Vancomycin-resistant Enterococcus faecium meningitis in adults: Case series and review of the literature

Abstract

Vancomycin-resistant Enterococcus faecium (VR E. faecium) is a rare cause of meningitis and is associated with substantial mortality. Limited therapeutic options are available for the treatment of VR E. faecium meningitis. The optimum therapy has not been established. We retrospectively identified adult cases of meningitis due to VR E. faecium that occurred at the Massachusetts General Hospital from 1999 to 2011 and performed a literature search for published adult cases using Medline and Embase. At our institution, 4 cases of meningitis due to VR E. faecium were identified. Three out of our 4 cases were successfully treated with linezolid in combination with rifampicin, or with daptomycin in combination with quinupristin-dalfopristin (QD), and 1 out of 4 with linezolid monotherapy. The literature search yielded 18 cases published to date. Published cases showed bacterial cure with linezolid, chloramphenicol or QD (intravenous (IV) and intrathecal (IT)) monotherapy, or linezolid in combination with ampicillin, gentamicin, rifampicin or chloramphenicol, or daptomycin in combination with gentamicin or QD. Bacterial cure of meningitis due to VR E. faecium can be achieved with various antimicrobial drugs used as monotherapy or in combination. IT in addition to IV therapy should be considered dependent on the pharmacological properties of the drugs. We also reported the successful treatment of a case with a vancomycin-resistant, linezolid-intermediate isolate with QD and daptomycin. The paucity of cases with this clinical syndrome does not allow the identification of an optimal treatment regimen.