Bacterial Aggregation in Cerebral Spinal Fluid: The Extent it Occurs and the Clinical Ramifications

Bacteria can form aggregates in synovial fluid that are resistant to antibiotics, but the ability to form aggregates in cerebral spinal fluid (CSF) is poorly defined. Consequently, the aims of this study were to assess the propensity of four bacterial species to form aggregates in CSF under various conditions. To achieve these aims, bacteria were added to CSF in microwell plates and small flasks at static and different dynamic conditions with the aid of an incubating shaker. The aggregates that formed were assessed for antibiotic resistance and the ability of tissue plasminogen activator (TPA) to disrupt these aggregates and reduce the number of bacteria present when used with antibiotics. The results of this study show that under dynamic conditions all four bacteria species formed aggregates that were resistant to high concentrations of antibiotics. Yet with static conditions, no bacteria formed aggregates and when the CSF volume was increased, only Staphylococcus aureus formed aggregates. Interestingly, the aggregates that formed were easily dispersed by TPA and significant (p < 0.005) decreases in colony-forming units were seen when a combination of TPA and antibiotics were compared to antibiotics alone. These findings have clinical significance in that they show bacterial aggregation does not habitually occur in central nervous system infections, but rather occurs under specific conditions. Furthermore, the use of TPA combined with antibiotics may be advantageous in recalcitrant central nervous system infections and this provides a pathophysiological explanation for an unusual finding in the CLEAR III clinical trial.

Measurement of cerebrospinal fluid lactate levels in pediatric patients with suspected ventriculoperitoneal shunt infection: A retrospective cohort study

INTRODUCTION

Ventriculoperitoneal shunt (VPS) infection is a severe complication. Early diagnosis could help to decrease morbidity and treatment costs. Lactate has been used for the diagnosis of other central nervous system infections. The aim of this study is to determine the usefulness of lactate for the diagnosis of VPS infection.

METHODOLOGY

Retrospective cohort study. Lactate was measured in patients who consulted with VPS dysfunction between May 2019 and May 2022. Mean were compared according to culture results. A Receiver Operating Characteristic (ROC) curve was performed to determine the appropriate cut-off point.

RESULT

Lactate has a high negative predictive value but a low positive predictive value for the diagnosis of ventriculitis.

Bilateral abducens and facial nerve palsies following fourth ventriculoperitoneal shunt with laparoscopic-assisted abdominal catheter placement

Introduction

Hydrocephalus, altering cerebrospinal fluid (CSF) dynamics, affects 175 per 100,000 adults worldwide. Ventriculoperitoneal shunts (VPS) manage symptomatic hydrocephalus, with 125,000 cases annually. Despite efficacy, VPS face complications, necessitating interventions.

Research question

"What are the mechanisms and risk factors for bilateral VIth and VIIth lower motor neuron palsies in hydrocephalus patients with a fourth ventriculoperitoneal shunt?"

Material and methods

This study details a 36-year-old female with a neonatal meningitis history, multiple shunt replacements, admitted for abdominal pain secondary to pelvic inflammatory disease. An abdominal shunt catheter removal and external ventricular drain placement occurred after consultation with a general surgeon. A cardiac atrial approach and subsequent laparoscopic abdominal approach were performed without complications.

Results

After one month, the patient showed neurological complications, including decreased facial expression, gait instability, and bilateral VIth and VIIth lower motor neuron palsies, specifically upgazed and convergence restriction.

Discussion

The complication's pathophysiology is discussed, attributing it to potential brainstem herniation from over-drainage of CSF. Literature suggests flexible endoscopic treatments like aqueductoplasty/transaqueductal approaches into the fourth ventricle.

Conclusions

This study underscores the need for increased awareness in monitoring neurological outcomes after the fourth ventriculoperitoneal shunt, particularly in cases with laparoscopic-assisted abdominal catheter placement. The rarity of bilateral abducens and facial nerve palsies emphasizes the importance of ongoing research to understand pathophysiology and develop preventive and therapeutic strategies for this unique complication.

Meropenem-Vaborbactam for the Treatment of Post-Neurosurgical Meningitis Caused by KPC Producer Klebsiella Pneumoniae: A Case Report and Review of the Literature

Meningitis and ventriculitis, due to carbapenem-resistant Enterobacterales, are frequently associated with significant morbidity and mortality. In the case of multi-drug-resistant pathogens, it is necessary to consider the limited susceptibility profile as well as the penetration of the antimicrobials into the brain. Limited data are available regarding the treatment of central nervous system infections caused by carbapenem-resistant Enterobacterales. We report a study of a patient treated with meropenem-vaborbactam in the case of post-neurosurgical meningitis due to carbapenemase-producing Klebsiella pneumoniae (CPKP).

Treatment of wound infections linked to neurosurgical implants

As neurosurgery has advanced technologically, more and more neurosurgical implants are being employed on an aging patient population with several comorbidities. As a result, there is a steady increase in the frequency of infections linked to neurosurgical implants, which causes serious morbidity and mortality as well as abnormalities of the skull and inadequate brain protection. We discuss infections linked to internal and external ventricular and lumbar cerebrospinal fluid drainages, neurostimulators, craniotomies, and cranioplasty in this article. Biofilms, which are challenging to remove, are involved in all implant-associated illnesses. It takes a small quantity of microorganisms to create a biofilm on the implant surface. Skin flora bacteria are implicated in the majority of illnesses. Microorganisms that cause disruptions in wound healing make their way to the implant either during or right after surgery. In about two thirds of patients, implant-associated infections manifest early (within the first month after surgery), whereas the remaining infections present later as a result of low-grade infections or by direct extension from adjacent infections (per continuitatem) to the implants due to soft tissue damage. Except for ventriculo-atrial cerebrospinal fluid shunts, neurosurgical implants are rarely infected by the haematogenous route. This research examines established and clinically validated principles that are applicable to a range of surgical specialties using implants to treat biofilm-associated infections in orthopaedic and trauma cases. Nevertheless, there is little evidence and no evaluation in sizable patient populations to support the success of this extrapolation to neurosurgical patients. An optimal microbiological diagnostic, which includes sonicating removed implants and extending culture incubation times, is necessary for a positive result. Additionally, a strategy combining surgical and antibiotic therapy is needed. Surgical procedures involve a suitable debridement along with implant replacement or exchange, contingent on the biofilm's age and the state of the soft tissue. A protracted biofilm-active therapy is a component of antimicrobial treatment, usually lasting 4-12 weeks. This idea is appealing because it allows implants to be changed or kept in place for a single surgical procedure in a subset of patients. This not only enhances quality of life but also lowers morbidity because each additional neurosurgical procedure increases the risk of secondary complications like intracerebral bleeding or ischemia.

Preoperative nomogram predicting ventriculoperitoneal shunt longevity after initial shunt failure

Background and objectives

Initial shunt failure following ventriculoperitoneal (VP) shunt surgery has a significant impact on the working time of the shunt. However, there are few studies regarding factors affecting VP shunt longevity. Hence, in this study, we aimed to build a nomogram to predict the longevity of the replacement VP shunt in patients with initial shunt failure.

