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Nielsen P, Olsen MH, Willer-Hansen RS, Hauerberg J, Johansen HK, Andersen AB, Knudsen JD, Møller K. Ventriculostomy-associated infection (VAI) in patients with acute brain injury-a retrospective study. Acta Neurochir (Wien) 2024; 166:128. [PMID: 38462573 PMCID: PMC10925569 DOI: 10.1007/s00701-024-06018-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/23/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Ventriculostomy-associated infection (VAI) is common after external ventricular drains (EVD) insertion but is difficult to diagnose in patients with acute brain injury. Previously, we proposed a set of criteria for ruling out VAI in traumatic brain injury. This study aimed to validate these criteria. For exploratory purposes, we sought to develop and validate a score for VAI risk assessment in patients with different types of severe acute brain injury. METHODS This retrospective cohort study included adults with acute brain injury who received an EVD and in whom CSF samples were taken over a period of 57 months. As standard non-coated bolt-connected EVDs were used. The predictive performance of biomarkers was analyzed as defined previously. A multivariable regression model was performed with five variables. RESULTS A total of 683 patients with acute brain injury underwent EVD placement and had 1272 CSF samples; 92 (13.5%) patients were categorized as culture-positive VAI, 130 (19%) as culture-negative VAI, and 461 (67.5%) as no VAI. A low CSF WBC/RBC ratio (< 0.037), high CSF/plasma glucose ratio (> 0.6), and low CSF protein (< 0.5g/L) showed a positive predictive value of 0.09 (95%CI, 0.05-0.13). In the multivariable logistic regression model, days to sample (OR 1.09; 95%CI, 1.03-1.16) and CSF WBC/RBC ratio (OR 34.86; 95%CI, 3.94-683.15) were found to predict VAI. CONCLUSION In patients with acute brain injury and an EVD, our proposed combined cut-off for ruling out VAI performed satisfactorily. Days to sample and CSF WBC/RBC ratio were found independent predictors for VAI in the multivariable logistic regression model.
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Affiliation(s)
- Pernille Nielsen
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
- Copenhagen Neuroanaesthesiology and Neurointensive Care Research Group (CONICA), Copenhagen, Denmark.
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Copenhagen Neuroanaesthesiology and Neurointensive Care Research Group (CONICA), Copenhagen, Denmark
| | - Rasmus Stanley Willer-Hansen
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Urology, Zealand University Hospital, Roskilde, Denmark
| | - John Hauerberg
- Copenhagen Neuroanaesthesiology and Neurointensive Care Research Group (CONICA), Copenhagen, Denmark
- Department of Neurosurgery, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Helle Krogh Johansen
- Department of Clinical Microbiology, Diagnostic Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Aase Bengaard Andersen
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jenny Dahl Knudsen
- Department of Clinical Microbiology, Diagnostic Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Copenhagen Neuroanaesthesiology and Neurointensive Care Research Group (CONICA), Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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2
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Stevens AR, Gilbody H, Greig J, Usuah J, Alagbe B, Preece A, Soon WC, Chowdhury YA, Toman E, Chelvarajah R, Veenith T, Belli A, Davies DJ. Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience. World Neurosurg 2023; 176:e265-e272. [PMID: 37207724 DOI: 10.1016/j.wneu.2023.05.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Diversion of cerebrospinal fluid (CSF) is a common neurosurgical procedure for control of intracranial pressure (ICP) in the acute phase after traumatic brain injury (TBI), where medical management is insufficient. CSF can be drained via an external ventricular drain (EVD) or, in selected patients, via a lumbar (external lumbar drain [ELD]) drainage catheter. Considerable variability exists in neurosurgical practice on their use. METHODS A retrospective service evaluation was completed for patients receiving CSF diversion for ICP control after TBI, from April 2015 to August 2021. Patients were included whom fulfilled local criteria deeming them suitable for either ELD/EVD. Data were extracted from patient notes, including ICP values pre/postdrain insertion and safety data including infection or clinically/radiologically diagnosed tonsillar herniation. RESULTS Forty-one patients were retrospectively identified (ELD = 30 and EVD = 11). All patients had parenchymal ICP monitoring. Both modalities affected statistically significant decreases in ICP, with relative reductions at 1, 6, and 24 hour pre/postdrainage (at 24-hour ELD P < 0.0001, EVD P < 0.01). Similar rates of ICP control failure, blockage and leak occurred in both groups. A greater proportion of patients with EVD were treated for CSF infection than with ELD. One event of clinical tonsillar herniation is reported, which may have been in part attributable to ELD overdrainage, but which did not result in adverse outcome. CONCLUSIONS The data presented demonstrate that EVD and ELD can be successful in ICP control after TBI, with ELD limited to carefully selected patients with strict drainage protocols. The findings support prospective study to formally determine the relative risk-benefit profiles of CSF drainage modalities in TBI.
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Affiliation(s)
- Andrew R Stevens
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK; National Institute of Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre (SRMRC), University Hospitals Birmingham, Edgbaston, Birmingham, UK; Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK.
| | - Helen Gilbody
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Julian Greig
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - John Usuah
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Basit Alagbe
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Anne Preece
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Wai Cheong Soon
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Yasir A Chowdhury
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Emma Toman
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK; National Institute of Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre (SRMRC), University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Ramesh Chelvarajah
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK; College of Life and Environmental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Tonny Veenith
- Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK; Department of Anaesthesia and Critical Care, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Antonio Belli
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK; National Institute of Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre (SRMRC), University Hospitals Birmingham, Edgbaston, Birmingham, UK; Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
| | - David J Davies
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK; National Institute of Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre (SRMRC), University Hospitals Birmingham, Edgbaston, Birmingham, UK; Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
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Mahto N, Owodunni OP, Okakpu U, Kazim SF, Varela S, Varela Y, Garcia J, Alunday R, Schmidt MH, Bowers CA. Postprocedural Complications of External Ventricular Drains: A Meta-Analysis Evaluating the Absolute Risk of Hemorrhages, Infections, and Revisions. World Neurosurg 2023; 171:41-64. [PMID: 36470560 DOI: 10.1016/j.wneu.2022.11.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 11/29/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND External ventricular drain (EVD) insertion is often a lifesaving procedure frequently used in neurosurgical emergencies. It is routinely done at the bedside in the neurocritical care unit or in the emergency room. However, there are infectious and noninfectious complications associated with this procedure. This meta-analysis sought to evaluate the absolute risk associated with EVD hemorrhages, infections, and revisions. The secondary purpose was to identify and characterize risk factors for EVD complications. METHODS We searched the MEDLINE (PubMed) database for "external ventricular drain," "external ventricular drain" + "complications" or "Hemorrhage" or "Infection" or "Revision" irrespective of publication year. Estimates from individual studies were combined using a random effects model, and 95% confidence intervals (CIs) were calculated with maximum likelihood specification. To investigate heterogeneity, the t2 and I2 tests were utilized. To evaluate for publication bias, a funnel plot was developed. RESULTS There were 260 total studies screened from our PubMed literature database search, with 176 studies selected for full-text review, and all of these 176 studies were included in the meta-analysis as they met the inclusion criteria. A total of 132,128 EVD insertions were reported, with a total of 130,609 participants having at least one EVD inserted. The pooled absolute risk (risk difference) and percentage of the total variability due to true heterogeneity (I2) for hemorrhagic complication was 1236/10,203 (risk difference: -0.63; 95% CI: -0.66 to -0.60; I2: 97.8%), infectious complication was 7278/125,909 (risk difference: -0.65; 95% CI: -0.67 to -0.64; I2: 99.7%), and EVD revision was 674/4416 (risk difference: -0.58; 95% CI: -0.65 to -0.51; I2: 98.5%). On funnel plot analysis, we had a variety of symmetrical plots, and asymmetrical plots, suggesting no bias in larger studies, and the lack of positive effects/methodological quality in smaller studies. CONCLUSIONS In conclusion, these findings provide valuable information regarding the safety of one of the most important and most common neurosurgical procedures, EVD insertion. Implementing best-practice standards is recommended in order to reduce EVD-related complications. There is a need for more in-depth research into the independent risk factors associated with these complications, as well as confirmation of these findings by well-structured prospective studies.
