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Barrit S, El Hadwe S, Al Barajraji M, Torcida N, Bogossian EG, André J, Niset A, Carron R, Taccone FS, Madsen J. Complications of Intracranial Multimodal Monitoring for Neurocritical Care: A Systematic Review and Meta-Analysis. Neurocrit Care 2024; 40:1182-1192. [PMID: 37991675 DOI: 10.1007/s12028-023-01885-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/19/2023] [Indexed: 11/23/2023]
Abstract
Intracranial multimodal monitoring (iMMM) is increasingly used for neurocritical care. However, concerns arise regarding iMMM invasiveness considering limited evidence in its clinical significance and safety profile. We conducted a synthesis of evidence regarding complications associated with iMMM to delineate its safety profile. We performed a systematic review and meta-analysis (PROSPERO Registration Number: CRD42021225951) according to the Preferred Reporting Items for Systematic Review and Meta-Analysis and Peer Review of Electronic Search Strategies guidelines to retrieve evidence from studies reporting iMMM use in humans that mention related complications. We assessed risk of bias using the Newcastle-Ottawa Scale and funnel plots. The primary outcomes were iMMM complications. The secondary outcomes were putative risk factors. Of the 366 screened articles, 60 met the initial criteria and were further assessed by full-text reading. We included 22 studies involving 1206 patients and 1434 iMMM placements. Most investigators used a bolt system (85.9%) and a three-lumen device (68.8%), mainly inserting iMMM into the most injured hemisphere (77.9%). A total of 54 postoperative intracranial hemorrhages (pooled rate of 4%; 95% confidence interval [CI] 0-10%; I2 86%, p < 0.01 [random-effects model]) was reported, along with 46 misplacements (pooled rate of 6%; 95% CI 1-12%; I2 78%, p < 0.01) and 16 central nervous system infections (pooled rate of 0.43%; 95% CI 0-2%; I2 64%, p < 0.01). We found 6 system breakings, 18 intracranial bone fragments, and 5 cases of pneumocephalus. Currently, iMMM systems present a similar safety profile as intracranial devices commonly used in neurocritical care. Long-term outcomes of prospective studies will complete the benefit-risk assessment of iMMM in neurocritical care. Consensus-based reporting guidelines on iMMM use are needed to bolster future collaborative efforts.
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Affiliation(s)
- Sami Barrit
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.
- Neurodynamics Laboratory, Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
- Institut Des Neurosciences du Système, Aix Marseille Université, INSERM - Timone Hospital (Assistance Publique - Hôpitaux de Marseille), Marseille, France.
- Neurocore, Consciense Foundation, Brussels, Belgium.
| | - Salim El Hadwe
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Neurocore, Consciense Foundation, Brussels, Belgium
| | - Mejdeddine Al Barajraji
- Neurocore, Consciense Foundation, Brussels, Belgium
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Nathan Torcida
- Neurocore, Consciense Foundation, Brussels, Belgium
- Department of Neurology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Elisa Gouvêa Bogossian
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Joachim André
- Neurocore, Consciense Foundation, Brussels, Belgium
- Department of Radiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Niset
- Neurocore, Consciense Foundation, Brussels, Belgium
- Department of Emergency, Hôpital Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Romain Carron
- Institut Des Neurosciences du Système, Aix Marseille Université, INSERM - Timone Hospital (Assistance Publique - Hôpitaux de Marseille), Marseille, France
- Neurocore, Consciense Foundation, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Joseph Madsen
- Neurodynamics Laboratory, Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
- Neurocore, Consciense Foundation, Brussels, Belgium
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Varshney S, Alam MA, Kaur A, Dhoundiyal S. Niosomes: A Smart Drug Delivery System for Brain Targeting. Pharm Nanotechnol 2024; 12:108-125. [PMID: 37226788 DOI: 10.2174/2211738511666230524143832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 03/28/2023] [Accepted: 04/14/2023] [Indexed: 05/26/2023]
Abstract
Niosomes are lipid-based nanovesicles that have the potential to act as drug-delivery vehicles for a variety of agents. They are effective drug delivery systems for both ASOs and AAV vectors, with advantages such as improved stability, bioavailability, and targeted administration. In the context of brain-targeted drug delivery, niosomes have been investigated as a drug delivery system for brain targeting, but more research is needed to optimize their formulation to improve their stability and release profile and address the challenges of scale-up and commercialization. Despite these challenges, several applications of niosomes have demonstrated the potential of novel nanocarriers for targeted drug delivery to the brain. This review briefly overviews the current use of niosomes in treating brain disorders and diseases.
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Affiliation(s)
- Sandesh Varshney
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University, Greater Noida, Uttar Pradesh, India
| | - Md Aftab Alam
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University, Greater Noida, Uttar Pradesh, India
| | - Awaneet Kaur
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University, Greater Noida, Uttar Pradesh, India
| | - Shivang Dhoundiyal
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University, Greater Noida, Uttar Pradesh, India
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Rojas-Lora M, Corral L, Zabaleta-Carvajal I, López-Ojeda P, Fuentes-Mila V, Romera-Peregrina I, Lerma-Briansò C, Plata-Menchaca E, Pavón A, Sabater J, Cabellos C. External ventriculostomy-associated infection reduction after updating a care bundle. Ann Clin Microbiol Antimicrob 2023; 22:59. [PMID: 37454149 DOI: 10.1186/s12941-023-00612-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 07/07/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Despite the clinical benefits of external ventricular drains (EVD), these devices can lead to EVD-related infections (EVDRI). The drainage insertion technique and standardized guidelines can significantly reduce the risk of infection, mainly caused by gram-positive bacteria. However, gram-negative microorganisms are the most frequent causative microorganisms of EVDRI in our hospital. We aimed to determine whether a new bundle of measures for the insertion and maintenance of a drain could reduce the incidence of EVDRI. This cohort study of consecutive patients requiring EVD from 01/01/2015 to 12/31/2018 compared the patients' characteristics before and after introducing an updated protocol (UP) for EVD insertion and maintenance in 2017. RESULTS From 204 consecutive patients, 198 requiring EVD insertion were included (54% females, mean age 55 ± 15 years). The before-UP protocol included 87 patients, and the after-UP protocol included 111 patients. Subarachnoid (42%) and intracerebral (24%) hemorrhage were the main diagnoses at admission. The incidence of EVDRI fell from 13.4 to 2.5 episodes per 1000 days of catheter use. Gram-negative bacteria were the most frequent causative microorganisms. Previous craniotomy remained the only independent risk factor for EVDRI. EVDRI patients had increased mechanical ventilation durations, hospital and ICU stays, and percutaneous tracheostomy requirements. CONCLUSIONS A care bundle focusing on fewer catheter sampling and more accurate antiseptic measures can significantly decrease the incidence of EVDRI. After implementing the management protocol, a decreased incidence of infections caused by gram-negative and gram-positive bacteria and reduced ICU and hospital lengths of stay were observed.
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Affiliation(s)
- Mariel Rojas-Lora
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Luisa Corral
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
- Departament de Ciències Clíniques, Universitat de Barcelona, Av. Mare de Déu de Bellvitge, 3, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
| | - Ivan Zabaleta-Carvajal
- Neurosurgery Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Pau López-Ojeda
- Neurosurgery Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Verónica Fuentes-Mila
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Iluminada Romera-Peregrina
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Cristina Lerma-Briansò
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Erika Plata-Menchaca
- Vall d'Hebron Research Institute, Passeig de La Vall d'Hebron, 129, 08035, Barcelona, Spain
- Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Alba Pavón
- Departament de Ciències Clíniques, Universitat de Barcelona, Av. Mare de Déu de Bellvitge, 3, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Joan Sabater
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Carmen Cabellos
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Barcelona, Spain
- Departament de Ciències Clíniques, Universitat de Barcelona, Av. Mare de Déu de Bellvitge, 3, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Centro de Investigación Biomédica de Enfermedades Infecciosas (CIBERINFEC, ISCIII), Madrid, Spain
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Chen Z, Taubert M, Chen C, Dokos C, Fuhr U, Weig T, Zoller M, Heck S, Dimitriadis K, Terpolilli N, Kinast C, Scharf C, Lier C, Dorn C, Liebchen U. Plasma and Cerebrospinal Fluid Population Pharmacokinetics of Vancomycin in Patients with External Ventricular Drain. Antimicrob Agents Chemother 2023; 67:e0024123. [PMID: 37162349 PMCID: PMC10269048 DOI: 10.1128/aac.00241-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/15/2023] [Indexed: 05/11/2023] Open
Abstract
Vancomycin is a commonly used antibacterial agent in patients with primary central nervous system (CNS) infection. This study aims to examine predictors of vancomycin penetration into cerebrospinal fluid (CSF) in patients with external ventricular drainage and the feasibility of CSF sampling from the distal drainage port for therapeutic drug monitoring. Fourteen adult patients (9 with primary CNS infection) were treated with vancomycin intravenously. The vancomycin concentrations in blood and CSF (from proximal [CSF_P] and distal [CSF_D] drainage ports) were evaluated by population pharmacokinetics. Model-based simulations were conducted to compare various infusion modes. A three-compartment model with first-order elimination best described the vancomycin data. Estimated parameters included clearance (CL, 4.53 L/h), central compartment volume (Vc, 24.0 L), apparent CSF compartment volume (VCSF, 0.445 L), and clearance between central and CSF compartments (QCSF, 0.00322 L/h and 0.00135 L/h for patients with and without primary CNS infection, respectively). Creatinine clearance was a significant covariate on vancomycin CL. CSF protein was the primary covariate to explain the variability of QCSF. There was no detectable difference between the data for sampling from the proximal and the distal port. Intermittent infusion and continuous infusion with a loading dose reached the CSF target concentration faster than continuous infusion only. All infusion schedules reached similar CSF trough concentrations. Beyond adjusting doses according to renal function, starting treatment with a loading dose in patients with primary CSF infection is recommended. Occasionally, very high and possibly toxic doses would be required to achieve adequate CSF concentrations, which calls for more investigation of direct intraventricular administration of vancomycin. (This study has been registered at ClinicalTrials.gov under registration no. NCT04426383).
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Affiliation(s)
- Zhendong Chen
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Max Taubert
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Chunli Chen
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Heilongjiang Key Laboratory for Animal Disease Control and Pharmaceutical Development, College of Veterinary Medicine, Northeast Agricultural University, Harbin, People’s Republic of China
| | - Charalambos Dokos
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Uwe Fuhr
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Thomas Weig
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Suzette Heck
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Konstantinos Dimitriadis
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Nicole Terpolilli
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig Maximilians University, Munich, Germany
- Department of Neurosurgery, Munich University Hospital, Munich, Germany
| | - Christina Kinast
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Constantin Lier
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, Regensburg, Germany
| | - Christoph Dorn
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, Regensburg, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
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Widén J, Cederberg D, Linder A, Westman G. Heparin-binding protein as a marker of ventriculostomy related infection and central nervous system inflammation in neuro-intensive care. Clin Neurol Neurosurg 2023; 229:107752. [PMID: 37156040 DOI: 10.1016/j.clineuro.2023.107752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Diagnosis of ventriculostomy related infections (VRI) in the neuro-intensive care unit remains challenging and current biomarkers lack adequate precision. The aim of this study was to explore the potential of Heparin-binding protein (HBP) in cerebrospinal fluid (CSF) as a diagnostic biomarker of VRI. METHODS All patients treated with an external ventricular drain (EVD) between January 2009 and March 2010 at Skåne university hospital in Lund, Sweden, were consecutively included. CSF samples obtained during routine care were analyzed for HBP. VRI was defined as a positive bacterial microbiology test result on a CSF sample with an erythrocyte-corrected leukocyte count of > 50 × 106/l. HBP levels at VRI diagnosis was compared to peak HBP levels in non-VRI controls. RESULTS In total, 394 CSF samples from 103 patients were analyzed for HBP. Seven patients (6.8%) fulfilled VRI criteria. Levels of HBP were significantly higher in VRI subjects (31.7 ng/mL [IQR 26.9-40.7 ng/mL]) compared to non-VRI controls (7.7 ng/mL [IQR 4.1-24.5 ng/mL]) (p = 0.024). The AUC of the receiver operating characteristic (ROC) curve was 0.76 (95% confidence interval [CI], 0.62-0.90). Among non-VRI patients, HBP was highest in patients with acute bacterial meningitis. Patients with subarachnoid hemorrhage displayed higher HBP levels than those with traumatic brain injury or shunt dysfunction. CONCLUSIONS HBP levels were higher in VRI subjects and varied between patients and different diagnoses. To validate the clinical usefulness and added value of HBP as a biomarker for VRI, the results need to be confirmed in larger studies with head-to-head comparisons to current biomarkers.
