Ventriculitis: A Severe Complication of Central Nervous System Infections

Pediatric non-congenital central nervous system infections: role of imaging in the emergency department

Neurological emergencies in pediatric patients, including central nervous system infections like meningitis and encephalitis, account for significant morbidity and mortality. Neuroimaging plays an important role in the management of these infections, especially when children present with non-specific symptoms such as fever, seizures, or altered consciousness. While computed tomography scans are typically the initial imaging step, magnetic resonance imaging is preferred for its superior detail and lack of ionizing radiation. Radiologists play a crucial role in guiding clinicians to select the appropriate imaging modality based on clinical presentation, patient age, and available technology. Optimizing techniques for these studies may help to give an overview of imaging protocols and an optimal diagnostic algorithm for these patients. In this article, we delineate the prevalent radiological manifestations associated with the primary etiological agents of central nervous system infections, encompassing bacteria, fungi, viruses, and parasites. Furthermore, we share our clinical experience with particular radiologic findings in select pathologies, underscoring the critical importance of evaluating these non-congenital infections within the context of emergency medical care.

A retrospective study on the efficacy of neuro-endoscopic lavage compared to conventional antibiotic treatment in pyogenic ventriculitis

Pyogenic ventriculitis (PV) is a severe and challenging infection with high morbidity, commonly associated with neurosurgical procedure. Conventional treatment involves prolonged antibiotic therapy and cerebrospinal fluid drainage but is associated with poor outcome. Neuro-endoscopic lavage (NEL) is a promising technique allowing direct reduction of bacterial load, which can potentially improve patient outcomes. This study aims to address the safety and efficacy of NEL. A retrospective cohort study was conducted on 22 patients with PV treated at West China Hospital from December 2019 to March 2024. Patients were divided into two groups: one receiving conventional therapy and the other undergoing NEL in addition to standard treatment. Primary and secondary outcomes, including clinical cure rate, mortality, and CSF sterilization, were analyzed. NEL significantly improved the clinical cure rate (83.33% vs. 40.00%, P = 0.0480). Although the 6-month mortality rate was not significantly different (P = 0.3233), NEL showed a trend toward faster recovery and a higher CSF sterilization rate. Neuro-endoscopic lavage significantly improves clinical outcomes in patients with pyogenic ventriculitis and represents a safe, preferred treatment option.

Cerebrospinal fluid leak-associated ventriculitis - a case report

We present a case of a 74-year-old woman with headaches, pyrexia and intermittent right-sided otorrhoea and rhinorrhoea. Her nasal discharge tested positive for beta-2-transferrin, confirming a cerebrospinal fluid (CSF) leak. High-resolution CT (HRCT) mastoids showed a defect in the right tegmen, and CSF within the middle ear and mastoid air cells. A gadolinium-enhanced MRI brain showed high signal in the occipital horns of the lateral ventricles with diffusion-weighted imaging (DWI) and a low signal with DWI-apparent diffusion coefficient (DWI-ADC), consistent with ventriculitis. She made an uneventful recovery after 6 weeks of intravenous antibiotics. The patient had surgical repair of bony defects to prevent recurrence. This highlights a rare case of ventriculitis associated with a spontaneous CSF leak, with no existing set diagnostic criteria, and high mortality. High clinical suspicion aided by appropriate imaging, and a multidisciplinary approach to management are imperative.

Rapidly Progressive Pyogenic Ventriculitis Associated With Bacterial Meningitis Caused by Streptococcus intermedius