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Affiliation(s)
- Neil Mahto
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Oluwafemi P Owodunni
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Uchenna Okakpu
- West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Syed F Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Samantha Varela
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Yandry Varela
- Burrell College of Osteopathic Medicine, New Mexico, USA
| | - Josiel Garcia
- Burrell College of Osteopathic Medicine, New Mexico, USA
| | - Robert Alunday
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA.
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Tartara F, Armocida D, Cofano F, Guerrini F, Viganò M, Zoia C, Boeris D, Garbossa D. The Use of Intraventricular Instillation of Vancomycin to Prevent External Ventricular Drainage Related Infection: A Clinical Prospective Study. World Neurosurg 2022; 167:e527-e532. [PMID: 35977680 DOI: 10.1016/j.wneu.2022.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND External ventricular drainage (EVD)-related infection (ERI) represents an important condition with potential high morbidity with significant impact on patient outcomes. Prophylactic systemic antibiotics are routinely administered to patients with EVD, but they do not significantly lower the incidence of ERIs. Intraventricular treatment with vancomycin appeared to be safe and effective, but most reports are case-reports/-series and retrospective studies. METHODS A prospective non-randomized case-control study was conducted in a consecutive series of 116 patients treated with EVD insertion. The study includes the group of patients treated with intrathecal vancomycin (Group A, 62 patients) compared with the control group treated with daily intravenous cefazolin (Group B, 54 patients). RESULTS No statistically significant differences were found between the 2 groups with regard to the duration of catheterization and occurrence of ERI during hospitalization. EVD was replaced in 16 cases (25.8%) in group A and in 12 cases (22.2%) in the control group B (P 0.67). Three cases (4.8%) of ERI have been found in group A and 5 (9.3%) in the control group (P = 0.34). All reported cases of infection in group A were caused by gram-negative agents; on the opposite, cases of infections in the control group B were caused above all by gram-positive bacteria with a statistical difference (P = 0.03). CONCLUSIONS In this first prospective study on this topic, we found that intrathecal Vancomycin administration in EVDs does not reduce the occurrence of ERI compared with intravenous cefazolin prophylaxis, but induces selection of gram-negative bacteria.
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Affiliation(s)
| | - Daniele Armocida
- Human Neurosciences Department, Neurosurgery Division, "Sapienza" University, Rome (RM), Italy.
| | - Fabio Cofano
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin (TO), Italy; Spine Surgery Unit, Humanitas Gradenigo, Turin (TO), Italy
| | | | - Marco Viganò
- Orthopedic Biotechnology Lab, IRCCS Orthopedic Institute Galeazzi, Milan, Italy
| | - Cesare Zoia
- Neurosurgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Davide Boeris
- ASST Grande Ospedale Metropolitano Niguarda, Milano (MI), Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin (TO), Italy
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Kong Y, Ye Y, Ma J, Shi G. Accuracy of heparin-binding protein for the diagnosis of nosocomial meningitis and ventriculitis. Crit Care 2022; 26:56. [PMID: 35260175 PMCID: PMC8903701 DOI: 10.1186/s13054-022-03929-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 02/10/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Yueyue Kong
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi Ye
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiawei Ma
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Karvouniaris M, Brotis A, Tsiakos K, Palli E, Koulenti D. Current Perspectives on the Diagnosis and Management of Healthcare-Associated Ventriculitis and Meningitis. Infect Drug Resist 2022; 15:697-721. [PMID: 35250284 PMCID: PMC8896765 DOI: 10.2147/idr.s326456] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/05/2022] [Indexed: 12/31/2022] Open
Abstract
Ventriculitis or post-neurosurgical meningitis or healthcare-associated ventriculitis and meningitis (VM) is a severe infection that complicates central nervous system operations or is related to the use of neurosurgical devices or drainage catheters. It can further deteriorate patients who have already presented significant neurologic injury and is associated with high morbidity, mortality, and poor functional outcome. VM can be difficult to distinguish from aseptic meningitis, inflammation that follows hemorrhagic strokes and neurosurgical operations. The associated microorganisms can be either skin flora or nosocomial pathogens, most commonly, Gram-negative bacteria. Classical microbiology can fail to isolate the culprit pathogen. Novel cerebrospinal fluid (CSF) biomarkers and molecular microbiology can fill the diagnostic gap and expedite pathogen identification and treatment. The pathogens may demonstrate significant resistant patterns and their antibiotic treatment can be difficult, as many important drug classes, including the beta-lactams and the glycopeptides, hardly penetrate to the CSF, and do not achieve therapeutic levels at the site of the infection. Treatment modifications, such as higher daily dose and prolonged or continuous administration, might increase antibiotic levels in the site of infection and facilitate pathogens clearance. However, in the case of therapeutic failure or infection due to difficult-to-treat bacteria, the direct antibiotic instillation into the CSF, in addition to the intravenous antibiotic delivery, may help in the resolution of infection. However, intraventricular antibiotic therapy may result in aseptic meningitis and seizures, concerning the administration of aminoglycosides, polymyxins, and vancomycin. Meanwhile, bacteria form biofilms on the catheter or the device that should routinely be removed. Novel neurosurgical treatment modalities comprise endoscopic evacuation of debris and irrigation of the ventricles. VM prevention includes perioperative antibiotics, antimicrobial impregnated catheters, and the implementation of standardized protocols, regarding catheter insertion and manipulation.
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Affiliation(s)
- Marios Karvouniaris
- Intensive Care Unit, AHEPA University Hospital, Thessaloniki, Greece
- Correspondence: Marios Karvouniaris, ACHEPA University Hospital, S.Kiriakidi 1, Thessaloniki, 54636, Greece, Tel +302313303645, Fax +302313303096, Email
| | - Alexandros Brotis
- Neurosurgery Department, University Hospital of Larissa, Larissa, Greece
| | | | - Eleni Palli
- Intensive Care Unit, University Hospital of Larissa, Larissa, Greece
| | - Despoina Koulenti
- Second Critical Care Department, Attikon University Hospital, Athens, Greece
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Picetti E, Rosenstein I, Balogh ZJ, Catena F, Taccone FS, Fornaciari A, Votta D, Badenes R, Bilotta F. Perioperative Management of Polytrauma Patients with Severe Traumatic Brain Injury Undergoing Emergency Extracranial Surgery: A Narrative Review. J Clin Med 2021; 11:18. [PMID: 35011760 PMCID: PMC8745292 DOI: 10.3390/jcm11010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 01/28/2023] Open
Abstract
Managing the acute phase after a severe traumatic brain injury (TBI) with polytrauma represents a challenging situation for every trauma team member. A worldwide variability in the management of these complex patients has been reported in recent studies. Moreover, limited evidence regarding this topic is available, mainly due to the lack of well-designed studies. Anesthesiologists, as trauma team members, should be familiar with all the issues related to the management of these patients. In this narrative review, we summarize the available evidence in this setting, focusing on perioperative brain protection, cardiorespiratory optimization, and preservation of the coagulative function. An overview on simultaneous multisystem surgery (SMS) is also presented.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, 43100 Parma, Italy; (E.P.); (A.F.)
| | - Israel Rosenstein
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, 00161 Rome, Italy; (I.R.); (D.V.); (F.B.)