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Affiliation(s)
- Johan Widén
- Department of Clinical Sciences Lund, Division of Infection Medicine, Lund University, Lund, Sweden; Department of Medical Sciences Uppsala, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden.
| | - David Cederberg
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden; Department of Medical Sciences Uppsala, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Adam Linder
- Department of Clinical Sciences Lund, Division of Infection Medicine, Lund University, Lund, Sweden; Department of Medical Sciences Uppsala, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Gabriel Westman
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden; Department of Medical Sciences Uppsala, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
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König C, Martens-Lobenhoffer J, Czorlich P, Westphal M, Bode-Böger SM, Kluge S, Grensemann J. Cerebrospinal fluid penetration of fosfomycin in patients with ventriculitis: an observational study. Ann Clin Microbiol Antimicrob 2023; 22:29. [PMID: 37095559 PMCID: PMC10127017 DOI: 10.1186/s12941-023-00572-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 03/12/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND For treatment of ventriculitis, vancomycin and meropenem are frequently used as empiric treatment but cerebrospinal fluid (CSF) penetration is highly variable and may result in subtherapeutic concentrations. Fosfomycin has been suggested for combination antibiotic therapy, but data are sparse, so far. Therefore, we studied CSF penetration of fosfomycin in ventriculitis. METHODS Adult patients receiving a continuous infusion of fosfomycin (1 g/h) for the treatment of ventriculitis were included. Routine therapeutic drug monitoring (TDM) of fosfomycin in serum and CSF was performed with subsequent dose adaptions. Demographic and routine laboratory data including serum and CSF concentrations for fosfomycin were collected. Antibiotic CSF penetration ratio as well as basic pharmacokinetic parameters were investigated. RESULTS Seventeen patients with 43 CSF/serum pairs were included. Median fosfomycin serum concentration was 200 [159-289] mg/L and the CSF concentration 99 [66-144] mg/L. Considering only the first measurements in each patient before a possible dose adaption, serum and CSF concentrations were 209 [163-438] mg/L and 104 [65-269] mg/L. Median CSF penetration was 46 [36-59]% resulting in 98% of CSF levels above the susceptibility breakpoint of 32 mg/L. CONCLUSION Penetration of fosfomycin into the CSF is high, reliably leading to appropriate concentrations for the treatment of gram positive and negative bacteria. Moreover, continuous administration of fosfomycin appears to be a reasonable approach for antibiotic combination therapy in patients suffering from ventriculitis. Further studies are needed to evaluate the impact on outcome parameters.
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Affiliation(s)
- Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Jens Martens-Lobenhoffer
- Institute of Clinical Pharmacology, Otto-Von-Guericke University, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefanie M Bode-Böger
- Institute of Clinical Pharmacology, Otto-Von-Guericke University, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Yu ZY, Xing YQ, Li C, Wang SB, Song XN, Wang CC, Wang LJ. Ultrasonic optic disc height combined with the optic nerve sheath diameter as a promising non-invasive marker of elevated intracranial pressure. Front Physiol 2023; 14:957758. [PMID: 36969579 PMCID: PMC10036414 DOI: 10.3389/fphys.2023.957758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 02/13/2023] [Indexed: 03/12/2023] Open
Abstract
Background/aim: Patients with elevated intracranial pressure (ICP) tend to have optic disc edema and a thicker optic nerve sheath diameter (ONSD). However, the cut-off value of the optic disc height (ODH) for evaluating elevated ICP is not clear. This study was conducted to evaluate ultrasonic ODH and to investigate the reliability of ODH and ONSD for elevated ICP.Methods: Patients suspected of having increased ICP and who underwent a lumbar puncture were recruited. ODH and ONSD were measured before lumbar puncture. Patients were divided according to elevated and normal ICP. We analyzed the correlations between ODH, ONSD, and ICP. ODH and ONSD cut-off points for the identification of elevated ICP were determined and compared.Results: There were a total of 107 patients recruited for this study, 55 patients with elevated ICP and 52 with normal ICP. Both ODH and ONSD in the elevated ICP group were higher than in the normal group [ODH: median 0.81 (range 0.60–1.06) mm vs. 0.40 [0–0.60] mm, p < 0.001; ONSD: 5.01 ± 0.37 mm vs. 4.20 ± 0.38 mm, p < 0.001]. ICP was positively correlated with ODH (r = 0.613; p < 0.001) and ONSD (r = 0.792; p < 0.001). The cut-off values of ODH and ONSD for evaluating elevated ICP were 0.63 mm and 4.68 mm, respectively, with 73% and 84% sensitivity and 83% and 94% specificity, respectively. ODH combined with ONSD showed the highest value under the receiver operating characteristic curve of 0.965 with a sensitivity of 93% and a specificity of 92%.Conclusion: Ultrasonic ODH combined with ONSD may help monitor elevated ICP non-invasively.
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Affiliation(s)
- Ze-yang Yu
- Department of Neurology, The First Hospiatal of Jilin University, Changchun, China
- Department of Rehabilitation Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Ying-qi Xing
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Bejing, China
| | - Cong Li
- Department of Neurology, The First Hospiatal of Jilin University, Changchun, China
| | - Si-bo Wang
- Department of Neurology, The First Hospiatal of Jilin University, Changchun, China
| | - Xiao-nan Song
- Department of Neurology, The First Hospiatal of Jilin University, Changchun, China
| | - Cui-cui Wang
- Department of Neurology, The First Hospiatal of Jilin University, Changchun, China
| | - Li-juan Wang
- Department of Neurology, The First Hospiatal of Jilin University, Changchun, China
- *Correspondence: Li-juan Wang,
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Zeggay A, Patry I, Chirouze C, Bouiller K. Characteristics and outcomes of cerebrospinal fluid shunt and drain-associated infections. Infect Dis Now 2023; 53:104665. [PMID: 36736666 DOI: 10.1016/j.idnow.2023.104665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/11/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Data on infections associated with cerebrospinal fluid shunt (CSF-S) or device-associated infection (CSF-SDI) are limited in adults. We performed a retrospective study to describe characteristics, management, and outcome of CSF-SDI. METHODS All patients with CSF-SDI and admitted to our institution from January 2013 to December 2019 were included. RESULTS Among 50 patients, fifty-six episodes of CSF-SDI (41 external ventricular device-associated infections (CSF-D) and 15 other shunt infections (CSF-S) were included. The incidence of CSF-SDI was 11.9 %. Fever was the most common symptom (81 %). Enterobacterales were more prevalent in CSF-S than in CSF-D (20 % vs 53 %, p = 0.02). As regards CSF-D, deceased patients (11/41, 27 %) more frequently had a Glasgow coma scale score decreasing from baseline (p < 0.01), lower glycorrhachia (p < 0.01), a higher protein level in CSF (p = 0.001) and a positive control CSF culture (p = 0.031). CONCLUSIONS CSF-SDIs are rare but with a high mortality rate. Mortality was more closely related to the infection than to comorbidities or underlying neurosurgical disease. A second CSF analysis significantly helped to detect patients with CSF-D with a poor prognosis.
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Affiliation(s)
- Abdeljalil Zeggay
- Department of infectious and tropical diseases, CHRU Besançon, Besançon, France.
| | - Isabelle Patry
- Laboratory of microbiology, CHRU Besançon, Besançon, France
| | - Catherine Chirouze
- Department of infectious and tropical diseases, CHRU Besançon, Besançon, France; UMR CNRS 6249 Chrono-Environnement, University of Bourgogne Franche-Comté, Besançon, France
| | - Kevin Bouiller
- Department of infectious and tropical diseases, CHRU Besançon, Besançon, France; UMR CNRS 6249 Chrono-Environnement, University of Bourgogne Franche-Comté, Besançon, France
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Li C, Wang CC, Meng Y, Fan JY, Zhang J, Wang LJ. Ultrasonic optic nerve sheath diameter could improve the prognosis of acute ischemic stroke in the intensive care unit. Front Pharmacol 2022; 13:1077131. [PMID: 36618944 PMCID: PMC9816399 DOI: 10.3389/fphar.2022.1077131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives: Stroke patients with high intracranial pressure (ICP) may have poor prognosis. Non-invasive ultrasonic optic nerve sheath diameter (ONSD) could evaluate increased ICP. To investigate whether ONSD is valuable for prognosis of patients with acute ischemic stroke (AIS). Methods: AIS receiving intensive care were recruited with the Glasgow Coma Scale (GCS) score. Patients in group A underwent ultrasonic ONSD to assess ICP voluntarily, whereas group B without ONSD. Patients were followed up at discharge and once a week for 3 months with Glasgow Outcome Scale (GOS) score (four to five scores indicated good prognosis and one to three scores indicated poor prognosis). Results: Forty-nine patients were included. GCS scores did not differ significantly between groups A (26 patients) and B (8 ± 3 vs. 7 ± 3, p < 0.05). In group A, ONSD was 5.01 ± 0.48 mm, which correlated with GCS score (p < 0.05). At discharge, the GOS score was higher in group A than in group B (3.35 ± 1.35 vs. 2.57 ± 1.121, p = 0.034). The proportion of patients with a good prognosis was higher in group A than in group B (46.2% vs. 13.0%, p = 0.006). At discharge and after 3 months of follow-up, ONSD at admission was correlated with the GOS score in group A (r = -0.648 [p < 0.05] and -0.731 [p < 0.05], respectively). After 3 months of follow-up, the GOS score was higher in group A than group B (3.00 ± 1.673 vs. 2.04 ± 1.430, p < 0.05). The proportion of patients with a good prognosis was higher in group A than in group B (46.2% vs. 21.2%, p = 0.039). The Kaplan-Meier curve showed a higher rate of good prognosis in group A than in group B. ONSD (p < 0.05) was an independent predictor of poor prognosis. Conclusion: Non-invasive ultrasonic ONSD could be useful in improving the prognosis of patients with AIS receiving intensive care.
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Affiliation(s)
- Cong Li
- Department of Neurology, The Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Cui-Cui Wang
- Department of Neurology, The Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China,Department of Rehabilitation, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Yan Meng
- Department of Neurology, The Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Jia-Yu Fan
- Department of Neurology, The Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Jie Zhang
- Department of Neurology, The Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Li-Juan Wang
- Department of Neurology, The Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China,*Correspondence: Li-Juan Wang,
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10
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Brooks M, Duong D, Shivapathasundram G, Sheridan M. Cerebrospinal fluid white cell count to red cell count ratio as a predictor of ventriculitis in patients with external ventricular drains. ANZ J Surg 2022; 92:3278-3282. [PMID: 35437927 DOI: 10.1111/ans.17725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/04/2022] [Accepted: 04/03/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION External ventricular drain (EVD) associated ventriculitis is a complication of EVD placement associated with significant morbidity and mortality. Gold-standard for EVD associated bacterial ventriculitis diagnosis involves cerebrospinal fluid (CSF) sampling from the EVD with microscopy, culture and sensitivity testing. The ratio of white blood cells to red blood cells has anecdotally been considered a predictive factor in diagnosing EVD associated ventriculitis, however no study has been done demonstrating this. METHODS A retrospective cross-sectional study was designed to assess whether the ratio of CSF white blood cells to red blood cells could be used to diagnose EVD associated ventriculitis. Data was collected for all patients undergoing EVD insertion at a major neurosurgical unit in Sydney, Australia. A receiver operator characteristics (ROC) curve was used to determine if this ratio was useful, and Youden's index was calculated to determine the appropriate cut-off point. RESULTS This sample of n = 157 consecutive patients a total of 29 patients were diagnosed with ventriculitis. The area under the ROC curve was significant (0.706, P <0.001), and Youden's index demonstrated an appropriate cut-off point was a ratio of 1:106. DISCUSSION CSF parameters have long been considered predictive of EVD associated ventriculitis. We demonstrated that using a component of routine testing it is possible to accurately predict a ventriculitis diagnosis. As the ratio is used, it enables discrimination in a raised white blood cell count due to local trauma with interventricular bleeding. CONCLUSION CSF white blood cell to red blood cell ratio is an appropriate diagnostic test for ventriculitis.
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Affiliation(s)
- Michael Brooks
- Department of Neurosurgery, Liverpool Hospital, Elizabeth, New South Wales, Australia.,South West Sydney Clinical School, School of Medicine, University of New South Wales (UNSW), Randwick, New South Wales, Australia
| | - Dannielle Duong
- Department of Intensive Care, Liverpool Hospital, Elizabeth, New South Wales, Australia.,School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | | | - Mark Sheridan
- Department of Neurosurgery, Liverpool Hospital, Elizabeth, New South Wales, Australia
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11
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Elfadle AA, Zarad CA, Soliman AY, Eissa AAN, Elzoghby MA. Ventriculosubgaleal shunting for spontaneous intraventricular haemorrhage: is it a good alternative to external ventricular drainage? THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022. [DOI: 10.1186/s41983-022-00535-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
Spontaneous intraventricular haemorrhage (IVH) is a life-threatening condition associated with high morbidity and mortality and is conventionally managed using external ventricular drain (EVD). However, EVD is commonly associated with a high rate of complications, which necessitates another alternative management with a comparable or better outcome. This study aims to compare the efficacy and safety of ventriculosubgaleal shunt (VSGS) compared to EVD for the management of adult patients with spontaneous IVH.
