Pre-emptive intrathecal vancomycin therapy reduces external ventricular drain infection: a single centre retrospective case-control study

Risk Factors for External Ventricular Drainage-Related Infection: A Systematic Review and Meta-analysis

Background and Objectives

External ventricular drainage (EVD) is one of the most commonly performed neurosurgical procedures, but EVD-related infection constitutes a significant health concern. Yet, little consensus identifies the risk factors for the development of EVD-related infection. Therefore, we performed a meta-analysis to systematically summarize existing evidence on the incidence and risk factors for EVD-related infection.

Methods

PubMed, Embase, and the Cochrane Library databases from database inception to February 28, 2022, were searched for all studies investigating the incidence and risk factors for EVD-related infection. Data were assessed by R-4.2.0 software. The meta-analysis was used to calculate pooled odds ratios (OR) and 95% confidence intervals (CI).

Results

A total of 48 studies were included. Among the 29 factors analyzed, statistically significant risk factors were subarachnoid hemorrhage(SAH)/intraventricular hemorrhage(IVH) (OR = 1.48, 95% CI = 1.20-1.82, p < 0.001), concomitant systemic infection (OR = 1.90, 95% CI = 1.34-2.70, p < 0.001), other neurosurgical procedures (OR = 1.76, 95% CI = 1.02-3.04, p = 0.041), change of catheter (OR = 5.05, 95% CI = 3.67-6.96, p < 0.001), bilateral EVDs (OR = 2.25, 95% CI = 1.03-4.89, p = 0.041), (cerebrospinal fluid) CSF leak (OR = 3.19, 95% CI = 2.12-4.81, p < 0.001) and duration of EVD >7 days (OR = 4.62, 95% CI = 2.26-9.43, p < 0.001). The use of silver-coated catheters (OR = 0.57, 95% CI = 0.38-0.87, p = 0.008) and antibiotic-impregnated catheters (OR = 0.60, 95% CI = 0.41-0.88, p = 0.009) might help reduce the risk of infection. No significant difference was indicated in studies evaluating factors like diabetes mellitus (OR = 1.25, 95% CI = 0.90-1.75, p = 0.178), steroids used (OR = 1.52, 95% CI = 0.96-2.4, p = 0.074), prophylactic antibiotics(OR = 0.87, 95% CI = 0.66-1.14, p = 0.308).

Discussion

The meta-analysis of various relevant factors in the onset of EVD-related infection in patients submitted to EVD enabled us to establish a more probable profile of the patients who are more likely to develop it during the treatment.

Postprocedural Complications of External Ventricular Drains: A Meta-Analysis Evaluating the Absolute Risk of Hemorrhages, Infections, and Revisions

BACKGROUND

External ventricular drain (EVD) insertion is often a lifesaving procedure frequently used in neurosurgical emergencies. It is routinely done at the bedside in the neurocritical care unit or in the emergency room. However, there are infectious and noninfectious complications associated with this procedure. This meta-analysis sought to evaluate the absolute risk associated with EVD hemorrhages, infections, and revisions. The secondary purpose was to identify and characterize risk factors for EVD complications.

METHODS

We searched the MEDLINE (PubMed) database for "external ventricular drain," "external ventricular drain" + "complications" or "Hemorrhage" or "Infection" or "Revision" irrespective of publication year. Estimates from individual studies were combined using a random effects model, and 95% confidence intervals (CIs) were calculated with maximum likelihood specification. To investigate heterogeneity, the t2 and I2 tests were utilized. To evaluate for publication bias, a funnel plot was developed.

RESULTS

There were 260 total studies screened from our PubMed literature database search, with 176 studies selected for full-text review, and all of these 176 studies were included in the meta-analysis as they met the inclusion criteria. A total of 132,128 EVD insertions were reported, with a total of 130,609 participants having at least one EVD inserted. The pooled absolute risk (risk difference) and percentage of the total variability due to true heterogeneity (I2) for hemorrhagic complication was 1236/10,203 (risk difference: -0.63; 95% CI: -0.66 to -0.60; I2: 97.8%), infectious complication was 7278/125,909 (risk difference: -0.65; 95% CI: -0.67 to -0.64; I2: 99.7%), and EVD revision was 674/4416 (risk difference: -0.58; 95% CI: -0.65 to -0.51; I2: 98.5%). On funnel plot analysis, we had a variety of symmetrical plots, and asymmetrical plots, suggesting no bias in larger studies, and the lack of positive effects/methodological quality in smaller studies.

CONCLUSIONS

In conclusion, these findings provide valuable information regarding the safety of one of the most important and most common neurosurgical procedures, EVD insertion. Implementing best-practice standards is recommended in order to reduce EVD-related complications. There is a need for more in-depth research into the independent risk factors associated with these complications, as well as confirmation of these findings by well-structured prospective studies.