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital, University of Newcastle, Newcastle 2305, Australia;
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital, 47521 Cesena, Italy;
| | - Fabio S. Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Anna Fornaciari
- Department of Anesthesia and Intensive Care, Parma University Hospital, 43100 Parma, Italy; (E.P.); (A.F.)
| | - Danilo Votta
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, 00161 Rome, Italy; (I.R.); (D.V.); (F.B.)
| | - Rafael Badenes
- Department of Anesthesiology and Intensive Care, Hospital Clìnico Universitario de Valencia, University of Valencia, 46010 Valencia, Spain
| | - Federico Bilotta
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, 00161 Rome, Italy; (I.R.); (D.V.); (F.B.)
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Coelho E, Costa L, Martins J, Costa M, Oliveira JE, Maia-Gonçalves A, Lencastre L. Healthcare-Associated Ventriculitis and Meningitis: A Retrospective Analysis. Cureus 2021; 13:e19069. [PMID: 34849306 PMCID: PMC8617354 DOI: 10.7759/cureus.19069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 11/05/2022] Open
Abstract
Background and objective Healthcare-associated ventriculitis and meningitis (HAVM) is frequent in neurocritical patients and associated with significant mortality. Surgery and intracranial devices are usually necessary and may lead to infection. Classical clinical signs and cerebral spinal fluid (CSF) analysis may be unreliable. The purpose of this study was to characterize the prevalence of HAVM, risk factors, and interventions in the neurocritical population admitted in the ICU. Methods This was a retrospective single-center analysis of all adult neurocritical patients admitted to an ICU during a three-year period. Results A total of 218 neurocritical patients were included. The prevalence of HAVM was 13% and it was found to be associated with mortality. When suspected, it was not possible to exclude HAVM in 30% of the patients. HAVM was significantly associated with surgery, surgical reintervention, and brain devices. Sustained fever was the most frequent clinical sign, and it was significantly associated with unexcluded HAVM. CSF cell count was significantly higher in HAVM, though without microbiological isolation in most of the cases. Conclusion Brain damage, interventions, and devices may significantly alter cerebral homeostasis. Sustained fever is very frequent and may be attributed to several conditions. CSF cell count is useful for the diagnosis of HAVM. HAVM is a clinical challenge in the management of neurocritical patients with important therapeutic and prognostic implications.
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Affiliation(s)
| | - Laura Costa
- Intensive Care Medicine, Hospital de Braga, Braga, PRT
| | - José Martins
- Intensive Care Medicine, Hospital de Braga, Braga, PRT
| | - Marina Costa
- Intensive Care Medicine, Hospital de Braga, Braga, PRT
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Xu L, Zhao H, Zhou M, Lang G, Lou H. Single and Repeated Episodes of Candida Species Isolated From Cerebrospinal Fluid for Diagnosing Probable Candida meningitis. Front Microbiol 2021; 12:742931. [PMID: 34721340 PMCID: PMC8554295 DOI: 10.3389/fmicb.2021.742931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The clinical relevance of single or repeated episodes of Candida spp. in cerebrospinal fluid (CSF) in adult patients is debatable. Methods: Forty-two patients with positive Candida episodes in CSF were enrolled in this retrospective study. Results: A total of 42.9% (18/42) were determined to have probable Candida meningitis (PCM). Neurosurgery [odds ratio (OR) (95% confidence interval), OR: 14.4 (1.6–126.1), P = 0.004], lumbar drainage [OR: 5.8 (1.5–23.3), P = 0.009], VP shunt [(OR: 5.6 (1.2–25.8), P = 0.020)], external ventricular drainage [OR: 4.7 (1.3–17.7), P = 0.018], CRP ≥ 10.0 mg/L [OR: 4.9 (1.3–18.1), P = 0.034], and postsurgical broad-spectrum antibiotics [OR: 9.5 (1.8–50.5), P = 0.004] were risk factors associated with PCM. A single CSF Candida episode for the diagnosis of PCM had 7.7% (0.4–37.9%) sensitivity and 20.7% (8.7–40.3%) specificity, whereas repeated episodes of Candida had 66.7% (41.2–85.6%) sensitivity and 95.8% (76.9–99.8%) specificity. No significant difference was found in radiological imaging or CSF profiles between PCM and non-PCM patients. A total of 37.5% (9/24) of patients without PCM received empirical antifungal treatment, and 88.9% (16/18) of patients with PCM received preemptive antifungal treatment. PCM patients had hospitalized mortality rates of 50.0% (9/18). The odds ratio of mortality was 23.0 (2.5–208.6) for PCM patients compared with non-PCM patients (P = 0.001). Conclusion: Both single and repeated positive CSF samples have low validity for the diagnosis of PCM, suggesting that novel strategies for diagnosis algorithms of PCM are urgently needed. Empirical antifungal treatment should be started immediately for suspicious patients with risk factors.
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Affiliation(s)
- Lijun Xu
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Handan Zhao
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Minghan Zhou
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Guanjing Lang
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Haiyan Lou
- Department of Radiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Ramanan M, Shorr A, Lipman J. Ventriculitis: Infection or Inflammation. Antibiotics (Basel) 2021; 10:antibiotics10101246. [PMID: 34680826 PMCID: PMC8532926 DOI: 10.3390/antibiotics10101246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD 4510, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- School of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia;
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Newtown, NSW 1466, Australia
- Correspondence:
| | - Andrew Shorr
- Washington Hospital Center, Medical Intensive Care Unit, Washington, DC 20010, USA;
| | - Jeffrey Lipman
- School of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia;
- Jamieson Trauma Institute and Intensive Care Services, Royal Brisbane and Women’s Hospital, Herston, QLD 4029, Australia
- Nimes University Hospital, University of Montpellier, 30029 Nimes, France
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11
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Abstract
PURPOSE OF REVIEW To review recent data on the epidemiology, microbiology, diagnosis, and management of central nervous system (CNS) infections associated with neurologic devices. RECENT FINDINGS The increasing use of implanted neurologic devices has led to an increase in associated infections. Cerebrospinal fluid (CSF) inflammation may be present after a neurosurgical procedure, complicating the diagnosis of CNS infection. Newer biomarkers such as CSF lactate and procalcitonin show promise in differentiating infection from other causes of CSF inflammation. Molecular diagnostic tests including next-generation or metagenomic sequencing may be superior to culture in identifying pathogens causing healthcare-associated ventriculitis and meningitis. SUMMARY Neurologic device infections are serious, often life-threatening complications. Rapid recognition and initiation of antibiotics are critical in decreasing morbidity. Device removal is usually required for cure.
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Bådholm M, Blixt J, Glimåker M, Ternhag A, Hedlund J, Nelson DW. Cerebrospinal fluid cell count variability is a major confounding factor in external ventricular drain-associated infection surveillance diagnostics: a prospective observational study. Crit Care 2021; 25:291. [PMID: 34380543 PMCID: PMC8359042 DOI: 10.1186/s13054-021-03715-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/29/2021] [Indexed: 11/20/2022] Open
Abstract
Background External ventricular drain (EVD)-related infections (EVDIs) are feared complications that are difficult to rapidly and correctly diagnose, which can lead to unnecessary treatment with broad-spectrum antibiotics. No readily available diagnostic parameters have been identified to reliably predict or identify EVDIs. Moreover, intraventricular hemorrhage is common and affect cerebrospinal fluid (CSF) cellularity. The relationship between leukocytes and erythrocytes is often used to identify suspected infection and triggers the use of antibiotics pending results of cultures, which may take days. Cell count based surveillance diagnostics assumes a homogeneous distribution of cells in the CSF. Given the intraventricular sedimentation of erythrocytes on computed tomography scans this assumption may be erroneous and could affect diagnostics. Aims To evaluate the consistency of cell counts in serially sampled CSF from EVDs, with and without patient repositioning, to assess the effect on infection diagnostics. Methods We performed a prospective single-center study where routine CSF sampling was followed by a second sample after 10 min, allocated around a standard patient repositioning, or not. Changes in absolute and pairwise cell counts and ratios were analyzed, including mixed regression models. Results Data from 51 patients and 162 paired samples were analyzed. We observed substantial changes in CSF cellularity as the result of both resampling and repositioning, with repositioning found to be an independent predictor of bidirectional cellular change. Glucose and lactate levels were affected, however clinically non-significant. No positive CSF cultures were seen during the study. Thirty percent (30%) of patients changed suspected EVDI status, as defined by the cell component of local and national guidelines, when resampling after repositioning. Conclusions CSF cell counts are not consistent and are affected by patient movement suggesting a heterogeneity in the intraventricular space. The relationship between leukocytes and erythrocytes was less affected than absolute changes. Importantly, cell changes are found to increase with increased cellularity, often leading to changes in suspected EVDI status. Faster and more precise diagnostics are needed, and methods such as emerging next generation sequencing techniques my provide tools to more timely and accurately guide antibiotic treatment. Trial Registration NCT04736407, Clinicaltrials.gov, retrospectively registered 2nd February 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03715-1.