Results
A total of 48 patients were enrolled in this study. Twenty patients underwent EVD and 28 had VSGS. Postoperative complications were non-significantly more prevalent in the EVD than in the VSGS group (75 vs. 64.3%, p = 0.430), including non-CR (20 vs. 32.1%), infection (20 vs. 7.1%), blocked ventricular catheter (15 vs. 3.6%), and dislodged catheter (10 vs. 7.1%). Convulsions and CSF leaks occurred more frequently in the VSGS group (7.1 vs 5%, p = 1.000). Postoperative GCS and Graeb’s score were comparable between the groups (p > 0.05). The EVD group had a non-significantly higher rate of hydrocephalus after ventricular catheter removal (80 vs. 53.6%, p = 0.059) and a higher mean GOS 3 months postoperatively (mean score: 4 vs. 3).
Conclusions
VSGS is as effective and safe compared to EVD, with a lower rate of infection, blocked/dislodged catheters, as well as a reduced incidence of hydrocephalus. On the other hand, EVD showed better GOS at 3 months. However, these differences did not reach statistical significance.
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12
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Zeng T, Wang M, Xu Z, Ni M, Gao L. Autologous Free Fascia Lata Can Be Used as Dura Graft in the Salvage Treatment of Recalcitrant Postcraniotomy Intracranial Infection Caused by Multidrug-Resistant Gram-Negative Bacteria. Infect Drug Resist 2022; 15:5667-5677. [PMID: 36193296 PMCID: PMC9526421 DOI: 10.2147/idr.s381087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/03/2022] [Indexed: 12/01/2022] Open
Abstract
Objective The multidrug-resistant (MDR) gram-negative bacteria-induced intracranial infections after neurosurgical procedures represent a particular therapeutic challenge. Combining the removal of infected prosthetic meninge plus an appropriate antibiotic administration appears to be the only therapeutic strategy likely to succeed when the infection is complicated by artificial dura mater. This study aimed to assess the efficacy of free fascia lata as a substitute for dura reconstruction in the salvage treatment for such recalcitrant nosocomial infections. Methods The retrospective, observational study was conducted at Shanghai Tenth hospital. Patients with definite intracranial infection caused by MDR Gram-Negative bacteria who underwent salvage dura reconstruction using autologous free fascia lata were included in the study. Electronic medical data on clinical characteristics, underlying condition, bacterial culture, antibiotic susceptibilities, perioperative management, surgical techniques, outcome, and follow-up were collected and analyzed. Results 19 patients were included in the study cohort. All these patients underwent salvage surgery, including removal of infected artificial dura substitute, achievement of complete dura seal with free fascia lata, and other adjunctive procedures to drain the CSF and infuse sensitive antimicrobial agents. Intraventricular or intrathecal administration of antibiotics, including Colistin (14 case), Tigecycline (1 case), Amikacin (1 case), was employed in 16 patients. The infection was cured in 17 patients. In-hospital death occurred in 3 patients. One died from multiple system/organ failure, 1 died from massive occipital ICH, 1 died from brain stem hemorrhage after ventricular-peritoneal shunt surgery. The patients remained without clinical evidence of recurrence during the follow-up period. Conclusion On the basis of a comprehensive approach to achieving prompt sterilization of causative pathogens and an optimal healing environment, free fascia lata can serve as a simpler but effective option for dura reconstruction even in the setting of a severe septic area for patients who otherwise need much more complicated and demanding tissue transfer surgery.
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Affiliation(s)
- Tao Zeng
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - MingSheng Wang
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Zijun Xu
- Department of Radiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Min Ni
- Department of Clinical Pharmacy, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Liang Gao
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
- Correspondence: Liang Gao, Department of Neurosurgery, Shanghai Tenth People’s Hospital, Shanghai, People’s Republic of China, Email
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13
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Sin EG. Early overdrain of cerebrospinal fluid in infected hydrocephalus: Simple and novel technique. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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14
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Walton MN, Hamilton LA, Kennedy SJ, Veve MP, Rowe AS. Antibiotic Prophylaxis and Incidence of Infection with External Ventricular Drains and Intra-Cranial Pressure Monitors. Surg Infect (Larchmt) 2022; 23:262-269. [PMID: 35133886 DOI: 10.1089/sur.2021.310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives: Guidelines do not recommend extended antibiotic prophylaxis for external ventricular drains (EVD) or intra-cranial pressure (ICP) monitors. The study objective was to determine if infection rates are different for patients receiving antibiotic prophylaxis for EVD or ICP monitors. Patients and Methods: This single-center retrospective cohort reviewed intensive care unit patients who had an EVD or ICP monitor placed. Patients receiving antibiotic prophylaxis were compared with those who did not receive prophylaxis. The primary end point was incidence of central nervous system (CNS) infection. Results: Overall, 228 patients were included, 120 of whom received prophylaxis and 108 who did not receive prophylaxis. The primary end point of CNS infection was not different between groups (18 [17%] vs. 23 [19%]; p = 0.6236). Conclusions: Antibiotic prophylaxis was not associated with a decreased incidence of CNS infection in patients with EVD or ICP monitors. Evaluation of antibiotic use in this patient population is warranted to prevent resistance and adverse drug effects.
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Affiliation(s)
- Mary N Walton
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Leslie A Hamilton
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, Tennessee, USA.,University of Tennessee Health Science Center College of Pharmacy, Knoxville, Tennessee, USA
| | - Sonia J Kennedy
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Michael P Veve
- Wayne State University College of Pharmacy and Health Sciences, Detroit, Michigan, USA
| | - A Shaun Rowe
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, Tennessee, USA.,University of Tennessee Health Science Center College of Pharmacy, Knoxville, Tennessee, USA
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15
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Schneider F, Gessner A, El-Najjar N. Efficacy of Vancomycin and Meropenem in Central Nervous System Infections in Children and Adults: Current Update. Antibiotics (Basel) 2022; 11:antibiotics11020173. [PMID: 35203776 PMCID: PMC8868565 DOI: 10.3390/antibiotics11020173] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 11/16/2022] Open
Abstract
The current antimicrobial therapy of bacterial infections of the central nervous system (CNS) in adults and pediatric patients is faced with many pitfalls as the drugs have to reach necessary levels in serum and cross the blood-brain barrier. Furthermore, several studies report that different factors such as the structure of the antimicrobial agent, the severity of disease, or the degree of inflammation play a significant role. Despite the available attempts to establish pharmacokinetic (PK) modeling to improve the required dosing regimen for adults and pediatric patients, conclusive recommendations for the best therapeutic strategies are still lacking. For instance, bacterial meningitis, the most common CNS infections, and ventriculitis, a severe complication of meningitis, are still associated with 10% and 30% mortality, respectively. Several studies report on the use of vancomycin and meropenem to manage meningitis and ventriculitis; therefore, this review aims to shed light on the current knowledge about their use in adults and pediatric patients. Consequently, studies published from 2015 until mid-July 2021 are included, and data about the study population, levels of drugs in serum and cerebrospinal fluid (CSF), and measured PK data in serum and CSF are provided. The overall aim is to provide the readers a recent reference that summarizes the pitfalls and success of the current therapy and emphasizes the importance of performing more studies to improve the clinical outcome of the current therapeutical approach.
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16
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Tverdal C, Aarhus M, Rønning P, Skaansar O, Skogen K, Andelic N, Helseth E. Incidence of emergency neurosurgical TBI procedures: a population-based study. BMC Emerg Med 2022; 22:1. [PMID: 34991477 PMCID: PMC8734328 DOI: 10.1186/s12873-021-00561-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 11/28/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The rates of emergency neurosurgery in traumatic brain injury (TBI) patients vary between populations and trauma centers. In planning acute TBI treatment, knowledge about rates and incidence of emergency neurosurgery at the population level is of importance for organization and planning of specialized health care services. This study aimed to present incidence rates and patient characteristics for the most common TBI-related emergency neurosurgical procedures. METHODS Oslo University Hospital is the only trauma center with neurosurgical services in Southeast Norway, which has a population of 3 million. We extracted prospectively collected registry data from the Oslo TBI Registry - Neurosurgery over a five-year period (2015-2019). Incidence was calculated in person-pears (crude) and age-adjusted for standard population. We conducted multivariate multivariable logistic regression models to assess variables associated with emergency neurosurgical procedures. RESULTS A total of 2151 patients with pathological head CT scans were included. One or more emergency neurosurgical procedure was performed in 27% of patients. The crude incidence was 3.9/100,000 person-years. The age-adjusted incidences in the standard population for Europe and the world were 4.0/100,000 and 3.3/100,000, respectively. The most frequent emergency neurosurgical procedure was the insertion of an intracranial pressure monitor, followed by evacuation of the mass lesion. Male sex, road traffic accidents, severe injury (low Glasgow coma score) and CT characteristics such as midline shift and compressed/absent basal cisterns were significantly associated with an increased probability of emergency neurosurgery, while older age was associated with a decreased probability. CONCLUSIONS The incidence of emergency neurosurgery in the general population is low and reflects neurosurgery procedures performed in patients with severe injuries. Hence, emergency neurosurgery for TBIs should be centralized to major trauma centers.
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Affiliation(s)
- Cathrine Tverdal
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway.
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Boks 1072 Blindern, 0316, Oslo, Norway.
| | - Mads Aarhus
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Pål Rønning
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Ola Skaansar
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Boks 1072 Blindern, 0316, Oslo, Norway
| | - Karoline Skogen
- Department of Neuroradiology, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
- Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, Institute of Health and Society, University of Oslo, Boks 1072 Blindern, 0316, Oslo, Norway
| | - Eirik Helseth
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Boks 1072 Blindern, 0316, Oslo, Norway
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17
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Rollin G, Rossi B, Brisse S, Decré D, Leflon-Guibout V, Bert F, Hoffmann I, Decousser JW, Fantin B, Lefort A. Spontaneous and postsurgical/traumatic Klebsiella pneumoniae meningitis: two distinct clinico-microbiological entities. Int J Infect Dis 2021; 114:185-191. [PMID: 34767984 DOI: 10.1016/j.ijid.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES To analyze and compare the characteristics and outcomes of spontaneous meningitis (SM) versus postsurgical/traumatic meningitis (PSTM) due to Klebsiella pneumoniae. METHODS A retrospective multicentric cohort study of all K. pneumoniae meningitis cases managed between January 2007 and May 2018 was carried out in seven university hospitals in the Paris area. The microbiological characteristics of 16 available K. pneumoniae isolates were further analyzed, and the genomes of seven of those isolated from SM were sequenced. RESULTS Among 35 cases, 10 were SM and 25 were PSTM. SM cases more severe than PSTM cases, with higher septic shock (p = 0.004) and in-hospital mortality rates (p = 0.004). In contrast, relapse occurred in five patients from the PSTM group versus no patients from the SM group. All K. pneumoniae strains recovered from SM but none of those recovered from PSTM displayed hypervirulent phenotypic (positive string test) and genotypic (genes corresponding to capsular serotypes K1 or K2; virulence genes rmpA and iutA) characteristics (p < 0.0001). PSTM tended to be more frequently polymicrobial (p = 0.08) and caused by an extended-spectrum β-lactamase producing strain (p = 0.08) than SM. CONCLUSIONS SM and PSTM are two entities differing both from a clinical and a microbiological standpoint. SM appears to be a more serious infection, induced by hypervirulent K. pneumoniae strains.
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Affiliation(s)
| | - Benjamin Rossi
- Internal Medicine, Hôpital Robert Ballanger, Aulnay-sous-Bois, France.
| | - Sylvain Brisse
- Biodiversity and Epidemiology of Bacterial Pathogens, Institut Pasteur, Paris, France.
| | - Dominique Decré
- Bacteriology Department, GH-Est Parisien, APHP, Paris, France, Sorbonne University, INSERM1135, Cimi team 2, Paris, France.
| | | | - Frédéric Bert
- Bacteriology Department, Hôpital Beaujon, Clichy, France.
| | | | - Jean-Winoc Decousser
- Bacteriology Department, Hôpital Henri Mondor, APHP, Paris, France; Paris University, IAME, UMR 1137, INSERM, Paris F-75018, France.
| | - Bruno Fantin
- Internal Medicine, Hôpital Beaujon, Clichy, France; Paris University, IAME, UMR 1137, INSERM, Paris F-75018, France.
| | - Agnès Lefort
- Internal Medicine, Hôpital Beaujon, Clichy, France; Paris University, IAME, UMR 1137, INSERM, Paris F-75018, France.