Ventriculitis commonly arises as a complication of various central nervous system conditions. The causes of ventriculitis include both iatrogenic conditions, such as catheter-related infections, and non-iatrogenic conditions, such as community-acquired bacterial meningitis. The incidence of pyogenic ventriculitis associated with community-acquired bacterial meningitis remains unclear. Additionally, the optimal treatment strategy for pyogenic ventriculitis secondary to community-acquired bacterial meningitis remains uncertain. A 47-year-old man presented with headache, fever, and impaired consciousness. At admission, cerebrospinal fluid analysis five days after the onset (day one) revealed elevated white blood cell count with neutrophilic predominance, increased protein levels, and significantly reduced glucose. Initial brain computed tomography (CT) showed bilateral lateral ventricular enlargement with subtle fluid accumulation in the right lateral ventricle. Despite the initiation of empirical antimicrobial therapy, follow-up CT two days later demonstrated a rapid progression of fluid accumulation in the bilateral lateral ventricles. Diffusion-weighted magnetic resonance imaging (MRI) confirmed high signal intensity within the ventricles, consistent with intraventricular pus. Emergency external ventricular drainage (EVD) was promptly performed, and cultures from the intraventricular pus identified Streptococcus intermedius. These findings led to a diagnosis of pyogenic ventriculitis with secondary hydrocephalus associated with bacterial meningitis. Initial clinical improvement was observed following EVD. The EVD catheter was removed 15 days after the procedure on day 18. However, the patient developed status epilepticus, necessitating a second EVD procedure on day 22. Subsequent intervention and continued antimicrobial therapy from day one until day 52 resulted in a follow-up MRI on day 55 confirming the resolution of intraventricular pus. The ventricular drain was safely removed, and the patient was discharged on day 68 in stable condition with only mild residual cognitive impairment. This case underscores several critical considerations in managing pyogenic ventriculitis with hydrocephalus secondary to bacterial meningitis. First, careful imaging follow-up is crucial for monitoring disease progression and guiding timely interventions. Second, the prompt implementation of EVD can play a pivotal role in improving patient outcomes. Finally, EVD should be maintained until imaging confirms the complete resolution of intraventricular pus. Adhering to these management principles likely helps optimize prognosis in these challenging cases.

Cerebrospinal fluid proteomics reveals the innate immunity and blood-brain barrier dysregulation in a patient with multidrug-resistant Acinetobacter baumannii ventriculitis treated with intrathecal and intravenous polymyxin B

Acinetobacter baumannii is a major pathogen of nosocomial meningitis and ventriculitis. Due to very limited antibiotic treatment options, polymyxins are often used as a last-line therapy. To optimise polymyxin use in the intraventricular environment, cerebrospinal fluid (CSF) proteomics was employed to investigate host-pathogen-polymyxin interactions in a 69-year-old patient with multidrug-resistant A. baumannii ventriculitis treated with a combination of intrathecal (ITH; 50,000 IU q24h/q48h), intraventricular (IVT; 50,000 IU q48h), and intravenous (500,000 IU, q12h) polymyxin B. CSF was collected before the first ITH dose in the ICU (0 h) and at 24 h, Day 7 and Day 26. The proteome was quantified at each time point and proteins with Qvalue <0.05 and fold change >1.2 were considered differentially expressed. Within 24 h of ITH/IVT polymyxin B administration, the innate immune system and neuroimmunity were highly active, evidenced by up-regulation of various pathways related to pathogen invasion, endocytosis and neutrophil degranulation. Blood-brain barrier impairment had worsened at 24 h but signs of repair were evident on Day 7 and Day 26. This is the first CSF proteomic study with polymyxins. Our findings provide critical mechanistic insights into optimizing ITH/IVT polymyxin administration.

Intracranial complications in adult patients with severe pneumococcal meningitis: a retrospective multicenter cohort study

BACKGROUND

We aimed to investigate the association of intracranial complications diagnosed on neuroimaging with neurological outcomes of adults with severe pneumococcal meningitis.

METHODS

We performed a retrospective multicenter study on consecutive adults diagnosed with pneumococcal meningitis requiring at least 48 h of stay in the intensive care unit (ICU) and undergoing neuroimaging, between 2005 and 2021. All neuroimaging were reanalyzed to look for intracranial complications which were categorized as (1) ischemic lesion, (2) intracranial hemorrhage (3) abscess/empyema, (4) ventriculitis, (5) cerebral venous thrombosis, (6) hydrocephalus, (7) diffuse cerebral oedema. The primary outcome was unfavorable outcome at 90 days after ICU admission, defined by a modified Rankin Scale (mRS) score > 2.