Methods

From 2011 to 2021, 142 patients with initial VP failure who underwent VP shunt revision were enrolled and relevant clinical and demographic factors were analyzed. Univariate and multivariate Cox proportional hazard regression models were used to choose predictors, and a nomogram was constructed using nine independent prognostic variables: sex, age, hydrocephalus type, intensive care unit admission, tracheostomy, decompressive craniectomy, craniotomy, lumbar cisterna drainage, and ventricular drainage. The prediction models' discrimination, accuracy, calibration, and clinical value were evaluated using Harrell's C-index, a calibration plot, and decision curve analysis.

Results

At 1 month, 3 months, and 5 years, the nomogram's C-index was 0.680, 0.708, and 0.694, respectively. The nomogram's calibration plot provided a good fit for the overall prediction over the course of 1 year. Decision curve analysis predicted that 1-3 months after surgery will yield good net benefits between 30 and 50% probability thresholds.

Conclusion

A preoperative nomogram may be an effective tool for assessing VP shunt longevity after initial VP shunt placement.

A Rare Complication of Proteus Brain Abscess Due to Coccidioidomycosis Causing Hydrocephalus

Proteus mirabilis is a very common gram-negative facultative anaerobe seen in urinary tract infections. This rod-shaped bacterium tends to cause urolithiasis via its ability to alkalinize the urine. However, in some cases, this bacterium has been shown to cause bacteremia as well as other complicated infections. Here we would like to present a rare case of Proteus mirabilis that has invaded the brain in a patient that has a ventriculoperitoneal (VP) shunt placed due to coccidioidal meningitis causing hydrocephalus. We would also like to discuss the importance of the monitoring of VP shunt and discuss their likelihood of infections and the medical as well as surgical management.

Ventriculoatrial Shunt Versus Ventriculoperitoneal Shunt: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Ventriculoperitoneal shunt (VPS) is usually the primary choice for cerebrospinal fluid shunting for most neurosurgeons, while ventriculoatrial shunt (VAS) is a second-line procedure because of historical complications. Remarkably, there is no robust evidence claiming the superiority of VPS over VAS. Thus, we aimed to compare both procedures through a meta-analysis.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, the authors systematically searched the literature for articles comparing VAS with VPS. The included articles had to detail one of the following outcomes: revisions, infections, shunt-related mortality, or complications. In addition, the cohort for each shunt model had to encompass more than 4 patients.

RESULTS

Of 1872 articles, 16 met our criteria, involving 4304 patients, with 1619 undergoing VAS and 2685 receiving VPS placement. Analysis of revision surgeries showed no significant difference between VAS and VPS (risk ratio [RR] = 1.10, 95% CI: 0.9-1.34; I2 = 84%, random effects). Regarding infections, the analysis also found no significant difference between the groups (RR = 0.67, 95% CI: 0.36-1.25; I2 = 74%, random effects). There was no statistically significant disparity between both methods concerning shunt-related deaths (RR = 2.11, 95% CI: 0.68-6.60; I2 = 56%, random effects). Included studies after 2000 showed no VAS led to cardiopulmonary complications, and only 1 shunt-related death could be identified.

CONCLUSION

Both methods show no significant differences in procedure revisions, infections, and shunt-related mortality. The literature is outdated, research in adults is lacking, and future randomized studies are crucial to understand the profile of VAS when comparing it with VPS. The final decision on which distal site for cerebrospinal shunting to use should be based on the patient's characteristics and the surgeon's expertise.

Neurocysticercosis and hydrocephalus: the value of ventriculoperitoneal shunting in its management

BACKGROUND

Hydrocephalus is the main complication of extraparenchymal neurocysticercosis (EP-NC). Its symptomatic management relies mainly on the placement of a ventriculoperitoneal shunt (VPS). Previous studies have shown that this surgical procedure is associated with a poor prognosis, but current information is lacking.

METHODS

We included 108 patients with a definitive diagnosis of EP-NC and hydrocephalus requiring VPS placement. We evaluated their demographic, clinical, and inflammatory characteristics, as well as the frequency of complications related to VPS placement.

RESULTS

Hydrocephalus was present at the time of NC diagnosis in 79.6% of patients. VPS dysfunction occurred in 48 patients (44.4%), mainly within the first year after placement (66.7%). The dysfunctions were not associated with the location of the cyst, the inflammatory characteristics of the cerebrospinal fluid or the administration of cysticidal treatment. They were significantly more frequent in patients in whom the decision to place a VPS was made in the emergency department. Two years after VPS, patients' Karnofsky score averaged 84.6±15 and only one patient died of a cause directly related to VPS.

CONCLUSIONS

This study confirmed the utility of VPS and showed a significant improvement in the prognosis of patients requiring VPS compared with previous studies.

Propionibacterium acnes: A Difficult-to-Diagnose Ventriculoperitoneal Shunt Infection. Case Report

BACKGROUND

 Ventriculoperitoneal (VP) shunt infections are a fairly common complication in both the early and late postoperative periods. Sometimes diagnosis is difficult despite the fact that infection is often accompanied by clinical symptoms. Furthermore, pathogenic bacteria can be detected in the cerebrospinal fluid.

METHOD

 We describe a case of chronic VP shunt infection in a 24-year-old female patient who was operated on for posterior fossa pilocytic astrocytoma and needed a VP shunt. The infection revealed itself 5 years after shunt implantation with nonspecific symptoms, and it took approximately 2 years to make a correct diagnosis. Meanwhile, the patient's condition became critical. The infection was caused by Propionibacterium acnes, which is capable of forming biofilms on implants, and which is difficult to identify due to the peculiarity of its cultivation.

RESULT

 When the bacterium was identified, the shunt was replaced and antimicrobial therapy was performed, after which the patient's condition improved dramatically and she got back to her normal life.

CONCLUSIONS

 This case shows how difficult the diagnosis of VP shunt infection can be and what clinical significance it can have for the patient.

Predictive signs and symptoms of bacterial meningitis isolates in Northern Ghana

Cerebrospinal meningitis (CSM) is a public health burden in Ghana that causes up to 10% mortality in confirmed cases annually. About 20% of those who survive the infection suffer permanent sequelae. The study sought to understand the predictive signs and symptoms of bacterial meningitis implicated in its outcomes. Retrospective data from the Public Health Division, Ghana Health Service on bacterial meningitis from 2015 to 2019 was used for this study. A pre-tested data extraction form was used to collect patients' information from case-based forms kept at the Disease Control Unit from 2015 to 2019. Data were transcribed from the case-based forms into a pre-designed Microsoft Excel template. The data was cleaned and imported into SPSS version 26 for analysis. Between 2015 and 2019, a total of 2446 suspected bacterial meningitis cases were included in the study. Out of these, 842 (34.4%) were confirmed. Among the confirmed cases, males constituted majority with 55.3% of the cases. Children below 14 years of age were most affected (51.4%). The pathogens commonly responsible for bacterial meningitis were Neisseria meningitidis (43.7%) and Streptococcus pneumoniae (53.0%) with their respective strains Nm W135 (36.7%), Nm X (5.1%), Spn St. 1 (26.2%), and Spn St. 12F/12A/12B/44/4 (5.3%) accounting for more than 70.0% of the confirmed cases. The presence of neck stiffness (AOR = 1.244; C.I 1.026-1.508), convulsion (AOR = 1.338; C.I 1.083-1.652), altered consciousness (AOR = 1.516; C.I 1.225-1.876), and abdominal pains (AOR = 1.404; C.I 1.011-1.949) or any of these signs and symptoms poses a higher risk for testing positive for bacterial meningitis adjusting for age. Patients presenting one and/or more of these signs and symptoms (neck stiffness, convulsion, altered consciousness, and abdominal pain) have a higher risk of testing positive for bacterial meningitis after statistically adjusting for age.