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18
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Bådholm M, Blixt J, Glimåker M, Ternhag A, Hedlund J, Nelson DW. Cerebrospinal fluid cell count variability is a major confounding factor in external ventricular drain-associated infection surveillance diagnostics: a prospective observational study. Crit Care 2021; 25:291. [PMID: 34380543 PMCID: PMC8359042 DOI: 10.1186/s13054-021-03715-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/29/2021] [Indexed: 11/20/2022] Open
Abstract
Background External ventricular drain (EVD)-related infections (EVDIs) are feared complications that are difficult to rapidly and correctly diagnose, which can lead to unnecessary treatment with broad-spectrum antibiotics. No readily available diagnostic parameters have been identified to reliably predict or identify EVDIs. Moreover, intraventricular hemorrhage is common and affect cerebrospinal fluid (CSF) cellularity. The relationship between leukocytes and erythrocytes is often used to identify suspected infection and triggers the use of antibiotics pending results of cultures, which may take days. Cell count based surveillance diagnostics assumes a homogeneous distribution of cells in the CSF. Given the intraventricular sedimentation of erythrocytes on computed tomography scans this assumption may be erroneous and could affect diagnostics. Aims To evaluate the consistency of cell counts in serially sampled CSF from EVDs, with and without patient repositioning, to assess the effect on infection diagnostics. Methods We performed a prospective single-center study where routine CSF sampling was followed by a second sample after 10 min, allocated around a standard patient repositioning, or not. Changes in absolute and pairwise cell counts and ratios were analyzed, including mixed regression models. Results Data from 51 patients and 162 paired samples were analyzed. We observed substantial changes in CSF cellularity as the result of both resampling and repositioning, with repositioning found to be an independent predictor of bidirectional cellular change. Glucose and lactate levels were affected, however clinically non-significant. No positive CSF cultures were seen during the study. Thirty percent (30%) of patients changed suspected EVDI status, as defined by the cell component of local and national guidelines, when resampling after repositioning. Conclusions CSF cell counts are not consistent and are affected by patient movement suggesting a heterogeneity in the intraventricular space. The relationship between leukocytes and erythrocytes was less affected than absolute changes. Importantly, cell changes are found to increase with increased cellularity, often leading to changes in suspected EVDI status. Faster and more precise diagnostics are needed, and methods such as emerging next generation sequencing techniques my provide tools to more timely and accurately guide antibiotic treatment. Trial Registration NCT04736407, Clinicaltrials.gov, retrospectively registered 2nd February 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03715-1.
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Affiliation(s)
- Marcus Bådholm
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden. .,Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.
| | - Jonas Blixt
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Martin Glimåker
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Ternhag
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Infectious Diseases, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Jonas Hedlund
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Infectious Diseases, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - David W Nelson
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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19
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Schwering C, Kammler G, Wibbeler E, Christner M, Knobloch JKM, Nickel M, Denecke J, Baehr M, Schulz A. Development of the "Hamburg Best Practice Guidelines for ICV-Enzyme Replacement therapy (ERT) in CLN2 Disease" Based on 6 Years Treatment Experience in 48 Patients. J Child Neurol 2021; 36:635-641. [PMID: 33543660 PMCID: PMC8255505 DOI: 10.1177/0883073821989154] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Intracerebroventricular enzyme replacement therapy (ICV-ERT) for CLN2 disease represents the first approved treatment for neuronal ceroid lipofuscinosis (NCL) diseases. It is the first treatment where a recombinant lysosomal enzyme, cerliponase alfa, is administered into the lateral cerebral ventricles to reach the central nervous system, the organ affected in CLN2 disease. If untreated, CLN2 children show first symptoms such as epilepsy and language developmental delay at 2-4 years followed by rapid loss of motor and language function, vision loss, and early death. Treatment with cerliponase alfa has shown to slow the rapid neurologic decline. However, the mode of administration by 4 hour-long intracerebroventricular infusions every 14 days represents a potentially greater risk of infection compared to intravenous enzyme replacement therapies. The Hamburg NCL Specialty Clinic was the first site worldwide to perform intracerebroventricular enzyme replacement therapy in children with CLN2 disease. In order to ensure maximum patient safety, we analysed data from our center from more than 3000 intracerebroventricular enzyme replacement therapies in 48 patients over 6 years with regard to the occurrence of device-related adverse events and device infections. Since starting intracerebroventricular enzyme replacement therapy, we have also developed and continuously improved the "Hamburg Best Practice Guidelines for ICV-Enzyme Replacement Therapy (ERT) in CLN2 Disease." Results from this study showed low rates for device-related adverse events and infections with 0.27% and 0.33%, respectively. Therefore, following our internal procedural guidelines has shown to improve standardization and patient safety of intracerebroventricular enzyme replacement therapy for CLN2 disease.
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Affiliation(s)
- Christoph Schwering
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Christoph Schwering, Department of Pediatrics, Children’s Hospital, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20246 Hamburg, Germany.
| | - Gertrud Kammler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eva Wibbeler
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Christner
- Institute of Medical Microbiology, University Medical Center Hamburg-Eppendorf, Virology and Hygiene, Hamburg, Germany
| | - Johannes K.-M. Knobloch
- Institute of Medical Microbiology, University Medical Center Hamburg-Eppendorf, Virology and Hygiene, Hamburg, Germany
| | - Miriam Nickel
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jonas Denecke
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Baehr
- University Medical Center Hamburg-Eppendorf, Pharmacy, Hamburg, Germany
| | - Angela Schulz
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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20
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Luque-Paz D, Revest M, Eugène F, Boukthir S, Dejoies L, Tattevin P, Le Reste PJ. Ventriculitis: A Severe Complication of Central Nervous System Infections. Open Forum Infect Dis 2021; 8:ofab216. [PMID: 34095339 PMCID: PMC8176394 DOI: 10.1093/ofid/ofab216] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ventriculitis, a dreaded complication of brain abscess, meningitis, and various neurosurgical procedures, has attracted limited attention in the medical literature. METHODS This is a retrospective, single-center study. We screened the medical files of all patients who had a brain imaging report that included the word "ventriculitis" during years 2005-2019. Only patients with clinical, microbiological, and imaging features of ventriculitis were included. Data were collected through a standardized questionnaire. RESULTS Ninety-eight patients fulfilled inclusion criteria: 42 women and 56 men, and the median age was 60 years (interquartile range, 48-68). The primary mechanism for ventriculitis was classified as follows: brain abscess (n = 29, 29.6%), meningitis (n = 27, 27.6%), intraventricular catheter-related (n = 17, 17.3%), post-neurosurgery (n = 13, 13.3%), and hematogenous (n = 12, 12.2%). The main neuroimaging features were intraventricular pus (n = 81, 82.7%), ependymal enhancement (n = 70, 71.4%), and intraventricular loculations (n = 15, 15.3%). The main pathogens were streptococci (n = 44, 44.9%), Gram-negative bacilli (n = 27, 27.6%), and staphylococci (n = 15, 15.3%). In-hospital and 1-year mortality rates were 30.6% (n = 30) and 38.8% (n = 38), respectively. Neurological sequelae were reported in 34 of 55 (61.8%) survivors, including cognitive impairment (n = 11), gait disturbances (n = 9), paresis (n = 7), behavior disorder (n = 6), and epilepsy (n = 5). On multivariate analysis, age >65 years, Glasgow Coma Scale score <13 at initial presentation, status epilepticus, hydrocephalus, and positive cerebrospinal fluid culture were associated with 1-year mortality. We built a scoring system to stratify patients with ventriculitis into low risk (12.5%), intermediate risk (36.5%), and high risk (71.4%) of death. CONCLUSIONS Ventriculitis is a severe complication of brain abscess, meningitis, or neurosurgery, with an in-hospital mortality rate of 30% and neurological sequelae in 60% of survivors.
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Affiliation(s)
- David Luque-Paz
- Infectious Diseases and Intensive Care Unit, Rennes University Hospital, Rennes, France
- Rennes University, Inserm, Bacterial Regulatory RNAs and Medicine, UMR_S 1230, Rennes, France
| | - Matthieu Revest
- Infectious Diseases and Intensive Care Unit, Rennes University Hospital, Rennes, France
- Rennes University, Inserm, Bacterial Regulatory RNAs and Medicine, UMR_S 1230, Rennes, France
- CIC-Inserm 1414, Rennes University Hospital, Rennes, France
| | - François Eugène
- Department of Neuroradiology, Rennes University Hospital, Rennes, France
| | - Sarrah Boukthir
- Bacteriology Department, Rennes University Hospital, Rennes, France
| | - Loren Dejoies
- Bacteriology Department, Rennes University Hospital, Rennes, France
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Rennes University Hospital, Rennes, France
- Rennes University, Inserm, Bacterial Regulatory RNAs and Medicine, UMR_S 1230, Rennes, France
- CIC-Inserm 1414, Rennes University Hospital, Rennes, France
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Sakamoto VTM, Vieira TW, Viegas K, Blatt CR, Caregnato RCA. Nursing assistance in patient care with external ventricular drain: a scoping review. Rev Bras Enferm 2021; 74:e20190796. [PMID: 33886830 DOI: 10.1590/0034-7167-2019-0796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 05/21/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to map the available evidence about nursing care aimed at adult patients using external ventricular drain. METHODS this is a review using the scoping review method. RESULTS Initially, 965 studies were identified and, after the eligibility criteria, a sample of 54 publications was obtained. Each of them was assessed according to GRADE, resulting in three studies with high quality; 14 with moderate quality; 32 with low quality; and five with very low quality. It was highlighted 20 nursing care subdivided into nine categories, namely: drainage system; bed positioning and mobilization; catheter care; monitoring of intracranial pressure; and medication administration. CONCLUSIONS the scoping review made it possible to identify the main nursing care directed to adult patients undergoing placement of external ventricular drain from the evidence available to date.
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Affiliation(s)
| | - Tainara Wink Vieira
- Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brazil
| | - Karin Viegas
- Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brazil
| | - Carine Raquel Blatt
- Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brazil
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Sweid A, Weinberg JH, Abbas R, El Naamani K, Tjoumakaris S, Wamsley C, Mann EJ, Neely C, Head J, Nauheim D, Hauge J, Gooch MR, Herial N, Zarzour H, Alexander TD, Missios S, Hasan D, Chalouhi N, Harrop J, Rosenwasser RH, Jabbour P. Predictors of ventriculostomy infection in a large single-center cohort. J Neurosurg 2021; 134:1218-1225. [DOI: 10.3171/2020.2.jns192051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 02/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. The aim of this retrospective, single-center large series was to assess the rate and independent predictors of ventriculostomy-associated infection (VAI).
METHODS
The authors performed a retrospective chart review of consecutive patients who underwent EVD placement between January 2012 and January 2018.
RESULTS
A total of 389 patients were included in the study. The infection rate was 3.1% (n = 12). Variables that were significantly associated with VAI were EVD replacement (OR 10, p = 0.001), bilateral EVDs (OR 9.2, p = 0.009), duration of EVD placement (OR 1.1, p = 0.011), increased CSF output/day (OR 1.0, p = 0.001), CSF leak (OR 12.9, p = 0.001), and increased length of hospital stay (OR 1.1, p = 0.002). Using multivariate logistic regression, independent predictors of VAI were female sex (OR 7.1, 95% CI 1.1–47.4; p = 0.043), EVD replacement (OR 8.5, 95% CI 1.44–50.72; p = 0.027), increased CSF output/day (OR 1.01, 95% CI 1.0–1.02; p = 0.023), and CSF leak (OR 15.1, 95% CI 2.6–87.1; p = 0.003).
CONCLUSIONS
The rate of VAI was 3.1%. Routine CSF collection (every other day or every 3 days) and CSF collection when needed were not associated with VAI. The authors recommend CSF collection when clinically needed rather than routinely.
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Affiliation(s)
- Ahmad Sweid
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Joshua H. Weinberg
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Rawad Abbas
- 2American University of Beirut Faculty of Medicine, Beirut, Lebanon
| | - Kareem El Naamani
- 3Gilbert and Rose-Marie Chagoury School of Medicine, Beirut, Lebanon
| | - Stavropoula Tjoumakaris
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Christine Wamsley
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Erica J. Mann
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Christopher Neely
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Jeffery Head
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Nauheim
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Julie Hauge
- 4University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - M. Reid Gooch
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nabeel Herial
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Hekmat Zarzour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Tyler D. Alexander
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Symeon Missios
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- 5Department of Neurosurgery, University of Iowa, Iowa City, Iowa
| | - Nohra Chalouhi
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - James Harrop
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H. Rosenwasser
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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23
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Effect of a bundle approach on external ventricular drain-related infection. Acta Neurochir (Wien) 2021; 163:1135-1142. [PMID: 33427989 DOI: 10.1007/s00701-020-04698-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/28/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Emergency placement of an external ventricular drain (EVD) is one of the most frequently performed neurosurgical procedures. EVD-related infection continues to be a major challenge causing significant morbidity and costs. Bundle approaches have been shown to reduce infection rates; however, they are still not widely used, and observation periods often were rather short. METHODS The present study evaluated the effect of a multi-item bundle approach for EVD placement and care on the occurrence of EVD-related infection. A before/after approach was used to compare groups of consecutive patients over 5-year epochs to control for bias and secondary confounding variables. RESULTS The number of patients in the group before implementation of the bundle approach was 141 and 208 thereafter. There were no statistical differences in demographic and other variables. While 41/141 patients (29.1%) had an EVD-related infection before, this was the case in only 10/208 patients (4.8%) thereafter (p < 0.0001). The EVD-related infection rate was reduced from 13.7/1000 catheter days to 3.2/1000, and the 50% probability of an EVD-related infection in correlation to the mean duration of EVD placement was significantly lower (p < 0.0001). Routine EVD replacement was not helpful to reduce EVD-related infection. EVD-related infection rates remained low also over the next 8 years after the study was finished. CONCLUSIONS The introduction of a multi-item bundle approach for EVD insertion and care resulted in a marked reduction of EVD-related infection. Long observation periods over 5 years and beyond confirm that short-term changes are sustained with continued use of such protocols.
