Early healthcare-associated meningitis caused by new Delhi Metallo-β-Lactamase-Producing Enterobacter cloacae Complex Following Severe Traumatic Brain Injury: A case report and narrative review of the literature

Background: Healthcare-associated meningitis following severe traumatic brain injury (TBI) is an uncommon but life-threatening complication, particularly when caused by multidrug-resistant Gram-negative bacilli. New Delhi metallo-β-lactamase (NDM)-producing Enterobacter cloacae complex poses a major therapeutic challenge because of its extensive resistance to β-lactam antibiotics and the limited penetration of many antimicrobial agents into the central nervous system (CNS).
Case presentation: A 39-year-old previously healthy man was admitted following a road traffic accident resulting in severe TBI with bilateral extradural hematomas, frontotemporal cerebral contusions, multiple anterior skull base and facial fractures, and a probable osteodural breach associated with cerebrospinal fluid (CSF) rhinorrhea. On hospital day 4, persistent fever prompted lumbar puncture. CSF analysis revealed purulent meningitis characterized by marked neutrophilic pleocytosis, profound hypoglycorrhachia, and hyperproteinorrachia. CSF culture and multiplex polymerase chain reaction identified an NDM-producing Enterobacter cloacae complex. Targeted antimicrobial therapy consisted of high-dose extended-infusion meropenem, intravenous colistin following a loading dose, and adjunctive intrathecal colistin. Concomitant ventilator-associated pneumonia caused by Klebsiella pneumoniae, Escherichia coli, and multidrug-resistant Acinetobacter baumannii was treated with the same antimicrobial regimen. The patient became afebrile within 48 hours, repeat CSF cultures obtained on day 14 were sterile, and he was successfully extubated on day 14 with progressive neurological recovery to a Glasgow Coma Scale score of 12–13/15.
Conclusion: Early healthcare-associated post-traumatic meningitis caused by NDM-producing Enterobacter cloacae complex is rare but represents a major therapeutic challenge. Prompt microbiological diagnosis, rapid identification of resistance mechanisms, and individualized multidisciplinary management with optimized combination antimicrobial therapy, including intrathecal administration when appropriate, may improve clinical outcomes in these severe CNS infections.