Difficult-to-Treat Pathogens: A Review on the Management of Multidrug-Resistant Staphylococcus epidermidis

Multidrug-resistant Staphylococcus epidermidis (MDRSE) is responsible for difficult-to-treat infections in humans and hospital-acquired-infections. This review discusses the epidemiology, microbiology, diagnosis, and treatment of MDRSE infection and identifies knowledge gaps. By using the search term "pan resistant Staphylococcus epidermidis" OR "multi-drug resistant Staphylococcus epidermidis" OR "multidrug-resistant lineages of Staphylococcus epidermidis", a total of 64 records have been identified from various previously published studies. The proportion of methicillin resistance in S. epidermidis has been reported to be as high as 92%. Several studies across the world have aimed to detect the main phylogenetic lineages and antibiotically resistant genes through culture, mass spectrometry, and genomic analysis. Molecular biology tools are now available for the identification of S. epidermidis and its drug resistance mechanisms, especially in blood cultures. However, understanding the distinction between a simple colonization and a bloodstream infection (BSI) caused by S. epidermidis is still a challenge for clinicians. Some important parameters to keep in mind are the number of positive samples, the symptoms and signs of the patient, the comorbidities of the patient, the presence of central venous catheter (CVC) or other medical device, and the resistance phenotype of the organism. The agent of choice for empiric parenteral therapy is vancomycin. Other treatment options, depending on different clinical settings, may include teicoplanin, daptomycin, oxazolidinones, long-acting lipoglycopeptides, and ceftaroline. For patients with S. epidermidis infections associated with the presence of an indwelling device, assessment regarding whether the device warrants removal is an important component of management. This study provides an overview of the MDRSE infection. Further studies are needed to explore and establish the most correct form of management of this infection.

Characteristics and outcomes of cerebrospinal fluid shunt and drain-associated infections

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.

A Case of Coccidioidal Meningitis With Biofilm Obstructing VP Shunt Due to Cutibacterium acnes

Herein described is a case of biofilm obstructing ventriculoperitoneal shunt due to Cutibacteirum acnes infection in a patient with coccidioidal meningitis. Cutibacterium acnes infects and obstructs cerebral shunts by the production of biofilm; however, diagnosis is usually missed by routine aerobic cultures. Obtaining anaerobic cultures routinely in patients with foreign body implants leading to central nervous system infections could prevent a missed diagnosis of this pathogen. Penicillin G is the first-line treatment.

Cutibacterium acnes Prosthetic Joint Infections: Is Rifampicin-Combination Therapy Beneficial?

No consensus has been reached on the optimal antibiotic regimen to treat Cutibacterium acnes PJIs (Ca-PJIs). In vitro studies showed excellent rifampicin efficacy against biofilm-associated C. acnes infections, but clinical studies did not confirm the superiority of rifampicin-combined therapy over monotherapy. This prospective cohort study was undertaken to analyze the outcomes of 70 patients who underwent exchange arthroplasty for chronic monomicrobial Ca-PJI and were treated with rifampicin or without between 2004 and 2019. The 37 patients treated from January 2004 to August 2014 were prescribed rifampicin-combination therapy and the 33 treated from September 2014 to December 2019 received monotherapy without rifampicin. The primary endpoint was the 2-year Kaplan-Meier-estimated reinfection-free probability, including relapses and new-pathogen PJIs. The 2-year reinfection-free rate was high and not different for patients who had received rifampicin or not (89.2% vs. 93.8%, respectively; p = 0.524). None of the patients relapsed and six developed new-pathogen PJIs. Our results do not support a benefit of rifampicin-combination therapy for patients who underwent exchange arthroplasty for chronic Ca-PJIs.

Use of α-Defensins to Help Diagnose Nosocomial Ventriculitis

Ventriculitis is a severe complication of indwelling neurosurgical devices that is associated with significant morbidity and mortality. The incidence rate of ventriculitis is approximately 10% with external ventricular drains. Obstinately, patients with these indwelling neurosurgical devices are prone to have traditional cerebral spinal fluid parameters that lack sensitivity and specificity in diagnosing nosocomial ventriculitis. In addition, diagnosis can be arduous given that indolent pathogens are commonly implicated. Therefore, diagnosis is difficult but paramount to thwart the morbidity and mortality associated with this infectious condition as well as to reduce the prolonged use of broad-spectrum antibiotics. As we extrapolate from prosthetic joint infections, for which diagnosis can also be challenging, we learn that the use of α-defensins as a diagnostic biomarker for nosocomial ventriculitis may hold promise. Herein, the viewpoint of using α-defensins as a diagnostic biomarker for nosocomial ventriculitis is discussed.

Clinical features and risk factors of surgical site infections in HIV-negative patients with cryptococcal meningitis underwent ventriculoperitoneal shunt operations: a retrospective study

Background

To investigate the clinical features and risk factors of ventriculoperitoneal shunt (VPS) associated surgical site infections (SSIs) in HIV-negative patients with cryptococcal meningitis (CM).

Methods

We retrospectively reviewed the medical records of HIV-negative patients with CM underwent VPS operation admitted to The Third Affiliated Hospital of Sun Yat-sen University in Southwest China over the past 7 years.

Results

193 patients were included, of whom 25 (12.95%) had SSIs in 6 (median duration, 1–48 days) days after operation. Compared with patients without SSIs, patient with SSIs tended to be shorter preoperative stay. 52% patients in SSIs group and 25% patients in no-SSIs group underwent VPS operations within 3 days after admission (p = 0.017). Although body temperature and infectious indicators slightly elevated postoperative in both groups. The patients with SSIs experienced more fever; more central nervous system symptoms; higher PCT value and lower cerebrospinal fluid (CSF) glucose in contrast to the no-SSIs group. Multivariate regression analysis found a 2.653 fold increase in the risk of infection for every 1 °C increase in postoperative body temperature. Among the 25 patients, 9 patients had positive culture results, three samples reported to be oxacillin resistant coagulase-negative Staphylococci.

Conclusions

SSIs was one of the serious surgical complications after VPS operation. High body temperature, the occurrence of dizziness and headache, low postoperative hemoglobin are risk factors. Postoperative patients with high fever, high PCT and low CSF glucose should be paid more attention to.

The Role of Cutibacterium acnes in Sarcoidosis: From Antigen to Treatable Trait?

