Acinetobacter baumannii is a major cause of nosocomial infections in many hospitals and appears to have a propensity for developing multiple antimicrobial resistance rapidly. We report two cases with post-surgical meningitis due to multidrug resistant A. baumannii which were successfully treated with high-dose intravenous meropenem therapy. Multidrug resistant Acinetobacter spp. in intensive care units are a growing concern. High-dose meropenem is used in the treatment of these infections

Asan, Ali

Cenger, Derya Hırçın

Coşkun, Erdal

Kaleli, İlknur

Saçar, Suzan

Turgut, Hüseyin

English

Pamukkale Üniversitesi Açık Erişim Arşivi

Case Report 
 
Successful treatment of multidrug resistant Acinetobacter baumannii 
meningitis 
 
Suzan Saçar,1 H. Turgut,1 D. Hırçın Cenger,1 E. Coşkun,2 A. Asan,1 Đ. Kaleli.3 
 
1Pamukkale University Hospital, Infectious Diseases and Clinical Microbiology Department; 2Pamukkale University Hospital, 
Neurosurgery Department; 3Pamukkale University Hospital, Microbiology and Clinical Microbiology Department; Denizli, Turkey.  
 
 
Abstract 
Background: Acinetobacter baumannii is a major cause of nosocomial infections in many hospitals and appears to have a 
propensity for developing multiple antimicrobial resistance rapidly. 
Cases: We report two cases with post-surgical meningitis due to multidrug resistant A. baumannii which were successfully 
treated with high-dose intravenous meropenem therapy. 
Conclusions: Multidrug resistant Acinetobacter spp. in intensive care units are a growing concern. High-dose meropenem is 
used in the treatment of these infections.     
Key Words: Acinetobacter baumannii, Post-surgical meningitis, High dose meropenem.  
 
J Infect Developing Countries 2007; 1(3):342-344. 
  
Received 9 August 2007 - Accepted 15 November 2007. 
 
Copyright © 2007 Saçar et al. This is an open access article distributed under the Creative Commons Attribution License, which permits 
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 
  
 
Introduction 
A. baumannii is a major cause of nosocomial 
infections in worldwide. The infection caused by 
Acinetobacter is difficult to control due to multidrug 
resistance, which limits therapeutic options in 
critically ill and debilitated patients, especially 
those in intensive care units [1]. We report two 
cases of post-surgical meningitis due to multidrug 
resistant A. baumannii occurring in patients 
admitted in the same neurosurgical intensive care 
unit of Pamukkale University Hospital, Turkey. 
Upon institution of therapy with high doses of 
meropenem, the patients experienced successful 
clinical and microbiological outcomes. 
 
Case 1 
A 52-year-old man developed meningitis due 
to A. baumannii 4 days after placement of a 
ventriculostomy catheter for management of post 
traumatic left temporal lobe hemorrhage. Prior to 
the development of meningitis, the hospital course 
was significant for ventilator-associated 
pneumonia and receipt of multiple courses of 
broad-spectrum antibiotics. Seven days later, 
cerebrospinal fluid (CSF) was turbid and its 
examination revealed neutrophil pleocytosis. A. 
baumannii was isolated from the culture of the 
CSF. The following antimicrobial agents were 
tested and the microorganism was resistant to 
ampicillin, amoxycillin/clavulanic acid, cephalothin, 
ceftriaxone, cefixime, ceftazidime, cefuroxime, 
cephotaxime, ciprofloxacin, ofloxacin, fosfomycin, 
trimethoprim-sulphamethoxazole, aztreonam, 
tetracycline, piperacillin-tazobactam, piperacillin, 
amikacin, tobramycin, and gentamicin except 
carbapenems. The therapy with intravenous 
meropenem (daily total dose 6 grams) was started 
and the extraventricular drainage system was 
removed. CSF cultures became sterile at the forth 
day of the treatment. High-dose intravenous 
meropenem therapy continued 21 days. 
Laboratory results of CSF are shown in Table 1.     
   
Case 2 
A 62-year-old woman was admitted to 
Pamukkale University Hospital because of 
cerebellar hematoma and aspiration pneumonia.  
A ventriculostomy catheter was used on the 
patient for management of cerebellar hematoma. 
Post-operatively, her fever persisted and she 
developed convulsions and deterioration in the 
level of consciousness. The hospital course was 
Saçar et al – Successful treatment of MDR-Acinetobacter baumannii meningitis  
 343
 
J Infect Developing Countries 2007; 1(3): 342-344. 
 
significant for aspiration pneumonia, bloodstream 
infection, and receipt of multiple courses of broad-
spectrum antibiotics. Multidrug resistant A. 
baumannii was isolated from the CSF. The 
following antimicrobial agents were tested and the 
microorganism was resistant to ampicillin, 
amoxycillin/clavulanic acid, cephalothin, 
ceftriaxone, cefixime, ceftazidime, cefuroxime, 
cephotaxime, ciprofloxacin, ofloxacin, fosfomycin, 
trimethoprim-sulphamethoxazole, aztreonam, 
tetracycline, piperacillin-tazobactam, piperacillin, 
amikacin, tobramycin, and gentamicin except 
carbapenems. Diagnosis was accepted as hospital 
acquired meningitis due to A. baumannii. The 
therapy with intravenous meropenem (daily total 
dose 6 grams) was started and continued 21 days. 
The ventriculostomy catheter was removed on the 
32nd day of her hospitalization and the CSF 
remained sterile from A. baumannii throughout the 
rest of the hospitalization. Laboratory results of 
CSF are shown in Table 1.  
 
Table 1. Laboratory results of CSF. 
 