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Affiliation(s)
- Marcus Bådholm
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden. .,Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.
| | - Jonas Blixt
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Martin Glimåker
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Ternhag
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Infectious Diseases, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Jonas Hedlund
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Infectious Diseases, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - David W Nelson
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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13
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Acinetobacter baumannii strains isolated from cerebrospinal fluid (CSF) and bloodstream analysed by cgMLST: the dominance of clonal complex CC92 in CSF infections. Int J Antimicrob Agents 2021; 58:106404. [PMID: 34298091 DOI: 10.1016/j.ijantimicag.2021.106404] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 06/29/2021] [Accepted: 07/03/2021] [Indexed: 11/22/2022]
Abstract
A total of 54 unique clinical Acinetobacter baumannii strains isolated from cerebrospinal fluid (CSF) together with 21 bloodstream isolates collected from five tertiary hospitals in East China between April 2013 and November 2016 were studied for antimicrobial susceptibility patterns and the prevalence of antimicrobial resistance genes. Molecular epidemiological characteristics of CSF isolates and the phylogenetic relationship of isolates from different sources were assessed using multilocus sequence typing (MLST) and core genome MLST (cgMLST). Of the 54 CSF isolates, 51 (94.4%) were blaOXA-23-carrying carbapenem-resistant A. baumannii. Their average resistance rate to different classes of antibiotics was extremely high (>90%), except for tigecycline and colistin. According to the Oxford MLST scheme, all CSF isolates fell into 10 defined sequence types (STs) and 4 novel STs. ST195 and ST208 were the leading STs in isolates from either source. A total of 50 CSF isolates and 20 bloodstream isolates were assigned to clonal complex 92 (CC92), revealing a wild distribution of CC92 in the hospitals of East China. In combination with epidemiological data linked in time and space, cgMLST results elucidated intrahospital and interhospital polyclonal dissemination of A. baumannii causing meningitis. Based on cgMLST, there was no correlation between phylogeny and the source of isolation of A. baumannii. These results emphasise that the genetic potential of this pathogen is vast enough to infect multiple human body sites.
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Sakamoto VTM, Vieira TW, Viegas K, Blatt CR, Caregnato RCA. Nursing assistance in patient care with external ventricular drain: a scoping review. Rev Bras Enferm 2021; 74:e20190796. [PMID: 33886830 DOI: 10.1590/0034-7167-2019-0796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 05/21/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to map the available evidence about nursing care aimed at adult patients using external ventricular drain. METHODS this is a review using the scoping review method. RESULTS Initially, 965 studies were identified and, after the eligibility criteria, a sample of 54 publications was obtained. Each of them was assessed according to GRADE, resulting in three studies with high quality; 14 with moderate quality; 32 with low quality; and five with very low quality. It was highlighted 20 nursing care subdivided into nine categories, namely: drainage system; bed positioning and mobilization; catheter care; monitoring of intracranial pressure; and medication administration. CONCLUSIONS the scoping review made it possible to identify the main nursing care directed to adult patients undergoing placement of external ventricular drain from the evidence available to date.
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Affiliation(s)
| | - Tainara Wink Vieira
- Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brazil
| | - Karin Viegas
- Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brazil
| | - Carine Raquel Blatt
- Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brazil
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Qian L, Shi Y, Li F, Wang Y, Ma M, Zhang Y, Shao YW, Zheng G, Zhang G. Metagenomic Next-Generation Sequencing of Cerebrospinal Fluid for the Diagnosis of External Ventricular and Lumbar Drainage-Associated Ventriculitis and Meningitis. Front Microbiol 2021; 11:596175. [PMID: 33381092 PMCID: PMC7767851 DOI: 10.3389/fmicb.2020.596175] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/13/2020] [Indexed: 12/20/2022] Open
Abstract
Metagenomic next-generation sequencing (mNGS) has become a widely used technology that can accurately detect individual pathogens. This prospective study was performed between February 2019 and September 2019 in one of the largest clinical neurosurgery centers in China. The study aimed to evaluate the performance of mNGS on cerebrospinal fluid (CSF) from neurosurgical patients for the diagnosis of external ventricular and lumbar drainage (EVD/LD)-associated ventriculitis and meningitis (VM). We collected CSF specimens from neurosurgical patients with EVD/LD for more than 24 h to perform conventional microbiological studies and mNGS analyses in a pairwise manner. We also investigated the usefulness of mNGS of CSF for the diagnosis of EVD/LD-associated VM. In total, 102 patients were enrolled in this study and divided into three groups, including confirmed VM (cVM) (39), suspected VM (sVM) (49), and non-VM (nVM) (14) groups. Of all the patients, mNGS detected 21 Gram-positive bacteria, 20 Gram-negative bacteria, and five fungi. The three primary bacteria detected were Staphylococcus epidermidis (9), Acinetobacter baumannii (5), and Staphylococcus aureus (3). The mNGS-positive coincidence rate of confirmed EVD/LD-associated VM was 61.54% (24/39), and the negative coincidence rate of the nVM group was 100% (14/14). Of 15 VM pathogens not identified by mNGS in the cVM group, eight were negative with mNGS and seven were inconsistent with the conventional microbiological identification results. In addition, mNGS identified pathogens in 22 cases that were negative using conventional methods; of them, 10 patients received a favorable clinical treatment; thus, showing the benefit of mNGS-guided therapy.
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Affiliation(s)
- Lingye Qian
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yijun Shi
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fangqiang Li
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yufei Wang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Miao Ma
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yanfang Zhang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang W Shao
- Nanjing Geneseeq Technology Inc., Nanjing, China.,School of Public Health, Nanjing Medical University, Nanjing, China
| | - Guanghui Zheng
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guojun Zhang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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16
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Hasbun R. Healthcare-associated ventriculitis: current and emerging diagnostic and treatment strategies. Expert Rev Anti Infect Ther 2020; 19:993-999. [PMID: 33334204 DOI: 10.1080/14787210.2021.1866544] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Healthcare-associated ventriculitis and meningitis occur after neurosurgical procedures, is associated with an adverse outcome in the majority of patients and represent a diagnostic challenge to clinicians. As the cerebrospinal fluid (CSF) culture is the cornerstone of diagnosis, obtaining CSF studies prior to starting antibiotic therapy is key.Areas covered: This review will evaluate the incidence, risk factors, clinical presentation, diagnosis, empirical intravenous antibiotic therapy, adjunctive intrathecal therapy, microbiology, prognosis, and prevention of HCAVM. We highlight the challenges and limitations of the currently available diagnostic methods and definitions and explore novel technologies. Our review included the search for published literature until June 2020.Expert opinion: Despite available preventive measures, HCAVM continues to occur and to be independently associated with significant neurological morbidity and mortality in the majority of patients. The cornerstone of the diagnosis of HCAVM is a positive CSF culture but the microbiological yield is reduced to ~50% with prior antimicrobial therapy. Although the CSF profile is not affected by antibiotic therapy it has a fair diagnostic accuracy. Future research efforts should concentrate in identifying novel diagnostic tools such as polymerase chain reaction (PCR) or metagenomic sequencing.
