POST-NEUROSURGICAL MENINGITIS CAUSED BY ACHROMOBACTER XYLOXIDANS

Abstract

Intro: Achromobacter xyloxidans has emerged as a human pathogen in recent literature. Methods: This case discusses paedaitric post-neurosurgical meningitis due to A. xyloxidans. Findings: During July 2022, a 5 month-old patient presented to a private hospital in South Africa with features suggestive of hydrocephalus. A ventriculoperitoneal (VP) shunt was inserted without complication. Within two weeks of insertion, the patient developed features suggestive of meningitis/ventriculitis that prompted shunt removal. The shunt isolated A. xyloxidans and methicillinresistant Staphylococcus aureus from its ventricular and peritoneal ends. Cerebrospinal fluid (CSF) cultured A. xyloxidans. A 21-day course of meropenem and vancomycin successfully cleared the infection. Re-insertion of a new VP shunt was undertaken in September 2022. No pathogenic growth was noted from the CSF taken at shunt re-insertion. There have been no adverse outcomes to date. Discussion: This case contributes to evidence of the pathogenic nature of A. xyloxidans in association with medical intervention. A. xyloxidans is intrinsically resistant to many antibiotics creating therapeutic challenges. Species-level breakpoints have recently been established by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) for meropenem, trimethoprim/sulphamethoxazole and piperacillin/tazobactam. Antimicrobial susceptibility testing was not offered by the laboratory at the time of bacterial isolation. However, meropenem therapy effectively resolved the infection. Several points from this case can be used to re-inforce treatment strategies of complicated infections. Firstly, prompt source control interventions are essential. As such, the septic shunt was removed as soon as sepsis was evident. Secondly, a management approach based on guidelines, supplemented with the latest literature, is necessary. This case relied on treatment parameters outlined in guidelines on post-neurosurgical meningitis. However, the unique nature of A. xyloxidans warranted additional insights. Thirdly, a multi-disciplinary approach is advised as evidenced. Conclusion: Post-neurosurgical meningitis proves problematic and may be complicated by difficult-to-treat organisms. Management strategies that entail prompt source control, prolonged antibiotic treatment and team approaches can achieve clinical/microbiological cure.