A 34-year-old man with a medical history of cerebral palsy and spastic quadriparesis underwent an ITB Prometra programmable 20 ml pump (Flowonix Medical Inc., New Jersey, USA) implantation for spasticity refractory to high doses oral baclofen 2 years ago. ITB therapy resulted in a progressive improvement in patient's spasticity, functional capacity, daily activity, and social interactions, with a reduction in his previous disability. Three weeks ago, he had a routine refill procedure of the intrathecal pump programmed to deliver baclofen at a dose of 250 mug/day to control his spasticity.
He was admitted suffering from a pyrexia and headache, however, he had no other symptoms. On examination, he had a temperature of 38.5 C, but was not clinically toxic. He was alert, cooperative, and obeyed commands. He had no meningism and no obvious source of infection. A chest radiograph was normal. Empirical treatment with intravenous vancomycin (500 mg/6 h) and cefotaxime (1 g/12 h) was started, however, the next day vancomycin was switched to teicoplanin (400 mg/12 h) due to a "red man syndrome" onset. Microscopy and culture of the urine and three sets of blood cultures were negative. Specimens obtained by aspiration from the residual baclofen-containing reservoir and the side port of the cerebrospinal fluid (CSF) confirmed the presence of a S. epidermidis infection with high sensitivity to above antibiotics. Other CSF parameters included an elevated protein and white blood cell count. Patient's clinical condition was such that immediate removal of the device was not considered mandatory.
However, despite receiving high doses antibiotics treatment, the patient remained febrile over the next few days but still without meningism. Further aspiration and CSF culture from the access port confirmed the persistence of the S. epidermidis.
As the patient was unwilling to undergo surgery to replace the pump if the present one had to be removed, an attempt was made to sterilize the pump while in situ. Therefore, consent was obtained from both the patient and his family to maintain the implanted drug delivery system and administer a baclofen/teicoplanin solution intrathecally by using the pump that was already in place. After emptying of the reservoir and the catheter from baclofen independently, the pump was aseptically refilled with a 20-ml solution prepared containing 10 mg baclofen (5 ml), 800 mg teicoplanin (6 ml), and 9 ml normal saline. This provided a final concentration of 500 mug/ml baclofen and 40 mg/ml teicoplanin. The pump was programmed to run by simple continuous infusion at a rate of 0.5 ml of solution daily, which provided 250 mug of baclofen and 20 mg of teicoplanin intrathecally every 24 hours. Although pharmaceutical data suggests that teicoplanin is stable, it was decided to empty and refill the pump every 4 days as there was a possibility that bacteria would start to grow in the solution if resistant strains developed.
Five days after initiation of baclofen/teicoplanin infusion, the patient became afebrile. In CSF collected from the access port, white blood cell (WBC) and protein counts were shown to have fallen significantly. On the 11th day of intrathecal coadministration of baclofen and teicoplanin, the cultures of CSF via catheter access port and of the residual fluid in the reservoir became sterile. The intravenous administration of teicoplanin and cefotaxime were discontinued, and a regimen of 600 mg rifampin administered orally per day was initiated to augment the intrathecal teicoplanin therapy, which was continued for 9 more days. The patient was treated with oral rifampin for the next month.
At the time of writing this study, our patient is still well 1 year after completion of therapy, without new clinical or laboratory signs of recurrence of infection, showing a good therapeutic reduction in his spasticity.