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Affiliation(s)
- Rodrigo Hasbun
- Professor of Medicine, McGovern Medical School UT Health, Houston, TX, USA
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17
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A Systematic Review of Studies Reporting Antibiotic Pharmacokinetic Data in the Cerebrospinal Fluid of Critically Ill Patients with Uninflamed Meninges. Antimicrob Agents Chemother 2020; 65:AAC.01998-20. [PMID: 33077649 DOI: 10.1128/aac.01998-20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 11/20/2022] Open
Abstract
Ventriculostomy-associated infections in critically ill patients remain therapeutically challenging because of drug- and disease-related factors that contribute to suboptimal antibiotic concentrations in cerebrospinal fluid. Optimal antibiotic dosing for the treatment and prevention of such infections should be based on robust and contextually specific pharmacokinetic data. The objects of this study were to describe and critically appraise studies with reported antibiotic concentrations or pharmacokinetic data in cerebrospinal fluid of critically ill patients without meningeal inflammation. We systematically reviewed the literature to identify published reports and studies describing antibiotic concentrations, pharmacokinetics, and pharmacokinetics/pharmacodynamics in cerebrospinal fluid of critically ill patients with uninflamed meninges. Fifty-eight articles met the inclusion criteria. There was significant heterogeneity in methodologies and results. When available, antibiotic pharmacokinetic parameters displayed large intersubject variability. Intraventricular dosing achieved substantially higher antibiotic concentrations in cerebrospinal fluid than did intravenous doses. Few studies conducted a robust pharmacokinetic analysis and described relevant clinical pharmacokinetic/pharmacodynamic indices and exposure targets in cerebrospinal fluid. Robust and clinically relevant antibiotic pharmacokinetic data describing antibiotic disposition in cerebrospinal fluid are necessary. Such studies should use a standardized approach to accurately describe pharmacokinetic variability. These data should ideally be tied to clinical outcomes whereby therapeutic targets in the cerebrospinal fluid can be better defined. Altered dosing strategies, in conjunction with exploring the utility of therapeutic drug monitoring, can then be developed to optimize antibiotic exposure with the goal of improving outcomes in this difficult-to-treat patient group.
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18
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Piva S, Albani F, Fagoni N, Monti E, Signorini L, Turla F, Rasulo FA, Fontanella M, Latronico N. High-mobility group box-1 protein as a novel biomarker to diagnose healthcare-associated ventriculitis and meningitis: a pilot study. Minerva Anestesiol 2020; 87:43-51. [PMID: 33174402 DOI: 10.23736/s0375-9393.20.14222-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The diagnosis of healthcare-associated ventriculitis and meningitis (HAVM) is challenging in the ICU setting. Traditional cerebrospinal fluid (CSF) markers and clinical signs of infection fail to diagnose HAVM in the critically ill setting. We sought to determine the diagnostic accuracy of measuring levels of high-mobility group box 1 (HMGB1) protein in cerebrospinal fluid (CSF) for the diagnosis of HAVM. METHODS In this prospective observational cohort study, we enrolled 29 patients with an implanted external ventricular drainage (EVD). We tested the accuracy of CSF-HMGB1 as a diagnostic test for HAVM when compared to standard CSF parameters. RESULTS HAVM was diagnosed in 11/29 (37.9%) patients. These patients had significantly higher CSF-HMGB1 levels compared to patients without HAVM (median [IQR] 43.39 [83.51] ng/mL vs 6.46 ng/mL [10.94]; P<0.001). CSF-HMGB1 and CSF-glucose were independently related to HAVM, with OR's (95% CI) of 15.43 (15.37 to 15.48, P<0.0001) and 0.31 (0.30 to 0.32, P<0.0001), respectively. The AUC [CI] of CSF-HMGB1 to predict HAVM was 0.83 [0.72 to 0.94]. CONCLUSIONS HMGB1 is an accurate marker of HAVM and it adds incremental diagnostic value when paired with CSF-glucose measurements. Future larger and multicenter studies should assess the incremental diagnostic value of HMGB1 data when used alongside other established CSF markers of infection, and the external validity of these preliminary results.
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Affiliation(s)
- Simone Piva
- Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy - .,Department of Anesthesiology, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy -
| | - Filippo Albani
- Department of Anesthesiology, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Nazzareno Fagoni
- Department of Anesthesiology, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Eugenio Monti
- Unit of Biochemistry, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Liana Signorini
- Second Division of Clinical Infectious Diseases, Department of Infectious Diseases, Spedali Civili University Hospital, Brescia, Italy
| | - Fabio Turla
- Department of Anesthesiology, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Frank A Rasulo
- Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Department of Anesthesiology, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Marco Fontanella
- Division of Neurosurgery, Department of Neuroscience, Spedali Civili University Hospital, Brescia, Italy
| | - Nicola Latronico
- Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Department of Anesthesiology, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
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19
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Bakhshi SK, Suhail N, Mitha R, Moazzam M, Zahid N, Shamim MS. Lumbar Drain for Temporary Cerebrospinal Fluid Diversion: Factors Related to the Risks of Complications at a University Hospital. World Neurosurg 2020; 143:e193-e198. [DOI: 10.1016/j.wneu.2020.07.120] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
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20
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Heldt T, Zoerle T, Teichmann D, Stocchetti N. Intracranial Pressure and Intracranial Elastance Monitoring in Neurocritical Care. Annu Rev Biomed Eng 2020; 21:523-549. [PMID: 31167100 DOI: 10.1146/annurev-bioeng-060418-052257] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patients with acute brain injuries tend to be physiologically unstable and at risk of rapid and potentially life-threatening decompensation due to shifts in intracranial compartment volumes and consequent intracranial hypertension. Invasive intracranial pressure (ICP) monitoring therefore remains a cornerstone of modern neurocritical care, despite the attendant risks of infection and damage to brain tissue arising from the surgical placement of a catheter or pressure transducer into the cerebrospinal fluid or brain tissue compartments. In addition to ICP monitoring, tracking of the intracranial capacity to buffer shifts in compartment volumes would help in the assessment of patient state, inform clinical decision making, and guide therapeutic interventions. We review the anatomy, physiology, and current technology relevant to clinical management of patients with acute brain injury and outline unmet clinical needs to advance patient monitoring in neurocritical care.