Cutibacterium acnes (C. acnes, formerly Propionibacterium acnes) is considered to be a non-pathogenic resident of the human skin, as well as mucosal surfaces. However, it also has been demonstrated that C. acnes plays a pathogenic role in diseases such as acne vulgaris or implant infections after orthopedic surgery. Besides a role in infectious disease, this bacterium also seems to harbor immunomodulatory effects demonstrated by studies using C. acnes to enhance anti-tumor activity in various cancers or vaccination response. Sarcoidosis is a systemic inflammatory disorder of unknown causes. Cultures of C. acnes in biopsy samples of sarcoidosis patients, its presence in BAL fluid, tissue samples as well as antibodies against this bacterium found in serum of patients with sarcoidosis suggest an etiological role in this disease. In this review we address the antigenic as well as immunomodulatory potential of C. acnes with a focus on sarcoidosis. Furthermore, a potential role for antibiotic treatment in patients with sarcoidosis will be explored.

Etiology and Outcomes of Healthcare-Associated Meningitis and Ventriculitis—A Single Center Cohort Study

Healthcare associated meningitis and ventriculitis (HCAMV) are serious complications of neurosurgical procedures. We conducted a retrospective cohort study of patients with HCAMV treated at the University Hospital for Infectious Diseases Zagreb during the 2013–2019 period. A total of 144 patients with 151 episodes of HCAMV were included. The most common indications for neurosurgical procedures were brain tumor, hemorrhage and hydrocephalus. Etiology was identified in 90 (59.6%) episodes (either positive CSF culture or positive PCR), and in other 61 (40.39%) the diagnosis of HCAMV was made based on clinical and CSF parameters, without microbiologic confirmation. Carbapenem-resistant Acinetobacter baumannii was the most common pathogen (15.89%), followed by Staphylococcus aureus (13.91%), Pseudomonas aeruginosa (13.25%) and Coagulase negative staphylococci (7.95%). Overall, 24 (16.3%) patients died, and the majority had adverse outcomes, persistent vegetative state (8, 5.56%) and severe disability (31, 21.53%). The worst clinical outcomes were observed in A. baumannii infections. High rate of complications, the need for external ventricular drainage (re)placement often complicated with nosocomial infections and prolonged stay in intensive care units were observed. Clinicians should be aware of local microbial epidemiology on guiding proper empirical antimicrobial treatment in patients with HCAMV.

Cerebrospinal fluid drainage-related ventriculitis due to multidrug-resistant microorganisms

INTRODUCTION

The aim of the study was to analyze the clinical and microbiological characteristics of adult patients with cerebrospinal fluid (CSF) drainage-related ventriculitis.

METHODS

Retrospective study from January 2010 to June 2019 performed in the Complexo Hospitalario Universitario de Vigo (Spain). Cases of CSF drainage-related ventriculitis in patients ≥18-year-old were gathered. Clinical characteristics of patients, type of drainage devices, management and microbiological isolates were analyzed.

RESULTS

Ninety-one episodes of CSF drainage-related ventriculitis were identified. The most frequent organisms isolated were Gram-positive cocci (65%), mainly Staphylococcus epidermidis (48%). Multidrug-resistant microorganisms were detected in 21 episodes (23%). In multivariate analysis, the independent factors related with multidrug-resistant ventriculitis were the length of hospital stay >14 days (HR 6.7; 95%CI 1.75-25.86, p=0.006) and previous antimicrobial therapy (HR 5.58; 95%CI 1.44-21.65, p=0.013).

CONCLUSIONS

Our study shows a large number of drainage-related ventriculitis episodes caused by multidrug-resistant organisms and reinforce the importance of a judicious use of antibiotics.

Accuracy of heparin-binding protein for the diagnosis of nosocomial meningitis and ventriculitis

Background

The sensitive and accurate diagnosis of nosocomial meningitis and ventriculitis is still a critical problem. This study was designed to explore the diagnostic value of cerebrospinal fluid heparin-binding protein (HBP) in nosocomial meningitis and ventriculitis in comparison with procalcitonin and lactate.

Methods

In this observational study, 323 suspected patients were enrolled, of which 42 participants were excluded because they could not be accurately grouped, 131 subjects who were eventually diagnosed with nosocomial meningitis or ventriculitis and 150 patients in whom infection was ultimately ruled out were included in the final analysis. The main results are expressed as medians (interquartile ranges). The Chi-squared test was used to compare the baseline characteristics. The Mann–Whitney U-test was used for group and subgroup analyses. The area under the receiver operating characteristic curve was calculated to describe the diagnostic accuracy of the biomarkers. Spearman's partial correlation was used to analyze associations between the biomarkers. Statistical significance was set when p value < 0.05.

Results

HBP achieved the largest area under the receiver operating characteristic curve, which was 0.99 (95% confidence interval 0.98—1.00) compared with 0.98 (95% confidence interval 0.96—0.99) for lactate and 0.69 (95% confidence interval 0.62—0.75) for procalcitonin. With a cutoff level at 23 ng/mL, HBP achieved a sensitivity of 97%, a specificity of 95%, a positive predictive value of 93% and a negative predictive value of 98%. The levels of HBP presented no significant discrepancy between patients who received previous empiric anti-infective therapy and those who did not (p > 0.05). Higher concentrations of HBP were present in patients with positive microbiological findings (p < 0.05). Levels of HBP positively correlated with polymorphonuclear cell count (Spearman's rho = 0.68, p < 0.01), white blood cell count (Spearman's rho = 0.57, p < 0.01) and lactate (Spearman's rho = 0.34, p < 0.01).

Conclusions

Cerebrospinal fluid heparin-binding protein is a reliable auxiliary diagnostic marker that is preferable over lactate and procalcitonin in identifying nosocomial meningitis and ventriculitis, and it also contributes to solving the diagnostic difficulties caused by empiric antibiotherapy.

4-Hydroxyphenyllactic Acid in Cerebrospinal Fluid as a Possible Marker of Post-Neurosurgical Meningitis: Retrospective Study

The search for new potential biomarkers for the diagnostics of post-neurosurgical bacterial meningitis is required because of the difficulties in its early verification using results of the routine laboratory and biochemical analyses of the cerebrospinal fluid (CSF). The goal of the study was to determine the contents of the aromatic metabolites and biomarkers in the CSF samples of the post-neurosurgical patients (n = 82) and their potential diagnostical significance for the evaluation of the risk of post-neurosurgical meningitis. Patients with signs of post-neurosurgical meningitis (n = 30) had lower median values of glucose and higher values of cell count, neutrophils, lactate, protein, 3-(4-hydroxyphenyl)lactic acid (p-HPhLA), and interleukin-6 (IL-6) than patients without signs of post-neurosurgical meningitis (n = 52). ROC analysis for IL-6 and p-HPhLA resulted in 0.785 and 0.734 values of the area under the ROC curve, with sensitivity 96.30 and 66.67%; specificity 54.17 and 82.69%, respectively. IL-6 should be considered as a non-specific biomarker, in contrast to the microbial metabolite p-HPhLA. If the concentration of p-HPhLA was more or equal to 0.9 µmol/L, the risk of bacterial complications was 9.6 times higher. p-HPhLA is a promising marker for the prognosis of post-neurosurgical meningitis, and its determination on a larger group of post-neurosurgical patients can subsequently prove its diagnostic significance for the verification of CNS infections.