RESULTS

Among the 237 patients included, intracranial complications were diagnosed in 68/220 patients (31%, 95%CI 0.25-0.37) who underwent neuroimaging at ICU admission and in 75/110 patients (68%, 95%CI 0.59-0.77) who underwent neuroimaging during ICU stay. At 90 days, 103 patients (44%, 95%CI 37-50) had unfavorable outcome, including 71 (30%) deaths. The most frequent intracranial complications were ischemic lesion (69/237 patients, 29%), diffuse cerebral oedema (43/237, 18%) and ventriculitis (36/237, 15%). Through multivariable analysis, we found that intracranial complications (adjusted odds ratio (aOR) 2.88, 95%CI 1.37-6.21) were associated with unfavorable outcome, along with chronic alcohol consumption (aOR 3.10, 95%CI 1.27-7.90), chronic vascular disease (aOR 4.41, 95%CI 1.58-13.63), focal neurological sign(s) (aOR 2.38, 95%CI 1.11-5.23), and cerebrospinal fluid leukocyte count < 1000 cell/microL (aOR 4.24, 95%CI 2.11-8.83). Competing risk analysis, with persistent disability (mRS score 3-5) as the primary risk and ICU-death as the competing risk, revealed that chronic alcohol consumption was the sole significant variable associated with persistent disability at 90 days (cause-specific hazard ratio 4.26, 95%CI 1.83-9.91), whereas the remaining variables were associated with mortality.

CONCLUSIONS

In adults with severe pneumococcal meninigitis, intracranial complications were independently associated with a higher risk of poor functional outcome, in the form of persistent disability or death. This study highlights the value of neuroimaging studies in this population, and provides relevant information for prognostication.

Current understanding of infection of the ventricles and its complications

INTRODUCTION

Ventriculitis, characterized by inflammation of the ventricles in the brain, frequently occurs as a complication of neurosurgical interventions such as the insertion of cerebrospinal fluid (CSF) shunts or external ventricular drains. It can also present as a community-acquired pathology, broadening its clinical significance and complicating diagnosis and treatment. This condition presents significant challenges, primarily due to its association with various medical devices and the predisposing conditions of patients which enhance infection risks.

AREAS COVERED

The review comprehensively explores the etiology, risk factors, diagnostic methodologies, and treatment options for ventriculitis. A thorough literature search was conducted, focusing on recent studies, meta-analyses, and clinical reports that discuss the incidence rates, the effectiveness of different management strategies, and the impact of device-related and community-acquired infections. Particular attention is given to the role of CSF drains and shunts, biofilms, and the prophylactic measures employed in clinical settings to mitigate infection risks.

EXPERT OPINION

Despite advances in medical technology and infection control protocols, ventriculitis remains a severe complication in both neurosurgical and community settings. The review highlights the need for continued research into innovative diagnostic tools and more effective infection control strategies.

Intrathecal Nicardipine as Treatment for Severe Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage: A Retrospective Clinical Study

Introduction Vasospasm and delayed cerebral ischemia (DCI) are complications of aneurysmal subarachnoid hemorrhage (aSAH) and contribute up to 23% of the disability and deaths from aSAH. The use of intrathecal nicardipine (ITN) as a possible treatment for DCI has been explored with mixed results. We present a retrospective series comparing standard post-aSAH care to standard care plus ITN therapy. The primary objective of this study was to assess for any difference in functional outcome in terms of modified Rankin scale (mRS) score between the standard therapy group and ITN group at discharge and one month after discharge.  Methods The Institutional Review Board (IRB) approval was obtained for a retrospective chart review of patients with aSAH who were treated at the University of Mississippi Medical Center between January 2012 and June 2019. The inclusion criteria included sufficient available medical documentation, aSAH with documentation of an intracranial aneurysm, and age ≥ 18. The exclusion criteria included non-aSAH, patients with insufficient medical records, and mycotic aneurysms. The decision to treat with ITN was based on the individual practice of a single neuro-intensivist in collaboration with the neurosurgical staff. Results A total of 385 patients were included in the study with 31 patients receiving ITN. Those within the nicardipine group presented with significantly worse Hunt and Hess grades and experienced significantly worse cerebral vasospasm, higher transcranial Doppler (TCD) velocities, higher rates of DCI, and higher rates of hydrocephalus. When controlling for placement of an external ventricular drain, the patients in the ITN group experienced higher rates of ventriculitis (10.0% vs. 2.0%, p < 0.05). There was no significant difference between the two groups in the intensive care unit (ICU) stay, hospital stay, mRS at discharge, or mRS at one-month follow-up. Conclusion In our series, ITN therapy did not significantly alter outcomes in terms of mRS at discharge or at one month after discharge. However, there was a significant increase in ventriculitis among patients who received this therapy.

