 mg/kg every 12 hours (without loading dose) provided similar drug exposure (area under the curve, AUC) with adult and children aged 8 to 11 years old.…”

“…In different case series, the loading dose has been administered in the most pediatric patients but in infant patients it was not generally given. [3][4][5][6][7]10 All patients in this case series were preterm infants, so the loading dose was not given due to the lack of pharmacokinetics and pharmacodynamics analysis in this population.…”

“…1,2 The off-label use of tigecycline to treat serious infections (blood stream infections, urinary tract infections, nosocomial pneumonia, or meningitis) has been reported in the pediatric age group. [3][4][5][6][7] The majority of patients in these clinical series were beyond infancy, and it was stated that tigecycline was generally well tolerated except for gastrointestinal adverse events (nausea, vomiting, diarrhea, acute pancreatitis), prolonged coagulation times, and mild increase of transaminases. [3][4][5][6]8 However, there is only scant information on tigecycline use in newborn infants.…”

Intraventricular tigecycline for the treatment of shunt infection: a case in pediatrics

“…There are only 3 pediatric patients with meningitis in the literature who were treated with IV tigecycline. 2,3,6 We present the first case in the literature of IV and IVT administration of tigecycline in a pediatric patient who had XDR K. pneumoniae due to a VP shunt infection.…”