Trends of Antimicrobial Susceptibility in Clinically Significant Coagulase-Negative Staphylococci Isolated from Cerebrospinal Fluid Cultures in Neurosurgical Adults: a Nine-Year Analysis

Coagulase-negative staphylococci (CoNS) are the main pathogens in health care-associated ventriculitis and meningitis (HCAVM). This study aimed to assess antimicrobial susceptibility. Moreover, the treatment and clinical outcome were described. All neurosurgical adults admitted to one of the largest neurosurgical centers in China with clinically significant CoNS isolated from cerebrospinal fluid cultures in 2012 to 2020 were recruited. One episode was defined as one patient with one bacterial strain. Interpretive categories were applied according to the MICs. The clinical outcomes were dichotomized into poor (Glasgow Outcome Scale 1 to 3) and acceptable (Glasgow Outcome Scale 4 to 5). In total, 534 episodes involving 519 patients and 16 bacteria were analyzed. Over the 9 years, eight antimicrobial agents were used in antimicrobial susceptibility tests, including six in over 80% of CoNS. The range of resistance rates was 0.8% to 84.6%. The vancomycin resistance rate was the lowest, whereas the penicillin resistance rate was the highest. The linezolid (a vancomycin replacement) resistance rate was 3.1%. The rate of oxacillin resistance, representing methicillin-resistant staphylococci, was 70.2%. There were no significant trends of antimicrobial susceptibility over the 9 years for any agents analyzed. However, there were some apparent changes. Notably, vancomycin-resistant CoNS appeared in recent years, while linezolid-resistant CoNS appeared early and disappeared in recent years. Vancomycin (or norvancomycin), the most common treatment agent, was used in 528 (98.9%) episodes. Finally, 527 (98.7%) episodes had acceptable outcomes. It will be safe to use vancomycin to treat CoNS-related HCAVM in the immediate future, although continuous monitoring will be needed. IMPORTANCE Coagulase-negative staphylococci are the main pathogens in health care-associated ventriculitis and meningitis. There are three conclusions from the results of this study. First, according to antimicrobial susceptibility, the rates of resistance to primary antimicrobial agents are high and those to high-level agents, including vancomycin, are low. Second, the trends of resistance rates are acceptable, especially for high-level agents, although long-term and continuous monitoring is necessary. Finally, the clinical outcomes of neurosurgical adults with coagulase-negative staphylococci-related health care-associated ventriculitis and meningitis are acceptable after treatment with vancomycin. Therefore, according to the antimicrobial susceptibility and clinical practice, vancomycin will be safe to treat coagulase-negative staphylococci-related health care-associated ventriculitis and meningitis.

Bacterial translocation as a cause of ventriculoperitoneal shunt infection: A case report

Bacterial translocation as a mechanism of distal catheter infection may play a larger role in ventriculoperitoneal shunt infections than previously recognized.

Survival Rate and Shunt Infection Incidence Following Gastrostomy in Adult Patients with an Existing Ventriculoperitoneal Shunt

Ventriculoperitoneal shunts (VPS) and gastrostomies are frequently provided in daily practice. This study investigated the incidence of VPS infection and the survival rate among adult patients who underwent gastrostomy at least 1 month after VPS placement. This single-center retrospective cohort study was conducted among patients with a VPS, who underwent a gastrostomy. This procedure was performed on a standby basis after a period of at least 1 month had elapsed since VPS placement. Subsequent VPS infection and survival rates were assessed over a period of at least 6 months. We reviewed 31 patients who had a VPS at the time of gastrostomy. Gastrostomy was performed endoscopically in 29 cases and via open surgery in 2 cases. The average interval between VPS insertion and gastrostomy was 1135.5 ± 1717.1 days. A single case of VPS infection (3.2%) was diagnosed during the study. This infection rate was not significantly different than that among 230 patients who underwent their first VPS placement (without gastrostomy) at our institution during the same time period (P = .57); there was also no significant difference in the survival rate, compared to 38 age-matched patients (with cerebrovascular disease, but without a VPS) who underwent gastrostomy (P = .73). Gastrostomy performed after an interval of at least 1 month after VPS placement was extremely safe in adult patients, and their prognosis was excellent. Additional studies are required to develop appropriate nutritional interventions for patients with a VPS.

Laparoscopic-Assisted Ventriculoperitoneal Shunt Placement: A Less Invasive Approach to Treating Hydrocephalus

Hydrocephalus is caused by the disruption of the normal flow of cerebrospinal fluid (CSF), which results in a buildup of CSF. Hydrocephalus comprises two key categories: communicating and noncommunicating. Normal-pressure hydrocephalus, a type of communicating hydrocephalus, currently has no cure; the main treatment option is ventriculoperitoneal shunt (VPS) placement surgery. This procedure is performed to reestablish the balance between CSF production, flow, and absorption. Recently, general surgeons have begun assisting the neurosurgeon by placing the distal or abdominal end of the shunt using a laparoscopic technique. This article briefly reviews the pathophysiology and treatment options for hydrocephalus; presents a thorough review of the laparoscopic-assisted VPS placement procedure, as well as the expected perioperative course and care considerations; and concludes with a case study of a 68-year-old patient who undergoes a laparoscopic-assisted VPS placement.

A Janus-Faced Bacterium: Host-Beneficial and -Detrimental Roles of Cutibacterium acnes

The bacterial species Cutibacterium acnes (formerly known as Propionibacterium acnes) is tightly associated with humans. It is the dominant bacterium in sebaceous regions of the human skin, where it preferentially colonizes the pilosebaceous unit. Multiple strains of C. acnes that belong to phylogenetically distinct types can co-exist. In this review we summarize and discuss the current knowledge of C. acnes regarding bacterial properties and traits that allow host colonization and play major roles in host-bacterium interactions and also regarding the host responses that C. acnes can trigger. These responses can have beneficial or detrimental consequences for the host. In the first part of the review, we highlight and critically review disease associations of C. acnes, in particular acne vulgaris, implant-associated infections and native infections. Here, we also analyse the current evidence for a direct or indirect role of a C. acnes-related dysbiosis in disease development or progression, i.e., reduced C. acnes strain diversity and/or the predominance of a certain phylotype. In the second part of the review, we highlight historical and recent findings demonstrating beneficial aspects of colonization by C. acnes such as colonization resistance, immune system interactions, and oxidant protection, and discuss the molecular mechanisms behind these effects. This new insight led to efforts in skin microbiota manipulation, such as the use of C. acnes strains as probiotic options to treat skin disorders.