Central Nervous System Infections in Patients With Ventriculoperitoneal Shunts Admitted for Primary Abdominal Infections: A US Nationwide Cohort Analysis

BACKGROUND AND OBJECTIVES

Although ventriculoperitoneal (VP) shunts are a common treatment for hydrocephalus, there are complication risks including infections. Late complications such as ventriculitis from ascending abdominal infections can have severe consequences. However, the incidence of central nervous system (CNS) infections in VP shunt patients with abdominal infections is not well understood. We aimed to determine the incidence of CNS infections in VP shunt patients admitted with abdominal infections.

METHODS

Using the National Inpatient Sample, we studied patients from 2016 to 2019 to determine the incidence of CNS infections in VP shunt patients admitted with abdominal infections. Results were compared with VP shunt patients admitted for primary pneumonia.

RESULTS

Among 725 VP shunt patients presenting with abdominal infections, 20 (2.8%) had CNS infections. Chronic obstructive pulmonary disease, hypertension, older age, and a smoking history were more common in patients with CNS infections and primary abdominal infection (P < .05). Patients who developed CNS infection had a significantly higher likelihood of both blood transfusion and coma but a lower likelihood of seizures. VP shunt patients with CNS infections were more likely to undergo shunt removal (odds ratio [OR] = 23.167, P < .001). 4.1% of VP shunt patients with primary abdominal infections died during admission. In a population of primary abdominal infection and pneumonia patients with VP shunts, a multivariate logistic regression analysis controlling for age, sex, and comorbidities identified abdominal infection as an independent risk factor for both CNS infection (OR = 51.208, P < .001) and inpatient death (OR = 3.417, P < .001). Among 6620 VP shunt patients admitted with primary pneumonia, only 5 (0.1%) had CNS infection compared with 20 (2.8%) in those with a primary abdominal infection (OR = 37.532, P < .001), and mortality was 1.6% vs 4.1% for those with a primary abdominal infection (P < .05).

CONCLUSION

CNS infections in VP-shunted patients with abdominal infections are relatively rare but may lead to increased risks of death and other serious adverse outcomes.

Lesion region inpainting: an approach for pseudo-healthy image synthesis in intracranial infection imaging

The synthesis of pseudo-healthy images, involving the generation of healthy counterparts for pathological images, is crucial for data augmentation, clinical disease diagnosis, and understanding pathology-induced changes. Recently, Generative Adversarial Networks (GANs) have shown substantial promise in this domain. However, the heterogeneity of intracranial infection symptoms caused by various infections complicates the model's ability to accurately differentiate between pathological and healthy regions, leading to the loss of critical information in healthy areas and impairing the precise preservation of the subject's identity. Moreover, for images with extensive lesion areas, the pseudo-healthy images generated by these methods often lack distinct organ and tissue structures. To address these challenges, we propose a three-stage method (localization, inpainting, synthesis) that achieves nearly perfect preservation of the subject's identity through precise pseudo-healthy synthesis of the lesion region and its surroundings. The process begins with a Segmentor, which identifies the lesion areas and differentiates them from healthy regions. Subsequently, a Vague-Filler fills the lesion areas to construct a healthy outline, thereby preventing structural loss in cases of extensive lesions. Finally, leveraging this healthy outline, a Generative Adversarial Network integrated with a contextual residual attention module generates a more realistic and clearer image. Our method was validated through extensive experiments across different modalities within the BraTS2021 dataset, achieving a healthiness score of 0.957. The visual quality of the generated images markedly exceeded those produced by competing methods, with enhanced capabilities in repairing large lesion areas. Further testing on the COVID-19-20 dataset showed that our model could effectively partially reconstruct images of other organs.