 
Discussion 
Acinetobacter species are aerobic gram 
negative coccobacilli that have emerged as 
important opportunistic pathogens, especially 
among debilitated patients. A. baumannii can be a 
causal agent of diseases such as pneumonia, 
bacteremia, meningitis, soft tissue and urinary tract 
infections associated with high mortality [2]. Jover 
Saenz et al. [3] reported that the overall annual 
incidence of nosocomial infections by 
multiresistant pathogens was 4.0 per 1,000 
patients admitted. A. baumannii showed the 
highest incidence, particularly in the intensive care 
units (15.4 per 1,000 patients admitted). 
A. baumannii is a bacterium that appears to 
have a propensity for developing multiple 
antimicrobial resistance [1]. Because of frequent 
resistance to aminoglycosides, fluoroquinolones, 
ureidopenicillins and third-generation 
cephalosporins, carbapenems are important 
agents for managing Acinetobacter infections. 
Carbapenem resistance has been reported with 
many outbreaks of Acinetobacter spp. Many of 
these strains remain susceptible only to polymyxin, 
a toxic peptide antibiotic. The rapid evolution of 
drug resistance has severely limited the options for 
effective therapy for infections caused by this 
pathogen [2]. The mortality rate of patients with A. 
baumannii was significantly higher than that of 
patients without infection [4]. Vivek et al. [2] found 
that Acinetobacter species accounted for 10% of 
Gram negative isolates and from these isolates 
only half of Acinetobacter species were 
susceptible to carbapenems; 11 hospitals had at 
least one isolate resistant to carbapenems. Other 
Acinetobacter susceptibility rates were as follows: 
polymyxin, amikacin, ampicillin/sulbactam, 
ceftazidime and ciprofloxacin. Yaman et al. [5] 
reported that meropenem was the most effective 
antibiotic against gram negative organisms (89%); 
this was followed by imipenem (87.2%) and 
piperacillin/tazobactam.  
In many adults with acute bacterial meningitis, 
Acinetobacter spp. were found to be responsible 
for approximately 10% of Gram negative bacillary 
and 4% of all nosocomial meningitis [6]. Post-
neurosurgical meningitis is a serious complication. 
When this disease is caused by a multidrug-
resistant A. baumannii, the management of such a 
case is challenging. When the infection involves 
the meninges, the choice of an antibiotic is further 
limited by the blood–brain barrier. There are 
differences between the CSF concentrations of 
meropenem and imipenem. The diffusion of both 
drugs into the healthy meninges is very low (1-
10%); however, when the meninges become 
inflamed, the diffusion increases. For imipenem 
this rate is about 15%, but for meropenem it is 
increased up to 45-50%. Adverse effects, 
especially neurotoxicity, are lower in meropenem 
usage than in imipenem. For these reasons 
meropenem treatment is suggested for cases of 
meningitis. The recommended dosage is 6 grams 
per day [7]. In our cases, meropenem therapy was 
given due to A. baumannii meningitis and there 
was a clinical and laboratory response in a few 
days. In our cases CSF remained free of A. 
baumannii throughout the rest of the 
Saçar et al – Successful treatment of MDR-Acinetobacter baumannii meningitis  
 344
 
J Infect Developing Countries 2007; 1(3): 342-344. 
 
hospitalization. Our case reports are limited in that 
we were unable to conduct molecular analysis so 
we did not determine whether the strains were the 
same or not. 
In conclusion, in the last two decades 
Acinetobacter baumannii has emerged as a major 
relevant world nosocomial pathogen. Post-
neurosurgical meningitis is a serious complication 
when multidrug resistant A. baumannii are 
isolated. In our cases we presented the potential 
utility of high-dose meropenem for meningitis due 
to resistant A. baumannii. New antibiotics and new 
therapeutic strategies are needed to combat this 
multidrug resistant pathogen. 
 
References 
1. Cisneros JM, Rodríguez-Baño J (2002) Nosocomial 
bacteremia due to Acinetobacter baumannii: 
epidemiology, clinical features and treatment. Clin 
Microbiol Infect 8: 687-693. 
2. Manikal VM et al. (2000) Endemic Carbapenem-Resistant 
Acinetobacter Species in Brooklyn, New York: Citywide 
Prevalence, Interinstitutional Spread, and Relation to 
Antibiotic Usage.  Clinical Infectious Diseases 31: 101-
106. 
3. Jover Saenz A et al. (2005) Nosocomial infection by 
multiresistant pathogens during one year in a secondary 
hospital: clinical and epidemiological analysis. An Med 
Interna. 22: 59-64. 
4. Theaker C, Azadian B, Soni N (2003) The impact of 
Acinetobacter baumannii in the intensive care unit. 
Anaesthesia 58: 271-274. 
5. Yaman A et al. (2004) Investigation of the antibiotic 
susceptibility patterns of pathogens causing nosocomial 
infections. Saudi Med J. 25: 1403-1409. 
6. Durand ML et al. (1993) Acute bacterial meningitis in 
adults. A review of 493 episodes. N Engl J Med 328: 21–
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7. Çakır N (2003) Carbapenems, Leblebicioğlu H, Usluer G, 
Ulusoy S, editors. Antibiotics. Ankara: Bilimsel Tıp 
Yayınevi Press. 275-286. 
 
Corresponding Author: Suzan Saçar, Pamukkale 
University Faculty of Medicine, Infectious Diseases and 
Clinical Microbiology Department, Kınıklı 20070 Denizli, 
Turkey, Tel: +90 0258 2118585 / 2293, Fax: 2134922, 
e-mail: suzansacar@yahoo.com 
 
Conflict of interests: The authors declare that they have no conflict 
of interests. 
 
 
 


Successful treatment of multidrug resistant Acinetobacter baumannii meningitis.

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Successful treatment of multidrug resistant Acinetobacter baumannii meningitis.

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