Intrathecal quinupristin/dalfopristin for resistant enterococcal meningitis

Our goal was to examine the safety and efficacy of intrathecally (IT) administered quinupristin/dalfopristin, an injectable streptogramin antibiotic, for the treatment of vancomycin-resistant Enterococcus faecium central nervous system (CNS) infection. IT quinupristin/dalfopristin was administered to six patients enrolled in an emergency-use program. All patients had a positive CNS culture for vancomycin-resistant E. faecium. Five patients received both IT and intravenous quinupristin/dalfopristin; one patient had IT administration only. Intravenous dosing was 7.5 mg/kg every 8 hours for 10-74 days. IT dosing was 1 or 2 mg daily for 5-33 days. Bacteriologic eradication or presumed eradication was achieved in all six patients. In the five patients with a CNS shunt, the shunt was removed or replaced before or during treatment. One adverse event (stroke) was considered remotely related to quinupristin/dalfopristin therapy. The successful use of IT quinupristin/dalfopristin in this difficult clinical setting is encouraging. Additional studies are needed to elucidate the full safety and efficacy profile and the optimal dosing regimen for this route of administration.