The Use of Intraventricular Instillation of Vancomycin to Prevent External Ventricular Drainage Related Infection: A Clinical Prospective Study

BACKGROUND

External ventricular drainage (EVD)-related infection (ERI) represents an important condition with potential high morbidity with significant impact on patient outcomes. Prophylactic systemic antibiotics are routinely administered to patients with EVD, but they do not significantly lower the incidence of ERIs. Intraventricular treatment with vancomycin appeared to be safe and effective, but most reports are case-reports/-series and retrospective studies.

METHODS

A prospective non-randomized case-control study was conducted in a consecutive series of 116 patients treated with EVD insertion. The study includes the group of patients treated with intrathecal vancomycin (Group A, 62 patients) compared with the control group treated with daily intravenous cefazolin (Group B, 54 patients).

RESULTS

No statistically significant differences were found between the 2 groups with regard to the duration of catheterization and occurrence of ERI during hospitalization. EVD was replaced in 16 cases (25.8%) in group A and in 12 cases (22.2%) in the control group B (P 0.67). Three cases (4.8%) of ERI have been found in group A and 5 (9.3%) in the control group (P = 0.34). All reported cases of infection in group A were caused by gram-negative agents; on the opposite, cases of infections in the control group B were caused above all by gram-positive bacteria with a statistical difference (P = 0.03).

CONCLUSIONS

In this first prospective study on this topic, we found that intrathecal Vancomycin administration in EVDs does not reduce the occurrence of ERI compared with intravenous cefazolin prophylaxis, but induces selection of gram-negative bacteria.

Deep Brain Stimulation-Related Surgical Site Infections: A Systematic Review and Meta-Analysis

BACKGROUND

Over the last decades, the increased use of deep brain stimulation (DBS) has raised concerns about the potential adverse health effects of the treatment. Surgical site infections (SSIs) following an elective surgery remain a major challenge for neurosurgeons. Few studies have examined the prevalence and risk factors of DBS-related complications, particularly focusing on SSIs.

OBJECTIVES

We systematically searched published literature, up to June 2020, with no language restrictions.

MATERIALS AND METHODS

Eligible were studies that examined the prevalence of DBS-related SSIs, as well as studies that examined risk and preventive factors in relation to SSIs. We extracted information on study characteristics, follow-up, exposure and outcome assessment, effect estimate and sample size. Summary odds ratios (sOR) and 95% confidence intervals (CI) were calculated from random-effects meta-analyses; heterogeneity and small-study effects were also assessed.

RESULTS

We identified 66 eligible studies that included 12,258 participants from 27 countries. The summary prevalence of SSIs was estimated at 5.0% (95% CI: 4.0%-6.0%) with higher rates for dystonia (6.5%), as well as for newer indications of DBS, such as epilepsy (9.5%), Tourette syndrome (5.9%) and OCD (4.5%). Similar prevalence rates were found between early-onset and late-onset hardware infections. Among risk and preventive factors, the perioperative implementation of intra-wound vancomycin was associated with statistically significantly lower risk of SSIs (sOR: 0.26, 95% CI: 0.09-0.74). Heterogeneity was nonsignificant in most meta-analyses.

CONCLUSION

The present study confirms the still high prevalence of SSIs, especially for newer indications of DBS and provides evidence that preventive measures, such as the implementation of topical vancomycin, seem promising in reducing the risk of DBS-related SSIs. Large clinical trials are needed to confirm the efficacy and safety of such measures.

Systemic Antimicrobial Prophylaxis and Antimicrobial-Coated External Ventricular Drain Catheters for Preventing Ventriculostomy-Related Infections: A Meta-Analysis of 5242 Cases

BACKGROUND

External ventricular drain (EVD) placement is essential for the management of many neurocritical care patients. However, ventriculostomy-related infection (VRI) is a serious complication, and there remains no well-established protocol guiding use of perioperative or extended antibiotic prophylaxis to minimize risk of VRI.

OBJECTIVE

To analyze published evidence on the efficacy of extended prophylactic antimicrobial therapy and antibiotic-coated external ventricular drains (ac-EVDs) in reducing VRI incidence.

METHODS

We searched PubMed for studies related to VRIs and antimicrobial prophylaxis. Eligible articles reported VRI incidence in control and treatment cohorts evaluating prophylaxis with either extended systemic antibiotics (> 24 hr) or ac-EVD. Risk ratios and VRI incidence were aggregated by prophylactic strategy, and pooled estimates were determined via random or mixed effects models. Study heterogeneity was quantified using I2 and Cochran's Q statistics. Rigorous assessment of study bias was performed, and PRISMA guidelines were followed throughout.

RESULTS

Across 604 articles, 19 studies (3%) met eligibility criteria, reporting 5242 ventriculostomy outcomes. Extended IV and ac-EVD prophylaxis were associated with risk ratios of 0.36 [0.14, 0.93] and 0.39 [0.21, 0.73], respectively. Mixed effects analysis yielded expected VRI incidence of 13% to 38% with no prophylaxis, 7% to 18% with perioperative IV prophylaxis, 3% to 9% with either extended IV or ac-EVD prophylaxis as monotherapies, and as low as 0.8% to 2% with extended IV and ac-EVD dual prophylaxis.