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Qian L, Shi Y, Li F, Wang Y, Ma M, Zhang Y, Shao YW, Zheng G, Zhang G. Metagenomic Next-Generation Sequencing of Cerebrospinal Fluid for the Diagnosis of External Ventricular and Lumbar Drainage-Associated Ventriculitis and Meningitis. Front Microbiol 2021; 11:596175. [PMID: 33381092 PMCID: PMC7767851 DOI: 10.3389/fmicb.2020.596175] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/13/2020] [Indexed: 12/20/2022] Open
Abstract
Metagenomic next-generation sequencing (mNGS) has become a widely used technology that can accurately detect individual pathogens. This prospective study was performed between February 2019 and September 2019 in one of the largest clinical neurosurgery centers in China. The study aimed to evaluate the performance of mNGS on cerebrospinal fluid (CSF) from neurosurgical patients for the diagnosis of external ventricular and lumbar drainage (EVD/LD)-associated ventriculitis and meningitis (VM). We collected CSF specimens from neurosurgical patients with EVD/LD for more than 24 h to perform conventional microbiological studies and mNGS analyses in a pairwise manner. We also investigated the usefulness of mNGS of CSF for the diagnosis of EVD/LD-associated VM. In total, 102 patients were enrolled in this study and divided into three groups, including confirmed VM (cVM) (39), suspected VM (sVM) (49), and non-VM (nVM) (14) groups. Of all the patients, mNGS detected 21 Gram-positive bacteria, 20 Gram-negative bacteria, and five fungi. The three primary bacteria detected were Staphylococcus epidermidis (9), Acinetobacter baumannii (5), and Staphylococcus aureus (3). The mNGS-positive coincidence rate of confirmed EVD/LD-associated VM was 61.54% (24/39), and the negative coincidence rate of the nVM group was 100% (14/14). Of 15 VM pathogens not identified by mNGS in the cVM group, eight were negative with mNGS and seven were inconsistent with the conventional microbiological identification results. In addition, mNGS identified pathogens in 22 cases that were negative using conventional methods; of them, 10 patients received a favorable clinical treatment; thus, showing the benefit of mNGS-guided therapy.
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Affiliation(s)
- Lingye Qian
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yijun Shi
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fangqiang Li
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yufei Wang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Miao Ma
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yanfang Zhang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang W Shao
- Nanjing Geneseeq Technology Inc., Nanjing, China.,School of Public Health, Nanjing Medical University, Nanjing, China
| | - Guanghui Zheng
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guojun Zhang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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25
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Cuff SM, Merola JP, Twohig JP, Eberl M, Gray WP. Toll-like receptor linked cytokine profiles in cerebrospinal fluid discriminate neurological infection from sterile inflammation. Brain Commun 2020; 2:fcaa218. [PMID: 33409494 PMCID: PMC7772097 DOI: 10.1093/braincomms/fcaa218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/12/2020] [Accepted: 11/12/2020] [Indexed: 12/13/2022] Open
Abstract
Rapid determination of an infective aetiology causing neurological inflammation in the cerebrospinal fluid can be challenging in clinical practice. Post-surgical nosocomial infection is difficult to diagnose accurately, as it occurs on a background of altered cerebrospinal fluid composition due to the underlying pathologies and surgical procedures involved. There is additional diagnostic difficulty after external ventricular drain or ventriculoperitoneal shunt surgery, as infection is often caused by pathogens growing as biofilms, which may fail to elicit a significant inflammatory response and are challenging to identify by microbiological culture. Despite much research effort, a single sensitive and specific cerebrospinal fluid biomarker has yet to be defined which reliably distinguishes infective from non-infective inflammation. As a result, many patients with suspected infection are treated empirically with broad-spectrum antibiotics in the absence of definitive diagnostic criteria. To begin to address these issues, we examined cerebrospinal fluid taken at the point of clinical equipoise to diagnose cerebrospinal fluid infection in 14 consecutive neurosurgical patients showing signs of inflammatory complications. Using the guidelines of the Infectious Diseases Society of America, six cases were subsequently characterized as infected and eight as sterile inflammation. Twenty-four contemporaneous patients with idiopathic intracranial hypertension or normal pressure hydrocephalus were included as non-inflamed controls. We measured 182 immune and neurological biomarkers in each sample and used pathway analysis to elucidate the biological underpinnings of any biomarker changes. Increased levels of the inflammatory cytokine interleukin-6 and interleukin-6-related mediators such as oncostatin M were excellent indicators of inflammation. However, interleukin-6 levels alone could not distinguish between bacterially infected and uninfected patients. Within the patient cohort with neurological inflammation, a pattern of raised interleukin-17, interleukin-12p40/p70 and interleukin-23 levels delineated nosocomial bacteriological infection from background neuroinflammation. Pathway analysis showed that the observed immune signatures could be explained through a common generic inflammatory response marked by interleukin-6 in both nosocomial and non-infectious inflammation, overlaid with a toll-like receptor-associated and bacterial peptidoglycan-triggered interleukin-17 pathway response that occurred exclusively during infection. This is the first demonstration of a pathway dependent cerebrospinal fluid biomarker differentiation distinguishing nosocomial infection from background neuroinflammation. It is especially relevant to the commonly encountered pathologies in clinical practice, such as subarachnoid haemorrhage and post-cranial neurosurgery. While requiring confirmation in a larger cohort, the current data indicate the potential utility of cerebrospinal fluid biomarker strategies to identify differential initiation of a common downstream interleukin-6 pathway to diagnose nosocomial infection in this challenging clinical cohort.
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Affiliation(s)
- Simone M Cuff
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Joseph P Merola
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Jason P Twohig
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Matthias Eberl
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - William P Gray
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
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26
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Chen S, Xu P, Fang Y, Lenahan C. The Updated Role of the Blood Brain Barrier in Subarachnoid Hemorrhage: From Basic and Clinical Studies. Curr Neuropharmacol 2020; 18:1266-1278. [PMID: 32928088 PMCID: PMC7770644 DOI: 10.2174/1570159x18666200914161231] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a type of hemorrhagic stroke associated with high mortality and morbidity. The blood-brain-barrier (BBB) is a structure consisting primarily of cerebral microvascular endothelial cells, end feet of astrocytes, extracellular matrix, and pericytes. Post-SAH pathophysiology included early brain injury and delayed cerebral ischemia. BBB disruption was a critical mechanism of early brain injury and was associated with other pathophysiological events. These pathophysiological events may propel the development of secondary brain injury, known as delayed cerebral ischemia. Imaging advancements to measure BBB after SAH primarily focused on exploring innovative methods to predict clinical outcome, delayed cerebral ischemia, and delayed infarction related to delayed cerebral ischemia in acute periods. These predictions are based on detecting abnormal changes in BBB permeability. The parameters of BBB permeability are described by changes in computed tomography (CT) perfusion and magnetic resonance imaging (MRI). Kep seems to be a stable and sensitive indicator in CT perfusion, whereas Ktrans is a reliable parameter for dynamic contrast-enhanced MRI. Future prediction models that utilize both the volume of BBB disruption and stable parameters of BBB may be a promising direction to develop practical clinical tools. These tools could provide greater accuracy in predicting clinical outcome and risk of deterioration. Therapeutic interventional exploration targeting BBB disruption is also promising, considering the extended duration of post-SAH BBB disruption.
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Affiliation(s)
- Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - PengLei Xu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - YuanJian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - Cameron Lenahan
- Burrell College of Osteopathic Medicine, Las Cruces, NM, USA,Center for Neuroscience Research, School of Medicine, Loma Linda University, Loma Linda, CA, USA
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27
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Predictors of catheter-associated meningitis in pediatric patients after brain tumor surgery: A 10-year single center experience. J Neurol Sci 2020; 418:117100. [PMID: 32861083 DOI: 10.1016/j.jns.2020.117100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/22/2020] [Accepted: 08/14/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the incidence of catheter-associated meningitis (CAM) in a pediatric population receiving brain tumor surgery, and to identify the major risk factors involved. METHODS We retrospectively analyzed the medical and radiological records of 205 pediatric patients who received 251 external ventricular drains (EVDs) between January 2008 and December 2017. All patients less than 18 years old who underwent cerebrospinal fluid (CSF) diversion in the course of brain tumor surgery were included. Patients with central nervous system infection (CNS) at the time of EVD insertion were excluded. RESULTS A total of 99 patients receiving 107 EVDs met the study selection criteria. Among this population, the incidence of CAM was 19.2%. Median time-to-infection was 5 days. CAM prolonged the period of drainage in 57.9% of the cases. An extended ICU stay (>3 days) was statistically significantly associated with the occurrence of CAM. In the multivariate analysis, the presence of a high-grade CNS tumor was a predictor of an extended intensive care unit (ICU) stay. Furthermore, CSF leakage along the catheter tunnel was an independent predictor of CAM. CONCLUSION Our data confirms CAM as a significant complication in the acute treatment of hydrocephalus associated with pediatric brain tumors. To limit the incidence of CAM, measures must be taken to prevent CSF leakage, particularly among patients with high-grade CNS tumors that are likely to stay longer in the ICU and need prompt postoperative radiotherapy and oncological treatment.
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Association of Dexamethasone with Shunt Requirement, Early Disability, and Medical Complications in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2020; 34:760-768. [PMID: 32851604 DOI: 10.1007/s12028-020-01059-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/21/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND PURPOSE Current guidelines do not support the routine use of corticosteroids in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, corticosteroids use in aSAH has been practiced at some centers by convention. The aim of the study was to determine the incidence of hydrocephalus requiring ventriculoperitoneal shunt (VPS) placement as well as functional outcome on discharge and adverse events attributed to corticosteroids in patients with aSAH treated with different dexamethasone (DXM) treatment schemes. METHODS We retrospectively analyzed 206 patients with aSAH stratified to three groups based on the DXM treatment scheme: no corticosteroids, short course of DXM (S-DXM; 4 mg every 6 h for 1 day followed by a daily total dose reduction by 25% and then by 50% on last day), and long course of DXM (L-DXM; 4 mg every 6 h for 5-7 days followed by reduction by 50% every other day). The primary outcome measure was the placement of a VPS, and the secondary outcome was a good functional outcome [modified Rankin Scale (mRS) 0-3] at hospital discharge. Safety measures were the incidence of infection (pneumonia, urinary tract infection, ventriculitis, meningitis), presence of delirium, and hyperglycemia. RESULTS There was no difference in the rate of external ventricular drain (EVD) (p = 0.164) and VPS placement (p = 0.792), nor in the rate of good outcome (p = 0.928) among three defined treatment regimens. Moreover, the median duration of treatment with EVD did not differ between subjects treated with no corticosteroids, S-DXM, and L-DXM (p = 0.905), and the probability of EVD removal was similar when stratified according to treatment regimens (log-rank; p = 0.256). Patients who received L-DXM had significantly more complications as compared to patients, who received no corticosteroids or S-DXM (78.4% vs. 58.6%; p = 0.005). After adjustment, L-DXM remained independently associated with increased risk of combined adverse events (OR = 2.72; 95%CI, 1.30-5.72; p = 0.008), infection (OR = 3.45; 95%CI, 1.63-7.30; p = 0.001) and hyperglycemia (OR = 2.05; 95%CI, 1.04-4.04; p = 0.039). CONCLUSIONS DXM use among patients with aSAH did not relate to the rate of EVD and VPS placement, duration of EVD treatment, and functional disability at discharge but increased the risk of medical complications.