Optimal timing and sequence of ventriculoperitoneal shunt and gastrostomy placement

Background: The optimal timing of ventriculoperitoneal shunt (VPS) and gastrostomy placement, relative to the safety of simultaneous versus staged surgery, has not been clearly delineated in the literature.Objective: To study the optimal inter-procedural timing relative to distal VPS infection and pertinent reoperation.Methods: A fifteen-year, retrospective, single-center study was conducted on adults undergoing VPS and gastrostomy within 30-days. Patients were grouped according to inter-procedural interval: 0-24 hr (immediate), 24 hr-7 days (early), and 7-30 days (delayed). The primary endpoint of the study was VPS infection and distal shunt complications requiring reoperation. Potential predictors of the primary end point (baseline cohort characteristics, procedural factors) were examined with standard statistical methods.Results: A total of 188 patients met inclusion criteria. The average interval between procedures was 7 ± 6 days, with 43.1% undergoing VPS prior to gastrostomy. Primary endpoint was encountered in 5 patients (2.7%): 1 (5.9%) of 17 patients undergoing immediate placement, 3 (2.8%) of 107 with early placement, and 1 (1.6%) of 64 with delayed placement. Although not statistically significant, 3.7% of patients undergoing VPS first had the primary endpoint, compared to 1.9% of those with gastrostomy. There were no statistically significant associations between the primary outcome and peri-operative CSF counts, gastrostomy modality, hydrocephalus etiology, chronic steroid use, or extended antibiotic administration.Conclusion: Although the low overall event rate in this cohort precludes definitive determination regarding differential safety, the data generally support a practice of performing the procedures >24-hours apart, with placement of gastrostomy prior to VPS.

Cerebrospinal fluid drainage-related ventriculitis due to multidrug-resistant microorganisms

INTRODUCTION

The aim of the study was to analyze the clinical and microbiological characteristics of adult patients with cerebrospinal fluid (CSF) drainage-related ventriculitis.

METHODS

Retrospective study from January 2010 to June 2019 performed in the Complexo Hospitalario Universitario de Vigo (Spain). Cases of CSF drainage-related ventriculitis in patients ≥18-year-old were gathered. Clinical characteristics of patients, type of drainage devices, management and microbiological isolates were analyzed.

RESULTS

Ninety-one episodes of CSF drainage-related ventriculitis were identified. The most frequent organisms isolated were Gram-positive cocci (65%), mainly Staphylococcus epidermidis (48%). Multidrug-resistant microorganisms were detected in 21 episodes (23%). In multivariate analysis, the independent factors related with multidrug-resistant ventriculitis were the length of hospital stay >14 days (HR 6.7; 95%CI 1.75-25.86, p=0.006) and previous antimicrobial therapy (HR 5.58; 95%CI 1.44-21.65, p=0.013).

CONCLUSIONS

Our study shows a large number of drainage-related ventriculitis episodes caused by multidrug-resistant organisms and reinforce the importance of a judicious use of antibiotics.

Virulence Factors in Coagulase-Negative Staphylococci

Coagulase-negative staphylococci (CoNS) have emerged as major pathogens in healthcare-associated facilities, being S. epidermidis, S. haemolyticus and, more recently, S. lugdunensis, the most clinically relevant species. Despite being less virulent than the well-studied pathogen S. aureus, the number of CoNS strains sequenced is constantly increasing and, with that, the number of virulence factors identified in those strains. In this regard, biofilm formation is considered the most important. Besides virulence factors, the presence of several antibiotic-resistance genes identified in CoNS is worrisome and makes treatment very challenging. In this review, we analyzed the different aspects involved in CoNS virulence and their impact on health and food.

Ventriculoperitoneal Shunt without Hair Shaving Using Absorbable Suture Materials

OBJECTIVE

Infection is one of most devastating complications in ventriculoperitoneal (VP) shunt surgery. Preoperative hair removal has traditionally been performed to reduce infectious complications. We performed VP shunt surgeries and evaluated the prevalence of infection in patients who were shaved and those who were unshaven.

METHODS

A retrospective analysis was conducted of 82 patients with hydrocephalus of various pathologies who underwent VP shunt surgery, with or without having the head shaved, between March 2010 and March 2017. For patients in the non-shaved group (n=36), absorbable suture materials were used for wound closure, and Nylon sutures or staples were used in the shaved group (n=46). We evaluated the infection outcomes of patients in the two groups.

RESULTS

There was no difference in the average age of patients in the two groups. In the non-shaved group, there were no infections, while two patients in the shaved group required revision because of shunt infection.

CONCLUSION

Non-shaved shunt surgery may be safe and effective, with no increase of infection rate. We recommend that shunt procedures could be performed without shaving the hair, which may increase patients' satisfaction without increasing infection risk.

Clinical Evaluation a New Treatment for Infection After Ventriculoperitoneal Shunt

ABSTRACT

To explore a new surgical treatment for infection and obstruction of ventriculoperitoneal shunt in hydrocephalus. Two cases of post-operative infection of ventriculoperitoneal shunt were analyzed retrospectively. One case was cryptococcal infection, the other case was Acinetobacter lwoffii. The number of cerebrospinal fluid cells was high, the infection of ventriculoperitoneal shunt was generally complicated with abdominal obstruction, and the hydrocephalus was aggravated again, The authors try to pull out the drainage tube at the end of abdominal cavity for external drainage, combined with intravenous antibiotics, completely control of infection, and then use the original shunt device for intraventricular jugular shunt. The authors explore that this method is simple, safe and effective, and it is an effective and feasible method for the treatment of infection after ventriculoperitoneal shunt.

Peritonitis caused by Roseomonas mucosa after ventriculoperitoneal shunt revision: a case report

Ventriculoperitoneal shunt (VPS) is an adequate treatment for congenital hydrocephalus or chronic hydrocephalus in adults. Yet, it is a surgery associated with a significant rate of complications amongst neurosurgical procedures, with frequent shunt obstructions and infections. We report the first-ever case of peritonitis caused by Roseomonas mucosa, shortly after the revision of a VPS ventricular catheter. Hardware removal and proper antibiotic therapy led to the patient's recovery. Roseomonas mucosa is an opportunistic skin pathogen with an antibiotic resistance profile to many beta-lactamines and a tropism for indwelling catheters and post-operative period. Nowadays, it should be taken into account in case of infection of indwelling catheters and for some implantable medical devices.

Multidrug-Resistant Staphylococcus epidermidis Ventriculostomy-Related Infection Successfully Treated by Intravenous Ceftaroline after Failure of Daptomycin Treatment

BACKGROUND

Ventriculostomy-related infection with multidrug-negative strains are challenging to treat. We report the use of new antibiotics in such a case.

CASE DESCRIPTION

We report the case of a neurosurgical intensive care unit patient who developed ventriculostomy-related infection with a multidrug-resistant Staphylococcus epidermidis. Vancomycin, recommended in such cases, was not used due to high minimal inhibitory concentrations and concerns for lack of pharmacokinetic/pharmacodynamic target attainment. Daptomycin and ceftaroline remained the only treatment options. Daptomycin was shown microbiologically ineffective after 10 treatment days, with undetectable cerebrospinal fluid (CSF) concentration. Ceftaroline, a novel beta-lactam agent to which the strain showed susceptibility, was thus used. Serum and CSF samples were assessed for antibiotic concentrations. Our results show that CSF bacterial clearance was obtained after 6 days of such treatment. Serum and CSF samplings showed low penetration ratios (2.6%-4.8%), probably due to mild inflammatory CSF profile, with CSF concentration at minimal inhibitory concentration level.

CONCLUSIONS

We observed than even in the case of mild meningeal inflammation, ceftaroline penetration in CSF, although moderate, enabled efficient bacterial clearance and clinical efficacy, in adjunction to correct ventriculoperitoneal shunt management.

Sonication Improves Pathogen Detection in Ventriculoperitoneal Shunt-Associated Infections

BACKGROUND

Antimicrobial treatment of ventriculoperitoneal (VP) shunt infections is challenging when the causative pathogen is unknown.

