Introduction Anaerobic central nervous system (CNS) infection in extremely pre-term neonates is uncommon but life-threatening. Bacteroides fragilis is the most common cause of anaerobic sepsis. We describe the case of multidrug-resistant anaerobic CNS infection to highlight the challenges faced in the management of severe CNS infection, with a multidrug-resistant organism.
Methods A 24+6 weeks gestation with a birthweight of 673 g neonate was born following spontaneous vaginal delivery, post cervical suture placement. The baby was born in poor condition with Apgars of 2, 5 and 7 and 1, 5 and 10 min respectively. He showed signs of severe sepsis and hemodynamic instability. Despite adequate first-line antibiotic therapy his infective markers continued to be elevated. His blood cultures were sterile and he did not show signs of abdominal sepsis. His antibiotics were upgraded to ceftazidime and later to Meropenem and Amikacin with little improvement. On day 26, a lumbar puncture revealed cerebrospinal fluid with 220 white cells and culture positive for Bacteroides fragilis. Following this Metronidazole was added. Further sensitivity testing revealed multidrug resistance to Penicillin, Erythromycin and Metronidazole and hence Linezolid, Moxifloxacin was added. Serial cranial ultrasound revealed ongoing severe ventriculitis and cerebral abscess formation with increasing head circumference and ventricular indices. Neurosurgical intervention could not be offered due to ongoing hemodynamic instability and septic shock from which the baby could not be revived. Cranial USS showing grossly dilated ventricles filled with debris and clot.
Conclusion Anaerobic cultures are not routinely performed in neonates and hence infections can be missed, as seen in our case with negative blood cultures. With rising resistance patterns, the routine antibiotics used on the neonatal units would not provide the necessary protection. Placental cultures and histology could aid in the early identification of an organism. Due to high mortality (up to 34%), we recommend that routine anaerobic cultures should be considered.
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.