Tigecycline as Salvage Therapy in a Neonate with Multidrug-resistant Klebsiella pneumoniae Meningitis and Ventriculitis – Case Report and Literature Review

Abstract

Multi drug resistant (MDR) infections especially in paediatric population, with already limited treatment options, often leave clinicians at loss for an effective antimicrobial treatment making us as helpless as in pre-antibiotic era. Tigecycline is an ‘immature’ antibiotic for children. According to FDA, tigecycline is only indicated in patients 18 years of age and older for the treatment of complicated MDR infection. According to the published literature, the youngest patient on whom Tigecycline treatment has been attempted was 73 day old baby born at 27 weeks gestation with a birth weight of 1028 grams having Acinetobacter baumanii ventriculitis . Here, we discuss use of Tigecycline in a neonate with MDR Klebsiella Pneumoniae meningitis and ventriculitis who presented to us on day 12 of life. Child was born preterm at 34 weeks and 3 days by Lower Segment Caesarean Section in view of foetal distress, maternal preeclampsia and gestational hypothyroidism in a private hospital. On 12thday of life the baby presented to our hospital after being referred with complaints of abnormal body movements, lethargy, difficulty in taking feeds and difficulty in breathing. The complaints had been documented to be present since birth but were increasing over time. Aerobic culture of CSF led to isolation of multi-drug resistant (MDR) Klebsiella pneumoniae resistant to most empirical antibiotics, with intermediate susceptibility to Amikacin susceptibility to Colistin and Tigecycline. We found our isolate produced both NDM and OXA-48 contributing to the increased virulence and resistance of the strain. Considering the paucity of knowledge of Tigecycline’s efficacy and safety in children less than 8 years, lack of FDA approval and the fact that CSF bioavailability is considered low, Tigecycline therapy was deferred and infant was continued on injection Meropenem and injection Amikacin. Condition of child did not improve and marginal weight gain was documented over next 10 days. CSF culture from repeat LP again grew Klebsiella pneumoniae with same susceptibility pattern. On day 23 due adverse affects, and injection Tigecycline was added. A total of 42 days of Meropenem and 21 days of Tigecycline were completed and child was discharged after 42 days of hospital stay. Child was gaining weight, taking feeds orally and no abnormal body movements were present. The child is being followed up for long term sequelae of HIE 2 and meningitis on OPD basis