Endoscopic Ventricular Lavage in Pediatric Pyogenic Cerebral Ventriculitis Associated with Shunt: Outcomes and Technical Notes

OBJECTIVE

Pyogenic cerebral ventriculitis (PCV) is a rare infectious entity characterized by a potent inflammatory reaction of the ventricular ependyma, which in most cases leads to death. We aim to present the technical note and protocol, based on our center's 10-year experience of the use of endoscopic ventricular lavage (EVL) in pediatric patients with PCV and ventricular peritoneal shunt.

METHODS

For this study, all pediatric patients (<16 years) with VP shunts and PCV who were treated with EVL between January 2012 and January 2022 were included.

RESULTS

Thirty-four pediatric patients with ventriculitis were analyzed. The median age was 6 years, with 61.7% being male. Most consultations occurred on Day 2 of symptoms. Fever (38.2%) and altered consciousness (26.5%) were the most common initial symptoms. Early ventriculitis was observed in 67.7% of patients. Pathogen identification in the initial cerebrospinal fluid sample was 70.6%, while samples from ventricular peritoneal shunt yielded 23.53% and catheter culture 79.4%. Gram-positive bacteria, mainly S.epidermidis (44.1%), was the most commonly isolated agent. EVL was performed in 73.5% on the second or third day. Reinfection occurred in 23.5%, and 26.5% of patients died. Concordance analysis showed 85.3% agreement between LP and catheter tip samples. Functionality improved, with 55.88% achieving a Lansky score of 90. Early ventriculitis was associated with better Lansky scores.

CONCLUSION

EVL can be a useful tool in the management of PCV in cases with VP shunts. Our study suggests a higher chance of isolating an infection-causing germ in the catheter tip culture specimen compared to the cerebrospinal fluid culture. However, future studies with a larger number of patients, or multicentric studies are required for further analysis.

Community-Acquired Meningitis Complicated With Pyogenic Ventriculitis and Hydrocephalus in a Patient With Haematological Malignancy: A Case Report and Literature Review

Meningitis, an infection of the meninges of the central nervous system (CNS), can advance quickly and carries a mortality rate reaching 30% among affected patients. It may become complicated by conditions such as hydrocephalus, ventriculitis, and cerebral abscess. Here, we describe a case of meningitis that was complicated by pyogenic ventriculitis and hydrocephalus in a patient with diffuse large B-cell lymphoma (DLBCL) who underwent chemotherapy and radiotherapy. The patient presented with acute change in mental status and high-grade fever, with few episodes of non-bloody vomiting. Blood culture and cerebrospinal fluid (CSF) culture grew Streptococcus pneumoniae, which was sensitive to ceftriaxone. CT scan of the head showed ventriculomegaly, pansinusitis, and a large left mastoid effusion. MRI of the brain showed layering in ventricles, hydrocephalus, and dural enhancement consistent with pachymeningitis. She was treated with ceftriaxone for 21 days with a meaningful outcome. She was discharged home with near-baseline mental capacity for further physical therapy.

Treatment of cerebral ventriculitis with a new self-irrigating catheter system: narrative review and case series

Cerebral ventriculitis is a life-threatening condition that requires prompt and effective pharmacological intervention. The continuous irrigation of the cerebral ventricles with fluid and its drainage is a system to remove toxic substances and infectious residues in the ventricles; this system is called IRRAflow®. We used this kind of ventricular irrigation/drainage system to treat two patients with post-surgical cerebral ventriculitis and a patient with bacterial meningitis complicated with ventriculitis. In this case series, we discuss the management of these three cases of cerebral ventriculitis: we monitored cytochemical parameters and cultures of the cerebrospinal fluid of patients during their ICU stay and we observed a marked improvement after irrigation and drainage with IRRAflow® system. Irrigation/drainage catheter stay, mode settings, and antibiotic therapies were different among these three patients, and neurological outcomes were variable, according to their underlying pathologies. IRRAflow® system can be applied also in other types of brain injury, such as intraventricular hemorrhage, intracranial abscess, subdural hematomas, and intracerebral hemorrhage, with the aim to remove the hematic residues and enhance the functional recovery of the patients. IRRAflow® seems a promising and useful tool to treat infectious and hemorrhagic diseases in neuro-intensive care unit.

