Post-surgical Meningitis due to Multi-drug Resistant Acinetobacter baumannii. In Vivo Synergistic Activity of the Sulbactam/avibactam Association View PDF

^*Messina GO
Servicio De Infectologia, Sanatorio Franchin, Buenos Aires, Argentina

^*Corresponding Author:

Messina GO
Servicio De Infectologia, Sanatorio Franchin, Buenos Aires, Argentina

Published on: 2023-03-08

Abstract

Acinetobacter baumannii (AB) is a non-fermenting gram-negative bacillus, largely opportunistic, ubiquitous in the environment, with the ability to survive in adverse environmental conditions, promoting its persistence and dissemination in different areas of the hospital. It has been implicated in many outbreaks of healthcareassociated infections such as pneumonia, bacteremia, surgical wound contamination, or urinary tract infections, especially among patients with previous severe illnesses such as those requiring admission to intensive care units (ICU). The most problematic strains are those resistant to carbapenems, resistance caused by chromosomal or plasmid oxacillinase class (bla OXA), and more recently bla NDM-1. The appearance of these strains leaves few active antimicrobials (Colistin, Minocycline, Tigecycline; Amikacin) that are limited in their efficacy and toxic. To this, we must add, as is the case of our patient who presented post-surgical meningitis, the limited diffusion capacity in the central nervous system (CNS) of these last options. One of the therapeutic alternatives is to search for synergistic associations such as sulbactam/avibactam that showed rapid synergistic and bactericidal activity in isolates resistant to ampicillin/sulbactam due to a significant reduction in its MIC, which allows us to administer usual, better-tolerated doses that reach therapeutic concentrations in CNS. Here, we present a patient who developed post-surgical meningitis due to multi-resistant AB.

Keywords

Post-Surgical Meningitis; Extensively Drug-Resistant (XDR); Acinetobacter baumannii; Antimicrobial Synergistic Association Sulbactam/Avibactam

Introduction

AB is one of the main multi-resistant microorganisms linked to infections associated with health care and has become a problem of world importance. AB is identified in 13.6% of crops causing nosocomial infections, having 20.9% of the AB resistance to carbapenemic resistance (ABRC) [1]. The European and the United States Disease Control Centers (ECDC and CDC) classify AB resistance into three classes: multiple drug resistant (MDR), extensively resistant (XDR), and pan-resistant (PDR) [2].
In a study on the sensitivity profile of the complex of isolates from intra-hospital infections of the Whonet Net and blood culture, as well as an increase in the percentage of resistance for all antimicrobials and an increase in the number of insulations belonging to the MDR class during the Covid-19 Pandemic [3].
Colistin, minocycline, tigeciclin, and amikacin remain the drugs with the greatest in vitro activity against AB, but with a worrying increase in resistance to the first two. Post-surgical meningitis, a complication with high mortality, is aggravated when the cause is a multi-resistant microorganism where therapeutic alternatives are scarce, adding to the difficulties in achieving useful therapeutic concentrations in the CNS. Therapeutic strategies are based on administering antimicrobial associations and optimizing the pharmacokinetic/pharmacodynamic (pk/pd) relationship, those antimicrobials being of choice that maintains some degree of in vitro activity. In the patient described, preference was given in the antibiotic scheme to carbapenemic, phosphomycin, rifampicin or considered its intraventricular or intra-ethical use (e.g., aminoglycosides). An interesting alternative is the combination of sulbactam/avibactam which increases the activity of sulbactam against AB resistant to carbapenemic in-vitro studies [4].