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Antimicrobial Essential Oil Formulation: Chitosan Coated Nanoemulsions for Nose to Brain Delivery. Pharmaceutics 2020; 12:pharmaceutics12070678. [PMID: 32709076 PMCID: PMC7407154 DOI: 10.3390/pharmaceutics12070678] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/14/2020] [Accepted: 07/14/2020] [Indexed: 12/26/2022] Open
Abstract
Brain infections as meningitis and encephalitis are attracting a great interest. Challenges in the treatment of these diseases are mainly represented by the blood brain barrier (BBB) that impairs the efficient delivery of even very potent drugs to reach the brain. The nose to the brain administration route, is a non-invasive alternative for a quick onset of action, and enables the transport of numerous medicinal agents straight to the brain thus workarounding the BBB through the highly vascularized olfactory region. In this report, Thymus vulgaris and Syzygium aromaticum essential oils (EOs) were selected to be included in chitosan coated nanoemulsions (NEs). The EOs were firstly analyzed to determine their chemical composition, then used to prepare NEs, that were deeply characterized in order to evaluate their use in intranasal administration. An in vitro evaluation against a collection of clinical isolated bacterial strains was carried out for both free and nanoemulsioned EOs. Chitosan coated NEs showed to be a potential and effective intranasal formulation against multi-drug resistant Gram-negative bacteria such as methicillin-susceptible Staphylococcus aureus and multi-drug resistant Gram-negative microorganisms including carbapenem-resistant Acinetobacter baumannii and Klebsiella pneumoniae.
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30
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Blassmann U, Hope W, Roehr AC, Frey OR, Vetter-Kerkhoff C, Thon N, Briegel J, Huge V. CSF penetration of vancomycin in critical care patients with proven or suspected ventriculitis: a prospective observational study. J Antimicrob Chemother 2020; 74:991-996. [PMID: 30689877 DOI: 10.1093/jac/dky543] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 11/27/2018] [Accepted: 11/27/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Vancomycin is recommended for ventriculitis. However, penetration into the CNS is relatively poor. OBJECTIVES To investigate the population pharmacokinetics of vancomycin in serum and CSF in critical care patients with proven or suspected CNS infections from neurosurgical procedures. PATIENTS AND METHODS This was an observational pharmacokinetic study in critical care patients with proven or suspected CNS infections receiving intravenous vancomycin. Multiple blood and intraventricular CSF samples were collected. Population pharmacokinetic analysis and simulation were undertaken with ADAPT5 and Pmetrics. RESULTS A total of 187 blood and CSF samples were collected from 21 patients. The median (range) Cmax and Cmin concentrations in serum were 25.67 (10.60-50.78) and 9.60 (4.46-23.56) mg/L, respectively, with a median daily dose of 2500 (500-4000) mg. The corresponding median concentrations in CSF were 0.65 (<0.24-3.83) mg/L and 0.58 (<0.24-3.95) mg/L, respectively. The median AUC0-24 in serum and CSF was 455.09 and 14.10 mg·h/L, respectively. A three-compartment linear population pharmacokinetic model best fitted the observed data. Vancomycin demonstrated poor penetration into CSF, with a median CSF/serum ratio of 3% and high intersubject pharmacokinetic variability of its penetration. CONCLUSIONS Therapeutic drug monitoring in both serum and CSF and higher daily doses may be an option to ensure adequate trough levels and to optimize patient therapy. Novel dosing strategies designed to reduce renal toxicity, such as administration by continuous infusion, should be investigated in further clinical studies to avoid antibiotic underexposure in CSF.
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Affiliation(s)
- Ute Blassmann
- Department of Pharmacy, University Hospital of Heidelberg, Im Neuenheimer Feld 670, Heidelberg, Germany
| | - William Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Sherington Building, Liverpool, UK
| | - Anka C Roehr
- Department of Pharmacy, Heidenheim General Hospital, Schlosshausstrasse 100, Heidenheim, Germany
| | - Otto R Frey
- Department of Pharmacy, Heidenheim General Hospital, Schlosshausstrasse 100, Heidenheim, Germany
| | - Cornelia Vetter-Kerkhoff
- Department of Pharmacy, University Hospital, LMU Munich, Marchioninistrasse 15, Muenchen, Germany
| | - Niklas Thon
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, Muenchen, Germany
| | - Josef Briegel
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, Muenchen, Germany
| | - Volker Huge
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, Muenchen, Germany
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Piva S, Di Paolo A, Galeotti L, Ceccherini F, Cordoni F, Signorini L, Togni T, De Nicolò A, Rasulo FA, Fagoni N, Latronico N, D'Avolio A. Daptomycin Plasma and CSF Levels in Patients with Healthcare-Associated Meningitis. Neurocrit Care 2020; 31:116-124. [PMID: 30607829 DOI: 10.1007/s12028-018-0657-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND There are currently few data concerning the cerebrospinal fluid (CSF) penetration of daptomycin in patients with healthcare-associated meningitis. This study aims (1) to better characterize the pharmacokinetics of daptomycin in humans during a 7-day intravenous (IV) therapy course, and (2) to study the penetration of daptomycin in the CSF after IV infusion at the dose of 10 mg/kg. RESULTS In this prospective observational study, we enrolled nine patients with an implanted external ventricular drainage and a diagnosis of a healthcare-associated meningitis. Daptomycin was administered at 10 mg/kg for a maximum of 7 days. The pharmacokinetic of daptomycin was studied using a two-compartment population/pharmacokinetic (POP/PK) model and by means of a nonlinear mixed effects modeling approach. A large inter-individual variability in plasma area under the curve (Range: 574.7-1366.3 h mg/L), paralleled by high-peak plasma concentration (Cmax) (all values > 60 mg/L), was noted. The inter-individual variability of CSF-AUC although significant (range: 1.17-6.81 h mg/L) was narrower than previously reported and with a late occurrence of CSF-Cmax (range: 6.04-9.54 h). The terminal half-life between plasma and CSF was similar. tmax values in CSF did not show a high inter-individual variability, and the fluctuations of predicted CSF concentrations were minimal. The mean value for daptomycin penetration obtained from our model was 0.45%. CONCLUSIONS Our POP/PK model was able to describe the pharmacokinetics of daptomycin in both plasma and CSF, showing that daptomycin (up to 7 days at 10 mg/kg) has minimal penetration into central nervous system. Furthermore, the observed variability of AUC, tmax and predicted concentration in CSF was lower than what previously reported in the literature. Based on the present findings, it is unlikely that daptomycin could reach CSF concentrations high enough to have clinical efficacy; this should be tested in future studies.
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Affiliation(s)
- S Piva
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Spedali Civili di Brescia 1, Brescia, Italy. .,Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazza del Mercato, 15, Brescia, Italy.
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, Section of Pharmacology, University of Pisa, Via Roma, 67, Pisa, Italy
| | - Laura Galeotti
- Phymtech Srl (Physical and Mathematical Technologies), Via Giuntini 63, Navacchio di Cascina, Pisa, Italy
| | - Francesco Ceccherini
- Phymtech Srl (Physical and Mathematical Technologies), Via Giuntini 63, Navacchio di Cascina, Pisa, Italy
| | - Francesco Cordoni
- Phymtech Srl (Physical and Mathematical Technologies), Via Giuntini 63, Navacchio di Cascina, Pisa, Italy
| | - Liana Signorini
- Second Division of Clinical Infectious Diseases, Department of Infectious Diseases, Spedali Civili University Hospital, Piazzale Spedali Civili di Brescia, Brescia, Italy
| | - Tommaso Togni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Spedali Civili di Brescia 1, Brescia, Italy
| | - Amedeo De Nicolò
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Frank A Rasulo
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Spedali Civili di Brescia 1, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazza del Mercato, 15, Brescia, Italy
| | - Nazzareno Fagoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Spedali Civili di Brescia 1, Brescia, Italy
| | - N Latronico
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Spedali Civili di Brescia 1, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazza del Mercato, 15, Brescia, Italy
| | - Antonio D'Avolio
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
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Utility of the Cell Index in Predicting External Ventricular Drain-Related Ventriculo-Meningitis. Neurocrit Care 2020; 33:776-784. [PMID: 32314243 DOI: 10.1007/s12028-020-00964-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND/OBJECTIVE Ventriculo-meningitis (VM) is an important complication of external ventricular drains (EVDs) in neurosurgical patients. Consequences include increased morbidity, mortality, and duration of hospital stay. Early diagnosis of EVD-associated VM allows earlier treatment intervention. The cell index (CI) may provide a simple measure that overcomes the limitations of isolated cerebrospinal fluid (CSF) parameters and other diagnostic tests, allowing earlier prediction of VM. METHODS All patients admitted to a tertiary hospital and requiring EVD insertion during 2015 and 2016 were assessed for inclusion in this retrospective case-control study. Patients with a known or suspected intracranial infection were excluded. Of the 186 patients who underwent EVD insertion, 95 patients were included in the final cohort. Data pertaining to patient characteristics and laboratory indices were extracted from health records and the microbiology laboratory database. The CI was calculated as the ratio of temporally related CSF leukocytes/erythrocytes to peripheral blood leukocytes/erythrocytes. Data from patients with microbiologically confirmed VM were analyzed in comparison with those not developing VM during the course of their stay. Categorical and continuous variables with skewed distributions were analyzed by Chi square and Mann-Whitney tests, respectively. RESULTS EVD-associated VM developed in 7.4% of patients. The highest CSF CI (within 3 days prior to diagnosis of VM or at any time for those not developing VM) differed significantly between the two groups (16; IQR 10.8-48.5 vs. 3.3; IQR 1.0-12.8, respectively; p = .046). The area under the receiver operating characteristic curve (AUROC) for the highest CI was 0.727 (95% confidence interval [CI] 0.526-0.929; p = .027). A CI of 10.4 provided a sensitivity and specificity of 80.5% and 70.5%, respectively, for the early diagnosis of VM. CONCLUSIONS In neurosurgical patients with an EVD, the CSF CI significantly predicted the development of VM.
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Evaluation of a commercial multiplex PCR for diagnosis of central nervous system (CNS) nosocomial infections. J Microbiol Methods 2020; 171:105865. [PMID: 32057898 DOI: 10.1016/j.mimet.2020.105865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/09/2020] [Accepted: 02/09/2020] [Indexed: 11/22/2022]
Abstract
Nosocomial Central Nervous System (CNS) infections are often serious complications of neurosurgical procedures. Their diagnosis is complex and frequently based on microbiological culture. The aim of this work was to evaluate the effectiveness of the FilmArray® Blood Culture Identification (BCID) panel, a multiplex PCR designed to identify the most common etiologic agents of sepsis involved with nosocomial CNS infections. A total of ninety samples were analyzed with the BCID panel. The sensitivity and specificity achieved were 77.4% and 100% respectively, when compared with the reference method (culture). Based on the analysis of the melting curves, another cut-off was established improving sensitivity to 83.9% whilst maintaining 98.3% specificity. The BCID panel seems to be a helpful tool for the prompt diagnosis of CNS nosocomial infections. The cut-off proposed here can increase sensitivity, but further studies are required to confirm its effectiveness and its applicability in clinical microbiology laboratories.
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Kim J, Lee J, Feng R, Chartrain A, Sobotka S, Griffiths S, Weiss N, Dangayach N, Bederson J, Mayer SA, Gordon E. Ventricular Catheter Tract Hemorrhage as a Risk Factor for Ventriculostomy-Related Infection. Oper Neurosurg (Hagerstown) 2020; 18:69-74. [PMID: 31294451 DOI: 10.1093/ons/opz148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 01/08/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Ventriculostomy-related infection (VRI) is a feared complication of external ventricular drain (EVD) placement. Although many contributing factors to VRI have been examined, little is known whether there is an association between ventriculostomy-related catheter tract hemorrhage (VCTH) and VRI. OBJECTIVE To evaluate risk factors for VRI and assess possible correlations with VCTH. METHODS We performed a retrospective analysis of patients with EVD placement in a neurocritical care unit between 2011 and 2015. VRI was defined as clinical signs of infection with a positive cerebrospinal fluid gram stain and isolation of cerebrospinal fluid culture. VCTH was diagnosed by computed tomography immediately after EVD insertion. RESULTS A total of 247 patients with EVD were identified during the 5-yr study period. An association between VCTH and gram-negative VRI was identified (P = .02). Ten percent (25 of 247 patients) developed a VRI, and 7% (18 of 247 patients) had a VCTH. Of the 25 patients with VRI, 20% (n = 5) had a VCTH, compared to 6% (n = 13) of 222 patients who had an EVD placed but did not develop VRI. There were no significant differences in demographic and clinical factors except for multiple EVD insertions (P < .00001), EVD duration (P < .001), and hospital length of stay (P < .001). CONCLUSION VCTH is a potentially significant risk factor for VRI. Further analysis will be needed to confirm the strength of this association, and to delineate the possible mechanisms by which tract hemorrhage may serve as a nidus for bacterial penetration into the central nervous system.