The value of ventricular measurements in the prediction of shunt dependency after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Chronic hydrocephalus requiring shunt placement is a common complication of aneurysmal subarachnoid hemorrhage (SAH). Different risk factors and prediction scores for post-SAH shunt dependency have been evaluated so far. We analyzed the value of ventricle measurements for prediction of the need for shunt placement in SAH patients.

METHODS

Eligible SAH cases treated between 01/2003 and 06/2016 were included. Initial computed tomography scans were reviewed to measure ventricle indices (bifrontal, bicaudate, Evans', ventricular, Huckman's, and third ventricle ratio). Previously introduced CHESS and SDASH scores for shunt dependency were calculated. Receiver operating characteristic analyses were performed for diagnostic accuracy of the ventricle indices and to identify the clinically relevant cut-offs.

RESULTS

Shunt placement followed in 221 (36.5%) of 606 patients. In univariate analyses, all ventricular indices were associated with shunting (all: p<0.0001). The area under the curve (AUC) ranged between 0.622 and 0.662. In multivariate analyses, only Huckman's index was associated with shunt dependency (cut-off at ≥6.0cm, p<0.0001) independent of the CHESS score as baseline prediction model. A combined score (0-10 points) containing the CHESS score components (0-8 points) and Huckman's index (+2 points) showed better diagnostic accuracy (AUC=0.751) than the CHESS (AUC=0.713) and SDASH (AUC=0.693) scores and the highest overall model quality (0.71 vs. 0.65 and 0.67), respectively.

CONCLUSIONS

Ventricle measurements are feasible for early prediction of shunt placement after SAH. The combined prediction model containing the CHESS score and Huckman's index showed remarkable diagnostic accuracy regarding identification of SAH individuals requiring shunt placement. External validation of the presented combined CHESS-Huckman score is mandatory.

A High-Performance Liquid Chromatography—Mass Spectrometry Method for Simultaneous Determination of Vancomycin, Meropenem, and Valproate in Patients with Post-Craniotomy Infection

Vancomycin (VAN), meropenem (MER), and valproate (VPA) are commonly used to treat intracranial infection post-craniotomy and prevent associated epilepsy. To monitor their levels, we developed a novel bioassay based on liquid chromatography–tandem mass spectrometry (LC–MS/MS) for simultaneous determination of these three drugs in human serum and cerebrospinal fluid (CSF). Sample preparation by protein precipitation using acetonitrile was followed by HPLC on a Zorbax 300SB-C8 column (150 mm × 4.6 mm, 5 μm) maintained at 40 °C. The lower limit of quantification (LLOQ) was 5 ng/mL for MER, 0.1 μg/mL for VAN, and 1 μg/mL for VPA in serum and 50 ng/mL for MER, 1 μg/mL for VAN, and 2 μg/mL for VPA in CSF. This method was validated with satisfactory linearity, sensitivity, precision, accuracy, recovery, matrix effects, and stability for all analytes. The assay was then successfully applied to evaluate VPA, MER, and VAN levels in serum and CSF from patients with intracranial infection administrated by intrathecal injection. Compared with intravenous injections, an intrathecal injection can provide sufficient therapeutic effects even if the CSF levels did not reach the effective concentration reported. Our method provided a detection tool to study the effective concentrations of these three drugs in CSF from patients administered via intrathecal injection.