OBJECTIVE

To evaluate the value of sonication of explanted shunt-devices to improve the microbiological detection rate.

METHODS

All consecutive patients undergoing revision surgery due to suspected VP-shunt infection from January 2015 to February 2017 were evaluated. Intraoperative tissue samples, wound swabs, and cerebrospinal fluid (CSF) were collected for microbiological examination. In a subgroup of patients, the removed implants were additionally sent for sonication.

RESULTS

A total of 35 patients were included with a mean age of 57.5 ± 18 yr, 21 were female (60%). In 13 patient's tissue samples, CSF and wound swabs were analyzed. In 22 patients, the explanted device was additionally sent for sonication. All 22 sonication cultures showed a positive microbiological result (100%), whereas with conventional microbiological methods, the causative microorganism was identified in 8 of 13 (61%; P = .018). Analyzed by method, all 22 sonication cultures (100%) were positive and 21 of 35 conventional microbiological analysis results (60%) detected the causative agent (P < .001.) In 18 patients (51%), antimicrobial treatment was started preoperatively. In those patients, the pathogen was detected in all 12 sonication cultures (100%), whereas conventional methods grew a pathogen in 3 of 6 patients (P = .005).

CONCLUSION

Sonication significantly increases the microbiological yield in VP-shunt infections, especially in patients receiving antibiotics prior to diagnostics and in infections caused by low-virulent organisms. The implementation of sonication into the clinical routine can substantially increase the rate of pathogen detection allowing targeted treatment.

Risk of ventriculoperitoneal shunt infection with coexisting percutaneous endoscopic gastrostomy tube and associated factors

Objectives

Percutaneous endoscopic gastrostomy (PEG) tubes and ventriculoperitoneal shunts (VPS) are commonly placed in neurologically impaired patients. There is concern about safety of VPS coexisting with PEG tubes due to the potential for an increased risk of infection. In this study, we assess the risk of VPS infection and the amount of time between both procedures.

Patients and methods

Retrospective chart review of patients from our institution who had VPS and PEG tubes placed during the same hospitalization between 2014 and 2018. Our primary focus was assessing risk of VPS infection and timing of procedures in this patient population. Additionally, we assessed other factors which may contribute to VPS infection including SIRS criteria at time of VPS placement, comorbidities and other procedures performed. None of the SIRS factors were associated with VPS infection.

Results

45 patients met inclusion criteria. Our VPS infection rate was found to be 7% (n = 3). These patients had 4, 16, and 36 days between procedures. 89% of our patients had PEG tube placed prior to VPS with 2 of these patients developing a VPS infection. At the time of VPS placement 42% of patients had SIRS. None of the SIRS factors were associated with VPS infection.

Conclusion

Our VPS infection rate remained low even when they were performed during the same hospitalization as a PEG tube placement. SIRS is not associated with the development of VPS infections and is not an absolute contraindication to placing a VPS.

Characteristics of Intracranial Group A Streptococcal Infections in US Children, 1997-2014

BACKGROUND

Few data on intracranial group A Streptococcus (GAS) infection in children are available. Here, we describe the demographic, clinical, and diagnostic characteristics of 91 children with intracranial GAS infection.

METHODS

Cases of intracranial GAS infection in persons ≤18 years of age reported between 1997 and 2014 were identified by the Centers for Disease Control and Prevention's population- and laboratory-based Active Bacterial Core surveillance (ABCs) system. Medical charts were abstracted using a active, standardized case report form. All available isolates were emm typed. US census data were used to calculate rates.

RESULTS

ABCs identified 2596 children with invasive GAS infection over an 18-year period; 91 (3.5%) had an intracranial infection. Intracranial infections were most frequent during the winter months and among children aged <1 year. The average annual incidence was 0.07 cases per 100000 children. For 83 patients for whom information for further classification was available, the principal clinical presentations included meningitis (35 [42%]), intracranial infection after otitis media, mastoiditis, or sinusitis (34 [41%]), and ventriculoperitoneal shunt infection (14 [17%]). Seven (8%) of these infections progressed to streptococcal toxic shock syndrome. The overall case fatality rate was 15%. GAS emm types 1 (31% of available isolates) and 12 (13% of available isolates) were most common.

CONCLUSIONS

Pediatric intracranial (GAS) infections are uncommon but often severe. Risk factors for intracranial GAS infection include the presence of a ventriculoperitoneal shunt and contiguous infections in the middle ear or sinuses.

Risk Factors and Outcomes of Cutibacterium acnes Postoperative Central Nervous System Infection: A Case-Control Study

OBJECTIVE

Cutibacterium acnes has emerged as a significant cause of postoperative central nervous system infections (PCNSIs). We sought to determine risk factors and outcomes associated with C. acnes PCNSI.

METHODS

This was a single-center 1:1 case-control study of patients with monobacterial C. acnes-associated PCNSI (cases) and unmatched controls with PCNSI caused by aerobic organisms. Patient and procedure-related characteristics were compared between groups. The main outcome was cure at 90 days after diagnosis. Mortality and neurologic disability were secondary outcomes.

RESULTS

We identified 13 patients with C. acnes PCNSI and 13 controls. All patients had postoperative intracranial abscess. Onset of infection was significantly later for cases versus controls (median and range, 22 [19-116] days and 15 [1-27] days, respectively; P = 0.002). Prolonged anaerobic incubation was required for C. acnes isolation (median, 8 days vs. 2 days for aerobic pathogens; P < 0.0001). The use of sealant and implants, fever at presentation, and white blood cell and C-reactive protein levels were similar between the 2 groups. All patients underwent surgical drainage. Patients received a median of 4 antibiotic drugs and 85 antibiotic days of treatment, with no significant between-group differences. Cure at 90 days was achieved for 10 patients (76.9%) with C. acnes PCNSI and 11 (84.6%) controls (P = 1.0).

CONCLUSIONS

C. acnes PCNSI presents later than infection with aerobic bacteria but is associated with similar risk factors and clinical outcomes. These results underscore the importance of prolonged anaerobic incubation to optimize the recovery of C. acnes in the laboratory.

Analysis of the Rate and Pattern of Ventriculoperitoneal Shunt Infection and Ventricular Catheter Culture Yield: A 10-Year Single-Institute Experience

AIM

We aimed to study the rate and pattern of ventriculoperitoneal shunt (VPS) infections at the Jordan University Hospital (JUH) over 10 years and investigate the yield of ventricular catheter tip culture in the evaluation of shunt infection.

PATIENTS AND METHODS

All patients operated on at our institution for ventriculoperitoneal shunt (VPS) insertion, reinsertion, and revision between 2009 and 2018 were included. Data (age, gender, pathology, and history of shunt infection) were collected from patients' files. Rates of infection and results of culture (cerebrospinal fluid and ventricular catheter tip) were obtained from laboratory records.

RESULTS

According to our hospital database, 310 patients were eligible for this study. The rate of infection was 11.1% per ventriculoperitoneal procedure, and the most common -organism was coagulase-negative Staphylococcus (CoNS) which was the cause of infection in 51.4% of the cases. Twenty-one percent of proved shunt infection cases showed a positive ventricular catheter tip culture.

