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Correspondence  |   March 2000
Enterococcus faecalis  Meningitis after Spinal Anesthesia
Author Notes
  • Specialist
  • Department of Anesthesia
  • Hospital Universitario “Virgen de la Arrixaca”
  • Murcia, Spain
  • isv01mu@nacom.es
Article Information
Correspondence
Correspondence   |   March 2000
Enterococcus faecalis  Meningitis after Spinal Anesthesia
Anesthesiology 3 2000, Vol.92, 909. doi:
Anesthesiology 3 2000, Vol.92, 909. doi:
To the Editor:—
We read with interest the recent case report of Streptococcus salivarius  meningitis occurring after spinal anesthesia described by Laurila et  al  . 1 We report another case of meningitis after spinal anesthesia caused by an unusual microorganism, Enterococcus faecalis  . A 20-yr-old healthy man underwent spinal anesthesia for surgery to treat inguinal hernia. The patient’s history and preoperative examination revealed no preexisting pathology. He had no symptoms of systemic infection. Spinal anesthesia was performed with the patient in the sitting position, and there was no evidence of local skin infection. The skin was prepared with povidone iodine 10% (Betadine; Asta Medica S.A., Madrid, Spain), which was wiped off vigorously from the puncture site with sterile sponges. Sterile technique (mask, hat, sterile drape, and sterile gloves) was used. A disposable 27-gauge pencil-point spinal needle with sterile introducer (Whitacre spinal set; Becton Dickinson S.A., Madrid, Spain) was inserted at the L3–L4 spinal interspace, on the first attempt, 3 min after back cleaning. Free flow of cerebrospinal fluid (CSF) was obtained on the first attempt, and a mixture of 10 mg hyperbaric bupivacaine, 0.5%, (B. Braun Medical S.A., Barcelona, Spain) and 20 μg fentanyl (Roche S.A., Madrid, Spain) was injected. The patient was turned supine. The immediate perioperative period was unremarkable, and the patient appeared well. Approximately 17 h after completion of the surgery, the patient became acutely confused and complained of severe headache and stiff neck. He was noted to have an altered mental status, fever, signs of meningeal irritability, and nausea and vomiting. A diagnosis of acute meningitis was considered. Lumbar puncture was performed, and CSF samples and blood were sent for analysis. There was no erythema or cellulitis at the site of needle insertion. A sample blood count was obtained, which revealed leukocytosis (23,050 cells/μl) with polymorphonucleocytes. A sample of CSF appeared turbid. Analysis of CSF showed a protein concentration of 1,239 mg/dl (normal range, 20–50 mg/dl), a glucose concentration of 19 ml/dl (normal range, 40–70 mg/dl), a leukocyte count of 9,550/μl (normal range, < 5/μl; 96% polymorphs, 4% monocytes). Gram-positive cocci were observed by Gram staining, and in bacterial culture, E faecalis  was found. Urine and blood cultures obtained concomitantly showed no growth. The patient was transferred to the intensive care unit, was treated with ampicilline and gentamicin, and was discharged home on the ninth postoperative day with no residual neurologic deficit.
Enterococci are the most common aerobic, Gram-positive cocci
found in the bowel flora of humans. These organisms are clinically important nosocomial pathogens. They are usually associated with urinary tract, wound, and blood infections that develop after instrumentation or intravascular-catheter contamination. These organisms less frequently cause meningitis 2 and endocarditis. 3 Meningitis is a rare complication of spinal anesthesia. When meningitis occurs after spinal or epidural block, it is often difficult to establish a cause-and-effect relationship between it and spinal anesthesia. 4 Two routes exist for such infection to reach the CSF. First, failure of aseptic techniques could result in the introduction of exogenous organisms into the CSF. Second, bacteria in the patient’s blood at the time of lumbar puncture may gain access to the subarachnoid space because of microscopic bleeding caused by insertion of the needle. However, most cases of meningitis after central nerve block are probably aseptic in origin. 5 
In our opinion, this case resulted from some unidentified failure of the aseptic technique, because an endogenous source, including hematogenous spread during elective herniorrhaphy in a healthy man, is unlikely.
References
Laurila JJ, Kostamovaara PA, Alahunhta S:Streptococcus salivarius  meningitis after spinal anesthesia. A NESTHESIOLOGY 1998; 89:1579–80Laurila, JJ Kostamovaara, PA Alahunhta, S
Ready LB, Heifer D: Bacterial meningitis in parturients after epidural anesthesia. A NESTHESIOLOGY 1989; 71:988–90Ready, LB Heifer, D
Stevenson KB, Murray EW, Sarubbi FA: Enterococcal meningitidis: Report of four cases and review. Clin Infect Dis 1994; 18:233–9Stevenson, KB Murray, EW Sarubbi, FA
Wedel DJ, Horlocker TT: Risks of regional anesthesia: Infectious, septic. Reg Anesth 1996; 21(Suppl 6):57–61Wedel, DJ Horlocker, TT
Burke D, Wildsmith JAW: Meningitis after spinal anaesthesia. Br J Anaesth 1997; 78:635–6Burke, D Wildsmith, JAW