CONCLUSION

Management with both extended systemic antibiotics and ac-EVDs could lower VRI risk in ventriculostomy patients, but the impact on associated morbidity and mortality, healthcare costs, and length of stay remain unclear.

Meningitis and encephalitis management in the ICU

PURPOSE OF REVIEW

Management of patients with meningitis and encephalitis oftentimes requires ICU level of care. This article is an update on management for meningitis and encephalitis with focus on clinical care in the ICU. Information provided is based on a review of recent studies with focus on studies since 2017.

RECENT FINDINGS

Advances in diagnostic and treatment approach for different pathogens are presented. Nosocomial meningitis now constitutes a major part of brain infections seen in ICUs in the developed world. Advances in ICU care of central nervous system (CNS) infections include application of newer diagnostic methods, improved understanding and delivery of antibiotics to the CNS, infection prevention for nosocomial infections, and application of neuromonitoring where indicated.

SUMMARY

Advances in diagnostics and therapeutic approach to CNS infections are continually made. For intensivists, focus on neuromonitoring and brain resuscitation in critically ill patients with CNS infections may present a path to enhance preservation of brain function and improve outcomes. VIDEO ABSTRACT: http://links.lww.com/COCC/A22.

Prevención y tratamiento de las infecciones del sitio operatorio en neurocirugía. Estado del arte

El manejo adecuado de las infecciones del sitio operatorio (ISO) en neurocirugía es fundamental para la disminución de la carga de morbilidad y mortalidad en estos pacientes. La sospecha y confirmación diagnóstica asociadas al aislamiento microbiológico son esenciales para asegurar el tratamiento oportuno y el adecuado gerenciamiento de antibióticos. En esta revisión se presenta de forma resumida los puntos fundamentales para la prevención y el tratamiento de infecciones del sitio operatorio en neurocirugía y se incluye un apartado sobre el uso de antibióticos intratecales/intraventriculares.

Healthcare-Associated Infections in the Neurocritical Care Unit

PURPOSE OF REVIEW

This article summarizes updated data and knowledge on healthcare-associated infections in the neurocritical care unit, with a focus on central nervous system infections and systemic infectious complications in patients with acute brain disease. It also reviews the concept of brain injury-induced immune modulation, an underlying mechanism to explain why the neuro-ICU population is particularly susceptible to infections.

RECENT FINDINGS

Healthcare-associated infections in the neuro-ICU are common: up to 40 % of meningitides in the developed world are now healthcare-associated. The number of gram-negative infections is rising. New diagnostic approaches attempt to aid in the diagnosis of healthcare-associated meningitis and ventriculitis. Healthcare-associated infections in the neurocritical care unit remain a challenge for diagnosis, treatment, and prevention. Gaining a better understanding of at-risk patients and development of preventative strategies will be the goal for future investigation.

Value of hospital antimicrobial stewardship programs [ASPs]: a systematic review

Background

Hospital antimicrobial stewardship programs (ASPs) aim to promote judicious use of antimicrobials to combat antimicrobial resistance. For ASPs to be developed, adopted, and implemented, an economic value assessment is essential. Few studies demonstrate the cost-effectiveness of ASPs. This systematic review aimed to evaluate the economic and clinical impact of ASPs.

Methods

An update to the Dik et al. systematic review (2000–2014) was conducted on EMBASE and Medline using PRISMA guidelines. The updated search was limited to primary research studies in English (30 September 2014–31 December 2017) that evaluated patient and/or economic outcomes after implementation of hospital ASPs including length of stay (LOS), antimicrobial use, and total (including operational and implementation) costs.

Results

One hundred forty-six studies meeting inclusion criteria were included. The majority of these studies were conducted within the last 5 years in North America (49%), Europe (25%), and Asia (14%), with few studies conducted in Africa (3%), South America (3%), and Australia (3%). Most studies were conducted in hospitals with 500–1000 beds and evaluated LOS and change in antibiotic expenditure, the majority of which showed a decrease in LOS (85%) and antibiotic expenditure (92%). The mean cost-savings varied by hospital size and region after implementation of ASPs. Average cost savings in US studies were $732 per patient (range: $2.50 to $2640), with similar trends exhibited in European studies. The key driver of cost savings was from reduction in LOS. Savings were higher among hospitals with comprehensive ASPs which included therapy review and antibiotic restrictions.

Conclusions

Our data indicates that hospital ASPs have significant value with beneficial clinical and economic impacts. More robust published data is required in terms of implementation, LOS, and overall costs so that decision-makers can make a stronger case for investing in ASPs, considering competing priorities. Such data on ASPs in lower- and middle-income countries is limited and requires urgent attention.