1427. Vancomycin-Resistant Enterococcus (VRE) Meningitis in Hematopoietic Stem Cell Transplant (HSCT) Recipients
Session: Poster Abstract Session: CNS Infections
Saturday, October 5, 2013
Room: The Moscone Center: Poster Hall C
Background:

VRE is a common cause of infection and bacteremia among neutropenic patients with cancer and among HSCT recipients. VRE meningitis is uncommon outside the setting of neurosurgical procedures, and it has only rarely been described after HSCT. 

Methods: We retrospectively identified cases of VRE meningitis at the NIH Clinical Center and did a literature search for published cases of VRE meningitis among HSCT recipients. 

Results: We identified 3 cases of VRE meningitis among HSCT recipients at the NIH Clinical Center, and identified another 3 published cases. Clinical findings:  A common feature among all cases was prolonged neutropenia (usually >14 days) prior to the development of meningitis; bacteremia preceded the meningitis in all cases. Fever and mental status changes were the most common symptoms. CSF findings: included pleocytosis with neutrophilic predominance, elevated protein and hypoglycorrhachia. Pleocytosis varied widely (0-2250 cell), likely due to the degree of neutropenia. Treatment: All the NIH patients were receiving daptomycin as treatment of the VRE bacteremia. Daptomycin failed to control the bacteremia in every case. CSF levels of daptomycin were undetectable, and one case that had a linezolid resistant isolate required intraventricular administration of daptomycin and gentamicin. Overall treatment consisted of combination therapy in 4 (linezolid and tigecycline; daptomycin and linezolid; daptomycin, tigecycline and gentamicin; quinupristin/dalfopristin (Q/D) and daptomycin) and monotherapy in 2: linezolid in 1 and Q/D in another. Four of six had a bacteriologic cure, but 5 patients died, 2 of them as a result of the infection.

Conclusion:

VRE meningitis after HSCT may occur as a consequence of persistent bacteremia during neutropenia. Successful treatment has been reported for patients receiving linezolid monotherapy or combination therapy with linezolid or daptomycin and a second agent. In our experience patients that received daptomcycin as the only active agent failed to clear the infection. Despite bacteriologic cure, overall mortality remains high.

Cristina Minguito, MD, Hospital Universitario Puerta de Hierro, Madrid, Spain, Jennifer Cuellar-Rodriguez, MD, National Institutes of Health, National Institute of Allergy and Infectious Diseases, Bethesda, MD, Robert Danner, MD, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, Brad Moriyama, PharmD, Dept Pharmacy, National Institutes of Health Clinical Center, Bethesda, MD and Juan Gea-Banacloche, MD, NCI, National Institutes of Health, Bethesda, MD

Disclosures:

C. Minguito, None

J. Cuellar-Rodriguez, None

R. Danner, None

B. Moriyama, None

J. Gea-Banacloche, None

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