title: Vancomycin-resistant Enterococcus faecium meningitis in adults: case series and review of the literature.
abstract: BACKGROUND
  Vancomycin-resistant Enterococcus faecium (VR E. faecium) is a rare cause of meningitis and is associated with substantial mortality. Limited therapeutic options are available for the treatment of VR E. faecium meningitis. The optimum therapy has not been established.
  
  
  METHODS
  We retrospectively identified adult cases of meningitis due to VR E. faecium that occurred at the Massachusetts General Hospital from 1999 to 2011 and performed a literature search for published adult cases using Medline and Embase.
  
  
  RESULTS
  At our institution, 4 cases of meningitis due to VR E. faecium were identified. Three out of our 4 cases were successfully treated with linezolid in combination with rifampicin, or with daptomycin in combination with quinupristin-dalfopristin (QD), and 1 out of 4 with linezolid monotherapy. The literature search yielded 18 cases published to date. Published cases showed bacterial cure with linezolid, chloramphenicol or QD (intravenous (IV) and intrathecal (IT)) monotherapy, or linezolid in combination with ampicillin, gentamicin, rifampicin or chloramphenicol, or daptomycin in combination with gentamicin or QD.
  
  
  CONCLUSIONS
  Bacterial cure of meningitis due to VR E. faecium can be achieved with various antimicrobial drugs used as monotherapy or in combination. IT in addition to IV therapy should be considered dependent on the pharmacological properties of the drugs. We also reported the successful treatment of a case with a vancomycin-resistant, linezolid-intermediate isolate with QD and daptomycin. The paucity of cases with this clinical syndrome does not allow the identification of an optimal treatment regimen.
authors.affiliation: Department of Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA. bknoll@partners.org
authors.forename: Bettina M
authors.initials: BM
authors.lastname: Knoll
authors.forename: Matt
authors.initials: M
authors.lastname: Hellmann
authors.forename: Camille N
authors.initials: CN
authors.lastname: Kotton
mesh_terms: D000081:Acetamides / Q000494:pharmacology; D000328:Adult; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D017576:Daptomycin / Q000494:pharmacology; D016984:Enterococcus faecium / Q000187:drug effects* / Q000302:isolation & purification; D005260:Female; D016908:Gram-Positive Bacterial Infections / Q000382:microbiology*; D006801:Humans; D000069349:Linezolid; D008297:Male; D016920:Meningitis, Bacterial / Q000382:microbiology*; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D023303:Oxazolidinones / Q000494:pharmacology; D012189:Retrospective Studies; D020713:Vancomycin Resistance; D014769:Virginiamycin / Q000494:pharmacology
chemical_list: D000081:Acetamides; D000900:Anti-Bacterial Agents; D023303:Oxazolidinones; D014769:Virginiamycin; C062940:quinupristin-dalfopristin; D000069349:Linezolid; D017576:Daptomycin