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Affiliation(s)
- Thomas Heldt
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA; .,Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA;
| | - Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; ,
| | - Daniel Teichmann
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA;
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; , .,Department of Physiopathology and Transplant Medicine, University of Milan, 20122 Milan, Italy
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21
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Whyte C, Alhasani H, Caplan R, Tully AP. Impact of an external ventricular drain bundle and limited duration antibiotic prophylaxis on drain-related infections and antibiotic resistance. Clin Neurol Neurosurg 2020; 190:105641. [DOI: 10.1016/j.clineuro.2019.105641] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/12/2019] [Accepted: 12/15/2019] [Indexed: 10/25/2022]
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Meyfroidt G, Kurtz P, Sonneville R. Critical care management of infectious meningitis and encephalitis. Intensive Care Med 2020; 46:192-201. [PMID: 31938828 DOI: 10.1007/s00134-019-05901-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 12/14/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Geert Meyfroidt
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium. .,Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Pedro Kurtz
- Neuro-Critical Care Unit, Instituto Estadual Do Cérebro Paulo Niemeyer and Hospital Copa Star, Rio de Janeiro, Brasil
| | - Romain Sonneville
- Université de Paris, INSERM UMR1148, team 6, 75018, Paris, France.,APHP, Intensive Care Medicine, Hôpital Bichat-Claude Bernard, 75018, Paris, France
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23
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Surveillance of external ventricular drainage-associated meningitis and ventriculitis in German intensive care units. Infect Control Hosp Epidemiol 2020; 41:452-457. [PMID: 31918776 DOI: 10.1017/ice.2019.367] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In light of the infection risk associated with external ventricular drainage (EVD), we decided to establish the surveillance of EVD-associated meningitis/ventriculitis in German intensive care units (ICUs) in the framework of the German national nosocomial infection surveillance system (KISS). Here, we present the current reference data and subsequent risk-factor analysis for EVD-associated meningitis/ventriculitis rates. METHODS The surveillance method corresponds with the surveillance methods for device-associated infections recommended by the National Healthcare Safety Network (NHSN). All ICUs participating for at least 1 month from 2008 to 2016 in the module ICU-KISS were included in the reference dataset and the multivariate analysis. RESULTS Current reference data (2008-2016) are based on input from 157 ICUs. The mean EVD-associated meningitis/ventriculitis rate per 1,000 EVD days was 3.96, with little variation between neurosurgical, surgical, interdisciplinary (hospitals with >400 beds), and neurological ICUs. In total, 893 EVD-associated meningitis/ventriculitis cases and 225,351 EVD days were included in the risk-factor analysis. After multivariate analysis, 2 factors remained significant: (1) stay in an ICU labeled other than neurosurgical, surgical, interdisciplinary (>400 beds), and neurological as a protective factor and (2) EVD utilization rate above the 75th quantile as a risk factor for acquisition of EVD-associated meningitis/ventriculitis. CONCLUSIONS EVD-associated meningitis and ventriculitis are frequent complications of care in intensive care patients at risk. A long hospital stay and/or the presence of the EVD puts the patient at high risk for pathogen acquisition with subsequent infection.
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George T, Moorthy RK, Rajshekhar V. Long tunnel external ventricular drain: an adjunct in the management of patients with infection associated hydrocephalus. Br J Neurosurg 2019; 33:659-663. [DOI: 10.1080/02688697.2019.1667483] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Tobin George
- Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Ranjith K. Moorthy
- Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Vedantam Rajshekhar
- Department of Neurological Sciences, Christian Medical College, Vellore, India
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Abstract
PURPOSE OF REVIEW This article summarizes updated data and knowledge on healthcare-associated infections in the neurocritical care unit, with a focus on central nervous system infections and systemic infectious complications in patients with acute brain disease. It also reviews the concept of brain injury-induced immune modulation, an underlying mechanism to explain why the neuro-ICU population is particularly susceptible to infections. RECENT FINDINGS Healthcare-associated infections in the neuro-ICU are common: up to 40 % of meningitides in the developed world are now healthcare-associated. The number of gram-negative infections is rising. New diagnostic approaches attempt to aid in the diagnosis of healthcare-associated meningitis and ventriculitis. Healthcare-associated infections in the neurocritical care unit remain a challenge for diagnosis, treatment, and prevention. Gaining a better understanding of at-risk patients and development of preventative strategies will be the goal for future investigation.
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Affiliation(s)
- Katharina M Busl
- Departments of Neurology and Neurosurgery, McKnight Brain Institute L3-100, University of Florida College of Medicine, 1149 Newell Drive, Gainesville, FL, 32610, USA.
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Antibiotic Distribution into Cerebrospinal Fluid: Can Dosing Safely Account for Drug and Disease Factors in the Treatment of Ventriculostomy-Associated Infections? Clin Pharmacokinet 2019; 57:439-454. [PMID: 28905331 DOI: 10.1007/s40262-017-0588-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Ventriculostomy-associated infections, or ventriculitis, in critically ill patients are associated with considerable morbidity. Efficacious antibiotic dosing for the treatment of these infections may be complicated by altered antibiotic concentrations in the cerebrospinal fluid due to variable meningeal inflammation and antibiotic properties. Therefore, doses used to treat infections with a higher degree of meningeal inflammation (such as meningitis) may often fail to achieve equivalent exposures in patients with ventriculostomy-associated infections such as ventriculitis. This paper aims to review the disease burden, infection rates, and common pathogens associated with ventriculostomy-associated infections. This review also seeks to describe the disease- and drug-related factors that influence antibiotic distribution into cerebrospinal fluid and provide a critical appraisal of current dosing of antibiotics commonly used to treat these types of infections. A Medline search of relevant articles was conducted and used to support a review of cerebrospinal fluid penetration of vancomycin, including critical appraisal of the recent paper by Beach et al. recently published in this journal. We found that in the intensive care unit, ventriculostomy-associated infections are the most common and serious complication of external ventricular drain insertion and often result in prolonged patient stay and increased healthcare costs. Reported infection rates are extremely variable (between 0 and 45%), hindered by the inherent diagnostic difficulty. Both Gram-positive and Gram-negative organisms are associated with such infections and the rise of multi-drug-resistant pathogens means that effective treatment is an ongoing challenge. Disease factors that may need to be considered are reduced meningeal inflammation and the presence of critical illness; drug factors include physiochemical properties, degree of plasma-protein binding, and affinity to active transporter proteins present in the blood-cerebrospinal fluid barrier. The relationship between cerebrospinal fluid antibiotic exposures in the setting of ventriculostomy-associated infection and clinical response has not been fully elucidated for many of the antibiotics commonly used in its treatment. More thorough and clinically relevant investigations are needed to better define blood pharmacokinetic/pharmacodynamics targets and optimal therapeutic exposures for treatment of ventriculostomy-associated infections. It is hoped that this future research will be able to provide clearer recommendations for clinicians frequently faced with dosing-related dilemmas when treating patients with these challenging infections.
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Safety and feasibility of lumbar drainage in the management of poor grade aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2019; 64:64-70. [DOI: 10.1016/j.jocn.2019.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 02/20/2019] [Accepted: 04/12/2019] [Indexed: 11/23/2022]
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Hussein K, Rabino G, Feder O, Eghbaryeh H, Zayyad H, Sviri G, Benenson R, Paul M. Risk factors for meningitis in neurosurgical patients with cerebrospinal fluid drains: prospective observational cohort study. Acta Neurochir (Wien) 2019; 161:517-524. [PMID: 30666453 DOI: 10.1007/s00701-019-03801-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/04/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) drainage or intracranial pressure (ICP) monitoring devices are life-saving devices. We examined the risk factors for infections related to them and assessed the effect of an infection control (IC) intervention. METHODS A prospective observational study was conducted in the Neurosurgical Department of our hospital between 2014 and 2017. We included all consecutive patients undergoing CSF catheter insertions, including external ventricular drainage (EVD), lumbar drainage (LD), and ICP catheters. An IC intervention was implemented between March and August 2016. We examined risk factors for meningitis or ventriculitis, defined according to Healthcare-associated infections surveillance definitions, on univariate and multivariate analysis. RESULTS A total of 232 patients with 437 drains (212 EVDs, 92 LDs, and 133 ICPs) were included. On univariate and multivariate analysis, the infection incidence was 13.7 per 1000 drain days (17.3/1000 before IC intervention, 7.9/1000 during, and 9.2/1000 after the intervention). Most episodes were caused by Gram-negative bacteria, and the most common pathogen was Acinetobacter baumanii. Risk factors for infection per patient included diabetes mellitus (p = 0.017), CSF leak (p = 0.032), drain opening (p = 0.027), and the duration of the drain in days (p = 0.035). Risk factors per catheter included drain opening (p < 0.001), drain days (p = 0.001), and the IC intervention period compared to before the intervention period (p = 0.037). When restricting the analysis to EVDs, drain days (p = 0.001) was the only significant risk factor. CONCLUSIONS Strict adherence to IC, shortening drain duration, and avoiding unnecessary opening and manipulation of the drains are crucial to preventing neurosurgical drain infections.