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Affiliation(s)
- Julie Kim
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - James Lee
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Rui Feng
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alexander Chartrain
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stanislaw Sobotka
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephen Griffiths
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nirit Weiss
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Neha Dangayach
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joshua Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, Detroit, Michigan
| | - Errol Gordon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
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Brotis AG, Churis I, Karvouniaris M. Local complications of adjunct intrathecal antibiotics for nosocomial meningitis associated with gram-negative pathogens: a meta-analysis. Neurosurg Rev 2019; 44:139-152. [PMID: 31875280 DOI: 10.1007/s10143-019-01226-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/21/2019] [Accepted: 12/11/2019] [Indexed: 10/25/2022]
Abstract
Direct delivery of antibiotics to the ventricular system offers an alternative for the management of nosocomial meningitis. However, the available literature frequently results in controversial findings regarding its safety. The present meta-analysis aimed at summarizing the risk of local complications after the administration of intraventricular/intrathecal (IVT/IT) antibiotics for the treatment of ventriculitis/meningitis (VM) associated with gram-negative pathogens. We systematically searched the medical literature from 1964 until July 2018, for clinical studies reporting on complications after the index treatment. The quality of the eligible studies was classified as "high," "moderated," and "low" for randomized controlled trials, observational studies, and case series, respectively. The results were summarized as pooled frequencies, estimated by the random- or fixed-effects models, according to the inter-study heterogeneity. The publication bias was visualized in trim-and-fill funnel plots. Τhe analysis included twenty-three primary studies with 229 patients. The overall complication rate was as high as 0.13 (95% CI 0.08; 0.19, I2 = 9%); chemical meningitis and seizures represented the majority of the complications, with an occurrence rate of 0.11 (95% CI 0.07; 0.17, I2 = 0%) and 0.07 (95% CI 0.04; 0.12; I2 = 0%), respectively. The meta-analysis was based on studies of "moderate" and "low" reporting quality, while the publication bias after inspecting of the funnel plots revealed significant asymmetry. The present review denotes the absence of large, high-quality studies in the field. Nevertheless, IVT/IT was associated with moderate morbidity, mainly attributed to chemical meningitis and seizures. Further high-quality studies are still required before this therapeutic modality becomes broadly established.
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Affiliation(s)
- Alexandros G Brotis
- Department of Neurosurgery, University Hospital of Larissa, Biopolis, Larissa, Greece.
| | - Isaac Churis
- Intensive Care Unit, General Hospital of Giannitsa, Giannitsa, Greece
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Lu P, Raynald, Liu W, Gong J, Sun T, Li C, Ma Ruf L, Fan Y, Zhu R, Tian Y. Risk Factors of External Ventricular Drainage-Related Infections: A Retrospective Study of 147 Pediatric Post-tumor Resection Patients in a Single Center. Front Neurol 2019; 10:1243. [PMID: 31849815 PMCID: PMC6892983 DOI: 10.3389/fneur.2019.01243] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 11/07/2019] [Indexed: 11/24/2022] Open
Abstract
Background: External ventricular drainage (EVD) is common after brain surgery. However, the incidence of EVD-related infection (ERI) is still relatively high and can increase morbidity and mortality. Objective: The objective of this study was to analyze ERI factors in pediatric population post-brain tumor surgery. Methods: From January 2016 to December 2017, 147 patients <18 years old underwent tumor removal at Beijing Tiantan Hospital and had postoperative EVD. We recorded basic demographic data as well as several risk factors. We then analyzed whether these factors were related to ERI. Results: Patients with a preoperative ventriculo-peritoneal (V-P) shunt, those with longer operation time, those who received blood transfusion, those with more frequent cerebrospinal fluid (CSF) sampling, and those with longer indwelling time of EVD had higher risks of infection (p < 0.05). Logistic regression analysis confirmed that a preoperative V-P shunt, operative duration, intraoperative blood transfusion, frequency of CSF sampling, and EVD duration were correlated with postoperative ERI (p < 0.05). Conclusion: EVD should be removed as soon as possible and any unnecessary procedures should be avoided to reduce the infection rate. However, prophylactic treatment should be given in case patients do not meet the indication for EVD removal.
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Affiliation(s)
- Pengwei Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Gong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tao Sun
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunde Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lukman Ma Ruf
- Department of Neurosurgery, Gatot Subroto Central Army Hospital, Jakarta, Indonesia
| | - Yanzhu Fan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruifang Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongji Tian
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Lenski M, Biczok A, Neufischer K, Tonn JC, Briegel J, Thon N. Significance of cerebrospinal fluid inflammatory markers for diagnosing external ventricular drain–associated ventriculitis in patients with severe traumatic brain injury. Neurosurg Focus 2019; 47:E15. [DOI: 10.3171/2019.8.focus19407] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 08/23/2019] [Indexed: 11/06/2022]
Abstract
ObjectiveThe aim of this study was to investigate the diagnostic potential of the inflammatory markers interleukin-6 (IL-6), total leukocyte count (TLC), and protein in the CSF and IL-6, C-reactive protein, and white blood cell count in the serum for the early diagnosis of ventriculitis in patients with traumatic brain injury (TBI) and an external ventricular drain compared with patients without ventriculitis.MethodsRetrospective data from 40 consecutive patients with TBI and an external ventricular drain treated in the authors’ intensive care unit between 2013 and 2017 were analyzed. For all markers, arithmetical means and standard deviations, area under the curve (AUC), cutoff values, sensitivity, specificity, positive likelihood ratio (LR), and negative LR were calculated and correlated with presence or absence of ventriculitis.ResultsThere were 35 patients without ventriculitis and 5 patients with ventriculitis. The mean ± SD IL-6 concentration in CSF was significantly increased, with 6519 ± 4268 pg/mL at onset of ventriculitis compared with 1065 ± 1705 pg/mL in patients without ventriculitis (p = 0.04). Regarding inflammatory markers in CSF, IL-6 showed the highest diagnostic potential for differentiation between the presence and absence of ventriculitis (AUC 0.938, cutoff 4064 pg/mL, sensitivity 100%, specificity 92.3%, positive LR 13, and negative LR 0), followed by TLC (AUC 0.900, cutoff 64.5 /µL, sensitivity 100%, specificity 80%, positive LR 5.0, and negative LR 0) and protein (AUC 0.876, cutoff 31.5 mg/dL, sensitivity 100%, specificity 62.5%, positive LR 2.7, and negative LR 0).ConclusionsThe level of IL-6 in CSF has the highest diagnostic value of all investigated inflammatory markers for detecting ventriculitis in TBI patients at an early stage. In particular, CSF IL-6 levels higher than the threshold of 4064 pg/mL were significantly associated with the probability of ventriculitis.
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Affiliation(s)
| | | | | | | | - Josef Briegel
- 2Anästhesiologische Klinik, Klinikum Großhadern, Ludwig Maximilian Universität München, Munich, Germany
| | - Niklas Thon
- 1Neurochirurgische Klinik und Poliklinik, and
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Oertel JMK, Huelser MJM. Telemetric home monitoring of intracranial pressure-where are we now. Acta Neurochir (Wien) 2019; 161:1603-1604. [PMID: 31187266 DOI: 10.1007/s00701-019-03962-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Joachim M K Oertel
- Department of Neurosurgery, Saarland University Medical Center, Kirrbergerstrasse, Building 90.5, 66421, Homburg, Germany.
- Faculty of Medicine, Saarland University, Saarbrücken, Germany.
| | - Matthias J M Huelser
- Department of Neurosurgery, Saarland University Medical Center, Kirrbergerstrasse, Building 90.5, 66421, Homburg, Germany
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Infections of the Central Nervous System in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Nag DS, Sahu S, Swain A, Kant S. Intracranial pressure monitoring: Gold standard and recent innovations. World J Clin Cases 2019; 7:1535-1553. [PMID: 31367614 PMCID: PMC6658373 DOI: 10.12998/wjcc.v7.i13.1535] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/11/2019] [Accepted: 05/23/2019] [Indexed: 02/05/2023] Open
Abstract
Intracranial pressure monitoring (ICP) is based on the doctrine proposed by Monroe and Kellie centuries ago. With the advancement of technology and science, various invasive and non-invasive modalities of monitoring ICP continue to be developed. An ideal monitor to track ICP should be easy to use, accurate, reliable, reproducible, inexpensive and should not be associated with infection or haemorrhagic complications. Although the transducers connected to the extra ventricular drainage continue to be Gold Standard, its association with the likelihood of infection and haemorrhage have led to the search for alternate non-invasive methods of monitoring ICP. While Camino transducers, Strain gauge micro transducer based ICP monitoring devices and the Spiegelberg ICP monitor are the emerging technology in invasive ICP monitoring, optic nerve sheath diameter measurement, venous opthalmodynamometry, tympanic membrane displacement, tissue resonance analysis, tonometry, acoustoelasticity, distortion-product oto-acoustic emissions, trans cranial doppler, electro encephalogram, near infra-red spectroscopy, pupillometry, anterior fontanelle pressure monitoring, skull elasticity, jugular bulb monitoring, visual evoked response and radiological based assessment of ICP are the non-invasive methods which are assessed against the gold standard.
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Affiliation(s)
- Deb Sanjay Nag
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Seelora Sahu
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Amlan Swain
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Shashi Kant
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
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Nisson PL, James WS, Gaub MB, Borgstrom M, Weinand M, Anton R. Peripheral white blood cell count as a screening tool for ventriculostomy-related infections. J Clin Neurosci 2019; 67:52-58. [PMID: 31266718 DOI: 10.1016/j.jocn.2019.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 03/28/2019] [Accepted: 06/09/2019] [Indexed: 10/26/2022]
Abstract
One of the most common complications following external ventricular drain (EVD) placement is infection. Routine cultures of cerebrospinal fluid (CSF) are often used to screen for infection, however several days may pass before infection is discovered. In this study, we compared the predictive value of daily recorded vital sign parameters and peripheral white blood count (WBC) in identifying ventriculostomy-related infections. Patients with EVDs who had CSF cultures for microorganisms performed between January 2011 and July 2017 were assigned to either an infected and/or uninfected study group. Clinical parameters were then compared using t-test, chi squared and multiple logistic regression analyses. Patients of any age and gender were included. One hundred seventy uninfected and 10 infected subjects were included in the study. Nine of the 10 infected patients had an elevated WBC (>10.4 × 103/μL), with a significantly greater WBC (15.9 × 103/μL) than the uninfected group (10.4 × 103/μL) (p-value ≤ 0.0001). Using logistic regression, we found no association between patient vital signs and CSF infection except for WBC (p = .003). As a diagnostic marker for CSF infection, the sensitivity and specificity of WBC elevation greater than 15 × 103/μL was 70% (7/10) and 90.2% (147/163), respectively. This study serves as a 'proof of concept' that WBC could be useful as potential screening tool for early detection of CSF infection post-EVD placement. Future investigation using a large, multicenter prospective study is needed to further assess the applicability of this parameter.
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Affiliation(s)
- Peyton L Nisson
- University of Arizona, College of Medicine, Tucson, AZ, United States; Department of Neurosurgery, Cedars-Sinai, Beverly Hills, CA, United States.
| | | | - Michael B Gaub
- University of Arizona, College of Medicine, Tucson, AZ, United States.
| | - Mark Borgstrom
- University Information Technology Services, University of Arizona, Tucson, AZ, United States.
| | - Martin Weinand
- University of Arizona, College of Medicine, Tucson, AZ, United States.
| | - Rein Anton
- University of Arizona, College of Medicine, Tucson, AZ, United States.
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Modi S, Shah K, Schultz L, Tahir R, Affan M, Varelas P. Cost of hospitalization for aneurysmal subarachnoid hemorrhage in the United States. Clin Neurol Neurosurg 2019; 182:167-170. [PMID: 31151045 DOI: 10.1016/j.clineuro.2019.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/13/2019] [Accepted: 05/19/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Recent large-scale studies describing hospitalization cost trends secondary to aneurysmal subarachnoid hemorrhage (aSAH) in the United States are lacking. We sought to discover the impact of aSAH-related factors upon its hospitalization cost. PATIENTS AND METHODS Patients with a primary diagnosis of aSAH were selected utilizing the National Inpatient Sample. Regression analyses were used to evaluate the impact of aSAH-related factors on hospitalization costs. RESULTS From 2002-2014, 22,831 cases of aSAH were identified. The inflation-adjusted mean cost of hospitalization was $82,514 (standard deviation ± $54,983). The proportion of males was lower (31%), but a higher cost of $3385 (± $685; p < .001) remained compared to females. Median length of hospitalization was 16 days (interquartile range 11-23) and each day increase in hospitalization was associated with a cost increase of $3228 (± $19; p < .001). There was no difference in cost between patients undergoing aneurysmal coiling or clipping. When compared to patients < 40 years old, the increase in cost for patients 40-59 years old was $3829 (± $914; p < .001), and $4573 (± $1033; p < .001) for patients 60-79 years old; however, for patients ≥ 80 years old, there was a decrease in cost of $8124 (± $1722; p < .001). Several central nervous system complications were also associated with increased cost. CONCLUSION aSAH is a significant financial burden on the United States healthcare system. We were able to identify many important factors associated with higher costs, and these results may help us understand resource utilization and develop future cost-reduction strategies.
