Multidrug-resistant Klebsiella oxytoca ventriculitis, successfully treated with intraventricular tigecycline: A case report.

A 38-year-old male presented to the hospital with headache, fever, and meningeal signs. He had undergone a surgical review of a ventriculoperitoneal shunt system one month earlier. A head computed tomography scan showed hydrocephalus. His medical history included a human immunodeficiency virus infection identified four years before and resolved cryptococcal meningitis, which had necessitated the implantation of the shunt system. Ventricular cerebrospinal fluid (CSF) was obtained, which showed inflammation and, in culture, grew a Gram-negative bacillus identified as multidrug-resistant Klebsiella oxytoca. The shunt was removed and a ventricular drain was installed. Treatment with meropenem and amikacin was established without a response; the CSF white blood cell count continued to increase, with cultures remaining positive. The patient's clinical condition deteriorated to stupor. With informed consent, intraventricular (ITV) treatment with tigecycline was initiated at a dose of 5 mg every 24 h and, three days later, the CSF cultures were negativized. Tigecycline levels in the CSF were quantified by liquid chromatography with ultraviolet detection and showed peak concentrations achieved at two hours after the dose of between 178 and 310 µg/mL. After 11 days of treatment with ITV tigecycline and eight negative CSF cultures, a new CSF shunt was installed. During follow-up review 10 months later, the patient reported he was working. The dose of tigecycline used in this study produced levels 15 to 20 times the minimum inhibitory concentration of the bacteria for up to six hours with adequate tolerance.

Intraoperative monitoring of the abducens nerve in extended endonasal endoscopic approach: a pilot study technical report.

BACKGROUND: To determine the reliability and usefulness of intraoperative monitoring of the abducens nerve during extended endonasal endoscopic skull base tumor resection. METHODS: We performed abducens nerve intraoperative monitoring in 8 patients with giant clival lesions recording with needle electrodes sutured directly into the lateral rectus muscles of the eye to evaluate spontaneous electromyographic activity and triggered responses following stimulation of the abducens nerves. RESULTS: A total of 16 abducens nerves were successfully recorded during endoscopic endonasal skull base surgeries. Neurotonic discharges were seen in two patients (12% [2/16] abducens nerves). Compound muscle action potentials of the abducens nerves were evoked with 0.1-4mA and maintained without changes during the neurosurgical procedures. No patient had new neurological deficits or ophthalmological complications post-surgery. CONCLUSIONS: Intraoperative monitoring of the abducens nerve during the extended endonasal endoscopic approach to skull base tumors appears to be a safe method with the potential to prevent neural injury through the evaluation of neurotonic discharges and triggered responses.