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Nosocomial recurrent bacterial meningitis/ventriculitis postelective surgery in a case of total knee replacement

Multiple causes can result in nosocomial meningitis. Here, we report a case of recurrent healthcare-associated bacterial meningitis caused by different bacteria in a postoperative case, who has been successfully treated with appropriate antibiotic therapy. A 65-year-old woman underwent an elective bilateral total knee replacement. On the postoperative day 5, she exhibited features of meningitis. Acinetobacter baumannii was isolated from the cerebrospinal fluid (CSF) culture. Magnetic resonance imaging of the brain was suggestive of ventriculitis. Later, she had to be shifted to the intensive care unit. An external ventricular drain (EVD) was placed due to persisting ventriculitis. Subsequent CSF culture sent from EVD repeatedly showed growth of Burkholderia cepacia. After the CSF cultures became sterile, a thecoperitoneal shunt was placed. She showed significant clinical improvement and was discharged. She was readmitted after 11 days with altered sensorium. Computed tomography of the head showed an increase in the noncommunicating hydrocephalus. The CSF cytology was inconclusive. An EVD was immediately placed. Vancomycin-resistant Enterococcus faecium was isolated from a repeat CSF culture. A ventriculoperitoneal shunt was placed after the CSF cultures showed no growth. She showed dramatic improvement in sensorium and cognition and was discharged. This case highlights the diagnosis and successful management of recurrent central nervous system nosocomial infection caused by rare but emerging healthcare-associated infections. To the best of our knowledge, this is the only case of recurrent nosocomial meningitis caused by three different bacteria and is also one of the rare cases of nosocomial meningitis caused by B. cepacia and vancomycin-resistant E. faecium.