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Affiliation(s)
- Khetam Hussein
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel.
| | - Galit Rabino
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel
| | - Omri Feder
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Haneen Eghbaryeh
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Hiba Zayyad
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel
| | - Gil Sviri
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Neurosurgery, Rambam Health Care Campus, Haifa, Israel
| | - Rima Benenson
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Tavakoli S, Peitz G, Ares W, Hafeez S, Grandhi R. Complications of invasive intracranial pressure monitoring devices in neurocritical care. Neurosurg Focus 2018; 43:E6. [PMID: 29088962 DOI: 10.3171/2017.8.focus17450] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial pressure monitoring devices have become the standard of care for the management of patients with pathologies associated with intracranial hypertension. Given the importance of invasive intracranial monitoring devices in the modern neurointensive care setting, gaining a thorough understanding of the potential complications related to device placement-and misplacement-is crucial. The increased prevalence of intracranial pressure monitoring as a management tool for neurosurgical patients has led to the publication of a plethora of papers regarding their indications and complications. The authors aim to provide a concise review of key contemporary articles in the literature concerning important complications with the hope of elucidating practices that improve outcomes for neurocritically ill patients.
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Affiliation(s)
- Samon Tavakoli
- Department of Neurosurgery, University of Texas Health San Antonio, Texas; and
| | - Geoffrey Peitz
- Department of Neurosurgery, University of Texas Health San Antonio, Texas; and
| | - William Ares
- Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Shaheryar Hafeez
- Department of Neurosurgery, University of Texas Health San Antonio, Texas; and
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Texas Health San Antonio, Texas; and
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Liang C, Yang L, Guo S. Serial lumbar puncture reduces cerebrospinal fluid (CSF) infection during removal of hemorrhagic CSF in aneurysmal subarachnoid hemorrhage after endovascular coiling. J Biomed Res 2018; 32:305-310. [PMID: 30047495 PMCID: PMC6117608 DOI: 10.7555/jbr.32.20170028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The present study aimed to compare the complications and clinical outcomes of serial lumbar puncture (LP) and lumbar cerebrospinal fluid (CSF) drainage (LD) of patients with aneurysmal subarachnoid hemorrhage and provide more evidence to guide clinical management. In this retrospective study, 41 and 39 aneurysmal subarachnoid hemorrhage patients were enrolled in the LP and LD group, respectively. Clinical outcomes, including CSF infection, intracerebral hemorrhage, vasospasm, hydrocephalus, death, length of stay, duration of drainage and the Glasgow Outcome Scale score were compared between the two groups. By comparing with the LP group, the LD group showed a significantly higher rate of CSF infection (P=0.029) and shorter duration of drainage (P<0.001). Both groups displayed similar rates of vasospasm, hydrocephalus, intracerebral hemorrhage, the Glasgow Outcome Scale score one month after endovascular coiling and length of stay (P>0.05, respectively). In conclusion, both LD and serial LP are effective methods in the treatment of aneurysmal subarachnoid hemorrhage; besides, serial LP can reduce the incidence of CSF infection in draining hemorrhagic CSF in aneurysmal subarachnoid hemorrhage after endovascular coiling.
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Affiliation(s)
- Chen Liang
- Department of Neurosurgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Ling Yang
- Department of Aeromedical Physical Examination, Xi'an Civil Aviation Hospital, Xi'an, Shaanxi 710082, China
| | - Shiwen Guo
- Department of Neurosurgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
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Champey J, Mourey C, Francony G, Pavese P, Gay E, Gergele L, Manet R, Velly L, Bruder N, Payen JF. Strategies to reduce external ventricular drain-related infections: a multicenter retrospective study. J Neurosurg 2018; 130:2034-2039. [PMID: 29932377 DOI: 10.3171/2018.1.jns172486] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/15/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Various strategies have been proposed to reduce the incidence of external ventricular drain (EVD)-related infections. The authors retrospectively studied the impact of EVD care management on EVD-related infections at 3 French university hospital intensive care units. METHODS Between 2010 and 2014, 462 consecutive adult patients with no evidence of a preexisting CSF infection received EVDs as part of their care at one of the following sites: Grenoble (221 patients), Saint-Etienne (130 patients), and Marseille (111 patients). Written protocols describing the EVD placement procedure, management, and removal were implemented at the 3 sites. Daily CSF sampling and intraventricular administration of antibiotics prior to EVD removal were performed at the Grenoble site only. EVD-related infection was considered for any confirmed ventriculostomy-related infection (VRI) and ventriculitis. VRI was defined as one or more positive CSF cultures or Gram stain with CSF pleocytosis and biochemical abnormalities. Ventriculitis was defined as CSF pleocytosis and biochemical abnormalities with degradation of neurological status and fever. RESULTS A total of 6945 EVD days were observed in the entire population. In the Grenoble cohort, the mean cumulative incidence of EVD-related infections was significantly lower than that in the 2 other cohorts: 1.4% (95% CI 0.0%-2.9%) versus 9.2% (95% CI 4.2%-14.2%) and 7.2% (95% CI 2.4%-12.0%) at Saint-Etienne and Marseille, respectively (p < 0.01). Accounting for the duration of external ventricular drainage at each site, the risk for EVD-related CSF infections was significantly higher at Saint-Etienne and Marseille than at Grenoble, with ORs of 15.9 (95% CI 3.6-71.4, p < 0.001) and 10.0 (95% CI 2.2-45.5, p = 0.003), respectively. CONCLUSIONS These findings indicate that it is possible to attain a low incidence of EVD-related infections, provided that an EVD care bundle, which can include routine daily CSF sampling, is implemented and strongly adhered to.
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Affiliation(s)
| | | | | | | | | | | | | | - Lionel Velly
- 6Pôle Anesthésie Réanimation, CHU La Timone, Marseille
| | | | - Jean-François Payen
- 1Pôle Anesthésie Réanimation
- 7Université Grenoble Alpes, Grenoble Institute of Neurosciences, Grenoble; and
- 8INSERM, U1216, Grenoble, France
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Clinical and Laboratory Characteristics for the Diagnosis of Bacterial Ventriculitis After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2018; 26:362-370. [PMID: 28004332 PMCID: PMC5443868 DOI: 10.1007/s12028-016-0345-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background The diagnosis of nosocomial bacterial ventriculitis in patients with subarachnoid hemorrhage (SAH) can be challenging. Methods
We performed a retrospective study on the diagnostic accuracy of clinical and laboratory characteristics for the diagnosis of bacterial ventriculitis in 209 consecutive patients with an aneurysmal SAH admitted in a tertiary referral center from 2008 to 2010. Diagnostic value of clinical characteristics and inflammatory indexes in CSF and blood were determined for three diagnostic categories: (1) no suspicion for bacterial ventriculitis; (2) clinical suspicion for bacterial ventriculitis, defined as initiation of empirical antibiotic treatment for ventriculitis, but negative CSF cultures; and (3) CSF culture-positive bacterial ventriculitis.
Results Empirical antibiotics for suspected ventriculitis was initiated in 48 of 209 (23 %) patients. CSF cultures were positive in 11 (5 %) patients. Within the group of suspected ventriculitis, only longer duration of CSF drainage and lower CSF red blood cell counts predicted for culture positivity. None of the other clinical features or inflammatory indexes in CSF and blood were associated with culture-proven bacterial ventriculitis. Conclusions Nosocomial bacterial ventriculitis in patients with aneurysmal SAH is often suspected but confirmed by culture in a minority of cases. Improvement of diagnostics for nosocomial bacterial ventriculitis in patients with aneurysmal SAH is needed.