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Affiliation(s)
- Sumul Modi
- Department of Neurology, Henry Ford Macomb Hospital, 15855 19 Mile Road, Clinton Township, MI, 48038, United States
| | - Kavit Shah
- Department of Neurology, University of Pittsburgh Medical Center, 811 Kaufmann Medical Building, 3471 Fifth Avenue, Pittsburgh, PA, 15213, United States
| | - Lonni Schultz
- Departments of Public Health Sciences, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI, 48202, United States
| | - Rizwan Tahir
- Departments of Neurosurgery, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI, 48202, United States.
| | - Muhammad Affan
- Departments of Neurology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI, 48202, United States
| | - Panayiotis Varelas
- Departments of Neurology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI, 48202, United States
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Groselj-Grenc M, Derganc M, Kopitar AN, Pavcnik M. Neutrophil CD64 index in cerebrospinal fluid as a marker of bacterial ventriculitis in children with external ventricular drainage. BMC Pediatr 2019; 19:132. [PMID: 31023301 PMCID: PMC6485067 DOI: 10.1186/s12887-019-1497-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 04/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background Bacterial ventriculitis is a common complication in children with temporary external ventricular drains (EVD) and the diagnosis is challenging. The present study compared the diagnostic accuracy of novel cerebrospinal fluid (CSF) marker - CD64 expression on neutrophils measured as neutrophil CD64 index (CD64in) to routine laboratory CSF and blood markers for bacterial ventriculitis in children with EVD. Methods We conducted a prospective, observational study, enrolling children with EVD. CD64in in CSF together with CSF markers (leukocyte count, percentage of neutrophils, glucose, and proteins) and blood markers (leukocyte and differential count, C-reactive protein (CRP), and procalcitonin (PCT)) were studied at the time of suspected bacterial ventriculitis. CD64in was measured by flow cytometry. Diagnostic accuracy determined by the area under the receiver–operating characteristic (ROC) curves (AUC) was defined for each marker. Results Thirty-three episodes of clinically suspected ventriculitis in twenty-one children were observed during a 26-month period. Episodes were classified into those with microbiologically proven ventriculitis (13 episodes) and into those with microbiologically negative CSF (20 episodes). CD64in and leukocyte count were the only CSF markers that could differentiate between groups with diagnostic accuracy of 0.875 and 0.694, respectively. Among blood markers only CRP and band neutrophils differentiated between groups with diagnostic accuracy of 0.792 and 0.721, respectively. Conclusions CD64in in CSF is a promising diagnostic marker of bacterial ventriculitis in children with EVD as it has higher diagnostic accuracy than routine blood and CSF markers for diagnosing bacterial ventriculitis at the time of clinical suspicion.
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Affiliation(s)
- Mojca Groselj-Grenc
- Department of Paediatric Surgery and Intensive Care, University Medical Centre, Bohoriceva 20, 1525, Ljubljana, Slovenia.
| | - Metka Derganc
- Department of Paediatric Surgery and Intensive Care, University Medical Centre, Bohoriceva 20, 1525, Ljubljana, Slovenia
| | - Andreja Natasa Kopitar
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Zaloska 4, 1000, Ljubljana, Slovenia
| | - Maja Pavcnik
- Department of Paediatric Surgery and Intensive Care, University Medical Centre, Bohoriceva 20, 1525, Ljubljana, Slovenia.,Faculty of Medicine - Division of Pediatrics, University of Ljubljana, Vrazov trg 2, 1104, Ljubljana, Slovenia
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Olguner SK, Boyar B, Alabaz D, Erman T, Oktay K, Arslan A, Bilgin E, Okten AI. Tumor necrosis factor alpha and interleukin-1 beta levels in cerebrospinal fluid examination for the diagnosis of ventriculoperitoneal shunt-related ventriculitis. Childs Nerv Syst 2019; 35:629-636. [PMID: 30687902 DOI: 10.1007/s00381-019-04070-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 01/20/2019] [Indexed: 01/01/2023]
Abstract
PURPOSE Ventriculitis is known to develop after chronic inflammation and bacterial invasion of the ventricular surface with a recurrence of shunt infections. The aim of this study is to evaluate the diagnostic value of elevation in cerebrospinal fluid (CSF) interleukin-1 beta (IL-1β) and tumor necrosis factor alpha (TNF-α) together with CSF culture and laboratory test results in the diagnosis of ventriculoperitoneal (VP) shunt-related ventriculitis, which is known to be more problematic than conventional shunt infection. METHODS The study included a total of 34 patients with a VP shunt due to hydrocephalus, who presented with a headache, fever, and shunt infection at the Emergency Department and had a pre-diagnosis of ventriculitis. Nineteen patients were diagnosed with shunt-related infection or ventriculitis using the CSF obtained from the shunt pump. The IL-1β and TNF-α levels from the CSF samples of all patients were measured using the Micro ELISA immunoassay method. RESULTS CSF direct microscopic observation revealed that the mean cell count, IL-1β level, CRP level, and blood leukocyte level were higher in patients with ventriculitis compared to those diagnosed with shunt infection (p = 0.02, p = 0.009, p = 0.004, and p = 0.009, respectively). The probability of predicting positive culture outcome was 92.7% with 90.9% sensitivity and 82.6% specificity when IL-1β values exceeded 4.0 pg/ml. TNF-α values did not show a significant, reliable pattern compared to IL-1β. CONCLUSIONS IL-1β is a reliable parameter which shall be used in the diagnosis of ventriculitis by predicting positive culture outcome with high sensitivity and specificity.
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Affiliation(s)
- Semih K Olguner
- Department of Neurosurgery, Adana City Training Research Hospital, Adana, Turkey.
| | - Bulent Boyar
- Department of Neurosurgery, Cukurova University of Medical School, Adana, Turkey
| | - Derya Alabaz
- Pediatric Infectious Disease Department, Cukurova University of Medical School, Adana, Turkey
| | - Tahsin Erman
- Department of Neurosurgery, Cukurova University of Medical School, Adana, Turkey
| | - Kadir Oktay
- Department of Neurosurgery, Medical Park Hospital, Gaziantep, Turkey
| | - Ali Arslan
- Department of Neurosurgery, Adana City Training Research Hospital, Adana, Turkey
| | - Emre Bilgin
- Department of Neurosurgery, Adana City Training Research Hospital, Adana, Turkey
| | - Ali Ihsan Okten
- Department of Neurosurgery, Adana City Training Research Hospital, Adana, Turkey
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Sorinola A, Buki A, Sandor J, Czeiter E. Risk Factors of External Ventricular Drain Infection: Proposing a Model for Future Studies. Front Neurol 2019; 10:226. [PMID: 30930840 PMCID: PMC6428739 DOI: 10.3389/fneur.2019.00226] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 02/22/2019] [Indexed: 11/23/2022] Open
Abstract
Background: External ventricular drain (EVD) has a major role in the management and monitoring of intracranial pressure (ICP) and its major complication is EVD infection. The risk factors for EVD infection are still a major topic of controversy, hence the need for further research. Objective: The objective of this review was to identify risk factors that affect the incidence of EVD infection and create a model, which can be used in future studies in order to contribute to elaborations on guideline for EVD. Methods: A PubMed and Google Scholar literature search was performed and data were extracted from studies published from 1966 through 2017. The search of the databases generated 604 articles and 28 articles of these were found to be relevant. A manual search of the 28 relevant papers generated 4 new articles. Of the 32 relevant articles, 20 articles that performed a multivariate analysis of the suspected risk factors of EVD infection and had a positive culture as a mandatory component in diagnosis were selected for data collection and analysis. Results: Because reviewed papers investigated only a few influencing factors, and could not determine convincingly the real risk factors of EVD infection and their real strengths. A total of 15 supposed influencing factors which includes: age, age & sex interactions, coinfection, catheter insertion outside the hospital, catheter type, CSF leakage, CSF sampling frequency, diagnosis, duration of catheterization, ICP > 20 mmHg, irrigation, multiple catheter, neurosurgical operation, reduced CSF glucose at catheter insertion and sex were identified. Conclusion: This review summarizes a set of variables which have to be covered by future clinical epidemiological investigations in order to describe the etiological background of EVD infection.
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Affiliation(s)
- Abayomi Sorinola
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
| | - Andras Buki
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Janos Sandor
- Department of Bio-statistics and Epidemiology, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Endre Czeiter
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary.,MTA PTE Clinical Neuroscience MR Research Group, University of Pécs, Pécs, Hungary
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Corrected white blood cell count, cell index, and validation of a clinical model for the diagnosis of health care-associated ventriculitis and meningitis in adults with intracranial hemorrhage. Clin Neurol Neurosurg 2019; 178:36-41. [DOI: 10.1016/j.clineuro.2019.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/11/2019] [Accepted: 01/20/2019] [Indexed: 11/23/2022]
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Haber MA, Abd-El-Barr M, Gormley W, Mukundan S, Sodickson AD, Potter CA. Neurosurgical complications: what the radiologist needs to know. Emerg Radiol 2019; 26:331-340. [PMID: 30761443 DOI: 10.1007/s10140-019-01672-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
Visits to the emergency department by patients who have recently undergone neurosurgery are a common occurrence, and these patients frequently receive emergent cross-sectional head imaging in order to evaluate for complications. Different neurosurgical approaches may have typical postoperative imaging findings that can be confused with pathology. Furthermore, particular abnormal postoperative imaging findings may signal an evolving complication. It is essential for the radiologist to understand common neurosurgical procedures and their potential complications in order to provide proper diagnostic evaluation of the postoperative neurosurgical patient. The purpose of this review is to assist radiologists in the evaluation of the postoperative neurosurgical patient and educate them on associated complications. Familiarity with common neurosurgical techniques and postoperative complications will help radiologists make the correct diagnosis, communicate effectively with the neurosurgeon, and expedite patient care.
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Affiliation(s)
- Matthew A Haber
- Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Muhammad Abd-El-Barr
- Department of Neurosurgery, Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC, 27710, USA
| | - William Gormley
- Harvard Medical School, Boston, MA, USA.,Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Srinivasan Mukundan
- Harvard Medical School, Boston, MA, USA.,Division of Neuroradiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Aaron D Sodickson
- Harvard Medical School, Boston, MA, USA.,Division of Emergency Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Christopher A Potter
- Harvard Medical School, Boston, MA, USA.,Division of Neuroradiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Division of Emergency Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
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Rogers T, Sok K, Erickson T, Aguilera E, Wootton SH, Murray KO, Hasbun R. Impact of Antibiotic Therapy in the Microbiological Yield of Healthcare-Associated Ventriculitis and Meningitis. Open Forum Infect Dis 2019; 6:ofz050. [PMID: 30899767 PMCID: PMC6422431 DOI: 10.1093/ofid/ofz050] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/30/2019] [Indexed: 11/13/2022] Open
Abstract
The impact of antibiotic therapy on the diagnosis of healthcare-associated ventriculitis and meningitis (HCAVM) is unknown. Antibiotics were administered before obtaining cerebrospinal fluid (CSF) in 217 out of 326 (66%) patients with HCAVM, and they impacted the sensitivity of the cerebrospinal fluid Gram stain and culture (P ≤ .004).
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Affiliation(s)
- Thomas Rogers
- Infectious Disease Division, Department of Internal Medicine, McGovern Medical School at the University of Texas Health Science Center in Houston, Houston, Texas
| | - Kevin Sok
- Infectious Disease Division, Department of Internal Medicine, McGovern Medical School at the University of Texas Health Science Center in Houston, Houston, Texas
| | - Timothy Erickson
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Elizabeth Aguilera
- Infectious Disease Division, Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Susan H Wootton
- Infectious Disease Division, Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Kristy O Murray
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Rodrigo Hasbun
- Infectious Disease Division, Department of Internal Medicine, McGovern Medical School at the University of Texas Health Science Center in Houston, Houston, Texas
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High-Dosage Cefazolin Achieves Sufficient Cerebrospinal Diffusion To Treat an External Ventricular Drainage-Related Staphylococcus aureus Ventriculitis. Antimicrob Agents Chemother 2019; 63:AAC.01844-18. [PMID: 30420481 DOI: 10.1128/aac.01844-18] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/01/2018] [Indexed: 11/20/2022] Open
Abstract
A patient received continuous infusion of cefazolin 10 g then 8 g daily for an external ventricular drainage-related methicillin-susceptible Staphylococcus aureus (MSSA) ventriculitis. Median free concentrations in the cerebrospinal fluid were 11.9 and 6.1 mg/liter after 10- and 8-g doses, respectively. Free concentrations in the cerebrospinal fluid were always above the MIC usually displayed by methicillin-susceptible Staphylococcus aureus (MSSA) isolates. These results support the use of high-dose cefazolin to achieve sufficient meningeal concentrations.
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