a 44-year - old kuwaiti woman with her-2/neu + score of + 3 infiltrating ductal carcinoma of the right breast was transferred from kuwait to the cancer treatment centers of america in philadelphia , pennsylvania , on august 8 , 2014 . she arrived hyporesponsive , tachycardic , and hypotensive ; with a temperature of 101.8f ; and mechanically ventilated . she had previously received multiple rounds of chemotherapy , radiation , and a craniotomy for resection of a tumor . before her arrival , she developed increased intracranial pressure ( icp ) and aspiration pneumonia leading to intubation . with presumed pneumonia and , possibly , meningitis , the intensive care unit medical team at cancer treatment centers of america continued meropenem of 2 g every 8 hours because of an unknown penicillin allergy and provided medical support for septic shock . a magnetic resonance imaging of the brain revealed mild hydrocephalus and a large enhancing cavitary lesion in the right hemisphere . on august 12 , a craniotomy was performed to place a ventricular drain and assist in monitoring icps due to her report of elevated icp at the previous hospital . epidural and intracavitary swabs were performed intraoperatively ; these and csf cultures revealed heavy growth of enterococcus faecalis . the patient continued to be nonresponsive despite no use of analgesics or sedatives . with benefits outweighing the risks of a reaction to a potential penicillin allergy , the patient was changed from meropenem and vancomycin to ampicillin plus gentamicin for better enterococcus coverage . antibiotic courses and culture data on august 18 , the patient tried to open her eyes for the first time and soon began to regain her strength on the right side . she was then extubated on august 20 and began to verbally communicate during the following week . despite improvement in her mental status the only option for further treating the csf was vancomycin administered intraventricularly via the ventriculostomy drain . however , it has been described that , in cases of ventriculitis , there may be a lack of significant inflammatory response . therefore , drug penetration across the blood - brain barrier is compromised , and csf concentrations may be reduced . direct instillation of vancomycin into the csf may be the optimal therapy to reach adequate concentrations . recommended dosing is based on the estimated ventricular volume . in adults , recommended vancomycin dosing is 5 mg with slit ventricles , 10 mg with normal - sized ventricles , and 15 to 20 mg with enlarged ventricles . the frequency of administration is based on volume of csf drainage : once - daily dosing for csf drainage of greater than 100 ml / d , every other day if the drainage is 50 to 100 ml / d , and every third day if drainage is less than 50 ml / d . some data suggest that monitoring concentrations of vancomycin in the csf is also useful as elevated levels can be associated with neurotoxicity . the desired 24-hour trough concentration for vancomycin in the csf is 10 to 20 g / ml . this patient had normal - sized ventricles , and the csf drainage frequently remained less than 50 ml / d . therefore , vancomycin of 10 mg was administered intraventricularly every 3 days for a total of 3 doses . the antibiotic was compounded and administered based on the intraventricular antimicrobial therapy for csf shunt infections protocol created by the nyu langone medical center ( see supplementary figure 1 , http://links.lww.com/idcp/a18 ) . unfortunately , csf vancomycin concentrations could not be monitored with the laboratory unable to process such samples . intraventricular vancomycin was administered to the patient on august 27 and 30 and september 3 . as the patient 's clinical status continued to improve , eventually , she was deemed safe enough to restart chemotherapy and any further treatments for her cancer . six months later , she is still infection free and continues to undergo physical therapy with positive improvements . enterococcus is a significant nosocomial pathogen , which commonly causes urinary tract , intra - abdominal , and bacteremia infections . however , enterococcal meningitis continues to be rare and described in the literature only as case reports . thirty - two of the 94 cases were included in the final analysis , and of these 32 cases , 6 adults ( 38% ) had central nervous system damage due to trauma , surgery , or the placement of an epidural catheter . the majority of the patients ( 67% ) received ampicillin in combination with an aminoglycoside . of the 24 patients who received combination therapy , 96% ( 23 ) had a full recovery . a second retrospective review identified enterococcus as the causative organism for 7.6% ( 20/261 ) of all nosocomial meningitis cases during the study period ( 19942003 ) . intrathecal vancomycin was added to intravenous antibiotic therapy in 5 patients ; however , no difference was observed in outcomes of these patients compared with those not treated with it antibiotics . as these reviews demonstrate , neurosurgical procedures and surgical devices are common risk factors for the development of enterococcal meningitis . additional risk factors include patients with comorbidities requiring steroids or other immunosuppressive therapy ( 63% , n = 10 ) and underlying infections with enterococcus from other sites ( 31% , n = 5 ) . it should be noted that vancomycin is not approved for it use . per infectious disease society of america guidelines , combination therapy with the addition of gentamicin is suggested for enterococcal meningitis , with vancomycin recommended as an alternative agent in the event of a penicillin allergy . patients not responding to intravenous therapy can be considered for vancomycin of 10 or 20 mg administered intraventricularly . direct instillation of antibiotics in the csf certainly may result in serious complications if instructions are not closely followed . improper technique with needle or catheter placement can result in hemorrhage , csf leakage , new infections , and seizures . all antibiotic doses must be prepared using only preservative - free diluents to prevent reactions such as arachnoiditis . despite these challenges , ivt antibiotics still remain novel treatment options in severe cases of meningitis nonresponsive to conventional therapy . vancomycin can be administered directly into the csf using 2 different techniques : lumbar it or ivt injection . intraventricular injection is the preferred technique , as administration of antibiotics into the lumbar sac produces unreliable cerebral csf concentrations and does not allow for measurement of drug concentrations in the cerebral fluid compartments . if access to the csf via an indwelling catheter is not available , then the lumber it route of administration should be used . intraventricular vancomycin can be administered using 3 different methods : direct injection into an evd , injection into an ivt shunt , or into a subcutaneous ommaya reservoir . the clearance of antibiotics instilled into the cerebral ventricles is dependent on the drainage facilitated by these devices . this may contribute to the previously mentioned recommendation on frequency of dosing recommended based on volume of csf drainage . if a shunt infection is suspected , removal of the infected shunt components , external drainage , and antimicrobial therapy has been proposed as the optimal treatment strategy . organisms such as enterococcus have been associated with formation of biofilms on indwelling devices that contributes to the challenge of eradicating nosocomial infections . one study demonstrated that the cure rate for ventriculitis significantly increased from 30% in patients treated with antimicrobial therapy alone without shunt removal to 90% in 1-stage shunt replacement to 100% cure rate in a 2-stage shunt replacement ( removal of infected csf shunt , replacement with a new shunt , and a second surgery after ventriculitis were treated successfully ) . although this patient did not have a shunt , the evd was replaced when cultures continued to remain positive . the toxicities and adverse effects of vancomycin ivt are controversial , and information is available only through case reports . some patients have experienced reduced consciousness , prolonged headache , csf eosinophilia , ototoxicity , and arachnoiditis . unfortunately , there is a lack of adequate data to correlate such adverse effects with specific vancomycin csf concentrations . fortunately , in this patient , despite the inability to monitor such levels , they did not experience any adverse effects or signs of toxicity . although literature on optimal treatment of postsurgical meningitis due to enterococcus still remains elusive , cases such as this may pave the path for further research and stronger national guideline recommendations for ivt therapy .
abstractinfections from enterococcus faecalis and enterococcus faecium are uncommon in the post - neurosurgical intervention setting . , 
 [ 1 , 2 , 3 , 4 ] intraventricular antibiotics are recommended when standard intravenous therapy fails . 
 [ 5 ] here we present a case of post - neurosurgical ventriculitis , meningitis , and cerebritis in an oncology patient caused by refractory enterococcus faecalis successfully treated with intraventricular vancomycin .