A rare case of Pseudomonas putida ventriculitis in intensive care unit: A case report

Pseudomonas putida is a rare pathogen leading to nosocomial and central nervous system infections. Despite having a low virulence and being a rare organism to cause bacteremia, it can evolve into a multidrug-resistant organism and lead to mortality and morbidity in the intensive care setting. A 64-year-old male gardener was presented with extensive acute subarachnoid hemorrhage with intraventricular extension causing hydrocephalus requiring embolization and coiling following a cerebral angiogram, which showed bilateral posterior circulation aneurysm and left anterior circulation aneurysm. External ventricular drain (EVD) was inserted given the worsening hydrocephalus. During his stay in the intensive care unit (ICU), he was becoming more septic and a full septic workup including a cerebral spinal fluid culture taken from the indwelling catheter of the EVD and was found to be positive for a ceftazidime-sensitive strain of P. putida. Following the treatment with intravenous ceftazidime for 1 week and a revision of the EVD on day 32 of admission, he continued to recover well and showed an improvement in his Glasgow Coma Scale (GCS) and septic parameters. Eventually, he was able to wean off mechanical ventilation. He was discharged from ICU care to the neurosurgical ward with supplemental oxygen on day 42 of admission. It is necessary to be aware of the possibility of nosocomial P. putida infection, especially in patients with indwelling catheters, and to consider the early initiation of appropriate antibiotic regimens once detected as well as strict precautions in hygiene during the management of these patients to avoid further development of multi-drug resistant (MDR) strains.

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

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.

Clinical cure of a difficult-to-treat resistant Pseudomonas aeruginosa ventriculitis using cefiderocol: a case report and literature review

Ventriculitis is a complication of meningitis (community-acquired or nosocomial) or other central nervous system (CNS) infections such as brain abscess. They are associated with a different spectrum of microorganisms, from resistant gram-negative bacilli to staphylococci, that can lead serious illness with high mortality. Difficult-to-treat resistance (DTR) gram-negative bacilli may increase to 20% of deaths respective to susceptible isolates of the same bacteria. We present the first report of a clinical cured case of DTR Pseudomonas aeruginosa ventriculitis in which cefiderocol penetration into the CNS has been confirmed in blood and cerebrospinal fluid. Cefiderocol might be considered for difficult-to-treat CNS infections in view of the recent new cases published as well as our case.

A Rare Case of Primary Pyogenic Ventriculitis in a Patient with Community-acquired Meningitis

Pyogenic ventriculitis is defined as the inflammation of the ependymal lining of the cerebral ventricular system. It is characterized by the presence of suppurative fluid in the ventricles. It mostly affects neonates and children but rarely can be seen in adult population. In adults, it usually affects the elderly population. It is usually healthcare associated and occurs secondary to ventriculoperitoneal shunt, external ventricular drain, intrathecal drug delivery, brain stimulation devices, and neurosurgical intervention. Primary pyogenic ventriculitis though rare should be considered as one of the differential diagnoses in patients who do not improve despite an appropriate antibiotic regimen in bacterial meningitis. Our case report on primary pyogenic ventriculitis secondary to community-acquired bacterial meningitis in an elderly diabetic male patient illustrates the importance of utilization of multiplex polymerase chain reaction (PCR), repeated neuroimaging, and prolonged course of antibiotics for the successful management and outcome.

How to cite this article

Maheshwarappa HM, Rai AV. A Rare Case of Primary Pyogenic Ventriculitis in a Patient with Community-acquired Meningitis. Indian J Crit Care Med 2022;26(7):874-876.

Brain abscess in immunocompetent patients: recent findings

PURPOSE OF REVIEW

We conducted a systematic review of the literature to update findings on the epidemiology and the management of cerebral abscesses in immunocompetent patients.

RECENT FINDINGS

Observational studies suggest that the overall prognosis has improved over the last decades but mortality rates remain high. Several parameters may contribute to a better prognosis, including the identification of common risk factors for brain abscess, the systematic use of brain MRI at diagnosis, the implementation of appropriate neurosurgical and microbiological techniques for diagnosis, the optimization of the antibacterial treatment based on epidemiology and pharmacokinetic/pharmacodynamic studies, and a long-term follow-up for detection of secondary complications. Outcome research on brain abscess is mainly based on observational studies. Randomized controlled trials have yet to be performed to identify clinically relevant interventions associated with improved patient-centered outcomes.