CONCLUSION

The rate and pattern of shunt infections at our institution are comparable with the international figures and data. Methods of catheter tip culturing should be improved to increase the yield of this practice.

Pediatric Ventriculoperitoneal Shunt Infection: The Role of Shunt Tract Debridement in Mycobacterium abscessus Eradication

Ventricular shunt infections caused by nontuberculous mycobacteria are uncommon, and those caused by Mycobacterium abscessus are particularly rare. This mycobacterium is intrinsically resistant to first-line anti-tuberculous drugs and is considered the most pathogenic of the atypical, rapidly growing mycobacteria. Given the paucity of reported M. abscessus ventricular shunt infections, the appropriate surgical treatment for these cases, especially in the pediatric setting, has yet to be described. The authors present a 4-year-old male with history of intraventricular hemorrhage resulting in hydrocephalus who presented with an M. abscessus ventricular shunt infection that disseminated to the skin and soft tissue of the entire shunt tract. Despite aggressive antimicrobial therapy, several shunt exchanges, and numerous incisions and debridements of separate infected tract areas, the patient's clinical course was prolonged by multiple relapses and re-admissions. Only after opening and debriding the entire length of the infected tract, which measured 100 cm and extended from the scalp to the groin, and months of intrathecal antibiotics did CSF and tissue culture results become negative, and the entire tract was able to be closed. This article describes the management of the second-encountered pediatric M. abscessus shunt infection along with the management of the 4 previously reported cases. In addition, it highlights the vital role of early, aggressive surgical debridement to achieve infection eradication.

Evaluation of Oxacillin and Cefoxitin Disk Diffusion and Microbroth Dilution Methods for Detecting mecA-Mediated β-Lactam Resistance in Contemporary Staphylococcus epidermidis Isolates

Methicillin (β-lactam) resistance in Staphylococcus epidermidis is mediated by the mecA gene, with resistance reported to be as high as 90%. The goal of this study was to evaluate oxacillin and cefoxitin disk diffusion (DD) and broth microdilution (BMD) methods for the detection of mecA-mediated β-lactam resistance in 100 human isolates of S. epidermidis (48 mecA-positive isolates and 52 mecA negative isolates). Oxacillin DD tests using the Clinical and Laboratory Standards Institute (CLSI) M100-S28 breakpoints for S. pseudintermedius/S. schleiferi accurately differentiated mecA-positive and -negative S. epidermidis isolates, with categorical agreement (CA) of 100% and no very major errors (VMEs) or major errors (MEs) identified. Likewise, oxacillin BMD and cefoxitin DD tests using the coagulase-negative Staphylococcus species (CoNS) breakpoints were highly reliable for detecting mecA-mediated β-lactam resistance in S. epidermidis isolates. For cefoxitin DD and BMD results interpreted using S. aureus/S. lugdunensis breakpoints, the CA was 97.6% and 96.2%, respectively. There were 4.9% VMEs for cefoxitin DD with 0% MEs, and 3.6% VMEs and 3.9% MEs for cefoxitin BMD. Oxacillin BMD using S. aureus/S. lugdunensis breakpoints yielded the highest VMEs at 17.4% and 90% CA. Our findings demonstrate that oxacillin DD tests using the CLSI M100-S28 breakpoints for S. pseudintermedius/S. schleiferi and oxacillin BMD and cefoxitin DD tests using the CoNS breakpoints reliably identified mecA-mediated β-lactam resistance in S. epidermidis Using mecA PCR as the gold standard, the PBP2a SA culture colony test (Abbott Diagnostics) exhibited 100% sensitivity and specificity whereas 2 false negatives were identified using the PBP2' latex agglutination test kit (Thermo Fisher Scientific) with sensitivity and specificity of 95.8% and 100%, respectively.

Natural history of ventriculostomy-related infection under appropriate treatment and risk factors of poor outcome: a retrospective study

OBJECTIVE

The authors aimed to describe the natural history of ventriculostomy-related infections (VRIs) under appropriate treatment and to assess risk factors for poor outcome.

METHODS

All patients older than 18 years in whom an external ventricular drain (EVD) had been implanted and who had developed a VRI requiring treatment were included in this retrospective study. D0 was defined as the first day of antibiotic administration. Clinical and biological parameters were compared each day beginning with D1 and ending with D10 to those of D0. The authors defined D0 in a control group as the day a CSF culture came back positive, without any sign of infection. The authors then searched for poor prognostic factors in the VRI group.

RESULTS

Among 567 patients requiring an EVD between January 2007 and October 2017, 39 developed a VRI. Most were monomicrobial infections, and 47 microbes were responsible (45% were gram-positive cocci). Clinical parameters differed significantly from the control group during the first 2 days and then returned to baseline. The CSF parameters differed significantly from the control group for a longer period, returning to baseline after 5 days. CSF sterilization occurred in a median time of 2 days. An intrathecal route or EVD exchange was not associated with a poor outcome. No clinical or biological parameter between D3 and D5 was linked to outcome.

CONCLUSIONS

Clinical status improved faster than CSF parameters (before and after D5, respectively). Some CSF parameters remained abnormal until D10. Body temperature and microbiological cultures normalized faster than other parameters.

Identification of Potential Cerebrospinal Fluid Biomarkers To Discriminate between Infection and Sterile Inflammation in a Rat Model of Staphylococcus epidermidis Catheter Infection

Staphylococcus epidermidis cerebrospinal fluid (CSF) shunt infection is a common complication of hydrocephalus treatment, creating grave neurological consequences for patients, especially when diagnosis is delayed. The current method of diagnosis relies on microbiological culture; however, awaiting culture results may cause treatment delays, or culture may fail to identify infection altogether, so newer methods are needed.

Staphylococcus epidermidis cerebrospinal fluid (CSF) shunt infection is a common complication of hydrocephalus treatment, creating grave neurological consequences for patients, especially when diagnosis is delayed. The current method of diagnosis relies on microbiological culture; however, awaiting culture results may cause treatment delays, or culture may fail to identify infection altogether, so newer methods are needed. To investigate potential CSF biomarkers of S. epidermidis shunt infection, we developed a rat model allowing for serial CSF sampling. We found elevated levels of interleukin-10 (IL-10), IL-1β, chemokine ligand 2 (CCL2), and CCL3 in the CSF of animals implanted with S. epidermidis-infected catheters compared to sterile controls at day 1 postinfection. Along with increased chemokine and cytokine expression early in infection, neutrophil influx was significantly increased in the CSF of animals with infected catheters, suggesting that coupling leukocyte counts with inflammatory mediators may differentiate infection from sterile inflammation. Mass spectrometry analysis revealed that the CSF proteome in sterile animals was similar to that in infected animals at day 1; however, by day 5 postinfection, there was an increase in the number of differently expressed proteins in the CSF of infected compared to sterile groups. The expansion of the proteome at day 5 postinfection was interesting, as bacterial burdens began to decline by this point, yet the CSF proteome data indicated that the host response remained active, especially with regard to the complement cascade. Collectively, these results provide potential biomarkers to distinguish S. epidermidis infection from sterile postoperative inflammation.