Version 1: Trend of Vancomycin resistance among Enterococcal meningitis patients in North India – an observational analysis

Introduction: Among bacterial meningitis, enterococcal meningitis is extremely uncommon and typically nosocomial in origin.

Aim: This study was done to estimate the prevalence of Vancomycin-resistant Enterococcal meningitis and to assess the risk factors amongst these patients. Also, resistance pattern of these Vancomycin resistant Enterococcal isolates towards other antibiotics were also assessed.

Materials and methods: This observational analysis was done in the Microbiology department of a tertiary care referral center from January 2021 to July 2023. Cerebrospinal fluid (CSF) samples of all cases of suspected meningitis were included in the study and sent to Microbiology lab for culture and sensitivity. Culture was done on chocolate agar, 5% blood agar and MacConkey agar and incubated aerobically for 72 hours. After incubation, the isolate was identified by MALDI-ToF MS. Sensitivity was done using Kirby Bauer disk diffusion method and interpreted using CLSI 2023 M-100 clinical breakpoints. The patients’ demographic details, associated risk factors, type of surgery done and the clinical outcome of the patients were analyzed.

Statistical analysis: Clinical data and values were entered in Excel sheet. Univariate analysis of the risk factors was done and p-values <0.05 were considered significant.

Results: A total of 2352 CSF samples were cultured, of which, 292 (12.4%) samples showed growth on culture. Enterococcus species were isolated in 30 (10.3%) samples. The predominant species was Enterococcus faecalis (n=17; 56.7%). Majority of the patients presented with fever (50%) and headache (33.3%). The risk factors in these patients were hypertension (40%) and diabetes mellitus (33.3%). All the patients had an extra-ventricular drain (EVD) present in them. Intracranial surgery was done in 15 patients. Only 1 (3.3%) patient died due to enterococcal meningitis. Of these, 6 (20%) isolates were Vancomycin resistant. Statistically significant risk factors in these patients were hypertension, prolonged hospital stay of >21 days. Majority of the isolates were resistant to Levofloxacin, high level gentamicin, doxycycline and ampicillin. Removal of the EVD helped in better prognosis of the patients

Conclusion: Early detection is crucial for a positive clinical result since vancomycin resistant enterococcal meningitis is associated with a high morbidity rate.