SUMMARY

Our review highlights the importance of a multidisciplinary approach to optimize brain abscess management both at the acute phase and in the long-term. Randomized controlled studies are urgently needed to identify interventions associated with improved outcomes.

Ventriculitis Presenting as a Complication of Haemophilus Influenzae Mastoiditis and Meningitis

Ventriculitis is a rare intracranial disease with potentially life-threatening consequences. Here, we present a case of acute mastoiditis that progressed to Haemophilus influenzae meningitis evolving to ventriculitis. This case was complicated by hydrocephalus that subsequently required the placement of a ventriculoperitoneal shunt. In patients presenting with mastoiditis, it is imperative to initiate early and appropriate treatment to prevent disease progression and devastating outcomes. We aim to increase recognition of potential complications and encourage childhood vaccination of Haemophilus influenzae.

Community-Acquired Meningitis Complicated by Pyogenic Ventriculitis: A Case Report

Ventriculitis is the inflammation of the ependymal lining of the ventricles in the brain which usually occurs as a complication of meningitis, intraventricular devices, intracranial surgery, or brain abscess. Common clinical features include fever, altered mental status, headache, and neck rigidity. Some commonly associated organisms are Streptococcus, gram-negative Bacillus, Staphylococcus, and Meningococcus. Here, we report the case of a 57-year-old female presenting with fever, headache, and altered mental status, along with positive physical examination findings of Kernig’s and Brudzinski’s signs without any focal neurological deficits. Cerebrospinal fluid analysis findings were consistent with bacterial infection with neutrophilic leukocytosis, high protein, and low glucose. The blood culture was positive for Streptococcus pneumoniae. Magnetic resonance imaging was negative for enhancement of the meninges but showed fluid-filled layering in the ventricles consistent with pyogenic ventriculitis. The patient improved clinically within three days of initiation of empiric antibiotics.

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.

Efficacy of Vancomycin and Meropenem in Central Nervous System Infections in Children and Adults: Current Update

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.

Management dilemmas in Nocardia brain infection

PURPOSE OF REVIEW

Brain nocardiosis is a rare but severe infection mostly occurring among immunocompromised patients. In this review, we present recent data on this infection and address some of the common clinical dilemmas encountered in patients with brain nocardiosis.

RECENT FINDINGS

Strategies used to approach a patient with suspected brain nocardiosis include the 'conservative strategy' (without early neurosurgery) and the 'neurosurgical strategy' (with early aspiration or excision of brain abscess[es]). The advantages and disadvantages of both strategies are summarised. Our opinion is that the use of the 'conservative strategy' should be limited to well-selected patients presenting with an easily accessible extra-neurological lesion(s) and have brain abscesses at low risk of treatment failure. In terms of antimicrobial therapy, we summarise the data supporting the use of a multidrug regimen in patients with brain nocardiosis.Last, we list possible reasons for treatment failure in patients with brain nocardiosis and suggest interventions to overcome them.

SUMMARY

Literature is scarce regarding brain nocardiosis, as a consequence of the rarity of this disease. A multidisciplinary and individualised management is required to optimise the outcome of patients with brain nocardiosis.

Ventriculitis: Infection or Inflammation

Ventriculitis, or infection of the cerebrospinal fluid, in the presence of external ventricular drains (EVD), is an important complication and associated with substantial mortality, morbidity, and healthcare costs. Further, the conditions that require the insertion of an EVD, such as neurotrauma and subarachnoid hemorrhage, are themselves associated with inflammation of the cerebrospinal fluid. Phenotypically, patients with inflammation of the cerebrospinal fluid can present with very similar symptoms, signs, and laboratory findings to those with infection. This review examines various controversies relating to the definitions, diagnosis, challenges of differentiating infection from inflammation, prevention, and treatment of ventriculitis in patients with EVDs.