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Kohli G, Singh R, Herschman Y, Mammis A. Infection Incidence Associated with External Ventriculostomy Placement: A Comparison of Outcomes in the Emergency Department, Intensive Care Unit, and Operating Room. World Neurosurg 2018; 110:e135-e140. [DOI: 10.1016/j.wneu.2017.10.129] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/19/2017] [Accepted: 10/21/2017] [Indexed: 11/27/2022]
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Concentrations of Cefuroxime in Brain Tissue of Neurointensive Care Patients. Antimicrob Agents Chemother 2018; 62:AAC.02164-17. [PMID: 29203481 DOI: 10.1128/aac.02164-17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 11/27/2017] [Indexed: 01/15/2023] Open
Abstract
Effective concentrations of antibiotics in brain tissue are essential for antimicrobial therapy of brain infections. However, data concerning cerebral penetration properties of antibiotics for treatment or prophylaxis of central nervous system infections are rare. Six patients suffering subarachnoid hemorrhage and requiring cerebral microdialysis for neurochemical monitoring were included in this study. Free interstitial concentrations of cefuroxime after intravenous application of 1,500 mg were measured by microdialysis in brain tissue, as well as in plasma at steady-state (n = 6) or after single-dose administration (n = 1). At steady state, free area under the concentration-time curve from 0 to 24 h (AUC0-24) values of 389.0 ± 210.3 mg/liter·h and 131.4 ± 72.8 mg/liter·h were achieved for plasma and brain, respectively, resulting in a brain tissue penetration ratio (AUC0-24 brain/AUC0-24 free plasma) of 0.33 ± 0.1. Plasma and brain tissue concentrations at individual time points correlated well (R = 0.59, P = 0.001). At steady-state time over MIC (t>MIC) values of >40% of dosing interval were achieved up to an MIC of 16 mg/liter for plasma and 4 mg/liter for brain tissue. Although MIC90 values could not be achieved in brain tissue for relevant bacteria, current dosing strategies of cefuroxime might be sufficient to treat pathogens with MIC values up to 4 mg/liter. The activity of cefuroxime in brain tissue might be overestimated when relying exclusively on plasma levels. Although currently insufficient data after single dose administration exist, lower brain-plasma ratios observed after the first dose might warrant a loading dose for treatment and perioperative prophylaxis.
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Bauer M, Sohm F, Thomé C, Ortler M. Refractory intracranial hypertension in traumatic brain injury: Proposal for a novel score to assess the safety of lumbar cerebrospinal fluid drainage. Surg Neurol Int 2017; 8:265. [PMID: 29184716 PMCID: PMC5682699 DOI: 10.4103/sni.sni_98_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 08/23/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) drainage via ventricular puncture is an established therapy of elevated intracranial pressure (ICP). In contrast, lumbar CSF removal is believed to be contraindicated with intracranial hypertension. METHODS We investigated the safety and efficacy of lumbar CSF drainage to decrease refractory elevated ICP in a small cohort of patients with traumatic brain injury (TBI). A score (0-8 points) was used to assess computed tomography (CT) images for signs of herniation and for patency of the basal cisterns. All patients received lumbar CSF drainage either as a continuous drainage or as a single lumbar puncture (LP). Type and method of CSF drainage, mean ICP 24 h prior and after CSF removal, and adverse events were documented. Outcome was assessed after 3 months (with dichotomized Glasgow outcome scale). RESULTS Eight patients were evaluated retrospectively. n = 5 suffered a moderate, n = 2 a severe TBI (one Glasgow coma score not documented). The CT score was ≥5 in all patients prior to LP and decreased after puncture without clinical consequences in two patients. The amount of CSF removal did not correlate with score changes (P = 0.45). CSF drainage led to a significant reduction of mean ICP (from 22.3 to 13.9 mmHg, P = 0.002). Continuous drainage was more effective than a single LP. Three of eight patients reached a favorable outcome. CONCLUSIONS Lumbar CSF removal for the treatment of intracranial hypertension is effective and safe, provided the basal cisterns are discernible, equivalent to ≥5 points in the proposed new score. The score needs further validation.
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Affiliation(s)
- Marlies Bauer
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Sohm
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Ortler
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
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Grille P, Verga F, Biestro A. Diagnosis of ventriculostomy-related infection: Is cerebrospinal fluid lactate measurement a useful tool? J Clin Neurosci 2017; 45:243-247. [DOI: 10.1016/j.jocn.2017.07.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 07/21/2017] [Indexed: 12/19/2022]
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Risk of Resistant Organisms and Clostridium difficile with Prolonged Systemic Antibiotic Prophylaxis for Central Nervous System Devices. Neurocrit Care 2017; 25:128-32. [PMID: 26920907 DOI: 10.1007/s12028-016-0254-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prolonged systemic antibiotic prophylaxis for central nervous system (CNS) devices may be associated with increased risk of antimicrobial resistance. The primary objective of this study was to determine the impact of prolonged CNS device antibiotic prophylaxis on the growth of resistant microorganisms and Clostridium difficile. METHODS This retrospective, observational, cohort study included patients admitted to intensive care units with traumatic brain injury or other neurocritical illness. Patients who received a CNS device and antibiotic prophylaxis for at least 72 h were compared to patients with similar neurologic injuries who did not receive a CNS device. RESULTS Study (n = 116) and control (n = 557) patients had mean APACHE II scores of 17.7 ± 9.2 and 15.1 ± 10.6 (p = 0.004) with 53.4 and 24.6 % receiving craniotomies (p < 0.001), respectively. Mean CNS device duration was 9.9 days, and 73 % of patients received cefuroxime for prophylaxis. The study cohort had a higher absolute incidence of resistant organisms compared with the control cohort (15.5 vs 4.1 %; odds ratio 1.93, 95 % CI 0.93-4.03, p = 0.078), though the study was underpowered to show statistical significance in multivariate analysis. C. difficile incidence was similar between groups (2.6 vs 2.0 %; odds ratio 1.45, 95 % CI 0.35-6.12, p = 0.61). CONCLUSION We found a higher incidence of resistant organisms in patients receiving prolonged antibiotic prophylaxis with a CNS device, but similar incidence of C. difficile compared to controls. Lack of data supporting prolonged antibiotic prophylaxis for CNS devices and the risk of nosocomial infections with resistant organisms encourage limiting prophylactic antibiotics to a short periprocedural course.
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Hussein K, Bitterman R, Shofty B, Paul M, Neuberger A. Management of post-neurosurgical meningitis: narrative review. Clin Microbiol Infect 2017; 23:621-628. [DOI: 10.1016/j.cmi.2017.05.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/10/2017] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
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Tsioutis C, Karageorgos SA, Stratakou S, Soundoulounaki S, Karabetsos DA, Kouyentakis G, Gikas A. Clinical characteristics, microbiology and outcomes of external ventricular drainage-associated infections: The importance of active treatment. J Clin Neurosci 2017; 42:54-58. [PMID: 28342707 DOI: 10.1016/j.jocn.2017.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 03/06/2017] [Indexed: 11/19/2022]
Abstract
Data concerning clinical characteristics, microbiology, treatment and outcomes of external ventricular drainage-associated infections (EVDAI) are limited. All hospitalized patients with EVDAI in a University Hospital between January 2009 and December 2015 were retrospective recorded. Only the first episode per patient was included. An antibiotic was considered "active" when its pharmacokinetic properties were appropriate for EVDAI and the implicated microorganism was in vitro susceptible. During the 7-year study period, 36 EVDAI were identified. Median patient age was 53years and 23 (63.9%) were male. Catheter types were intraventricular (70.6%) and lumbar (29.4%). Median catheterization duration before infection was 14days. Gram-negative bacteria (GNB) predominated (57.9%), followed by gram-positives (36.8%) and fungi (5.3%). Administered antibiotics were considered "active" in 69.4% of empirical and in 86.1% of definitive treatment regimens. In 10 infections, intraventricular/intrathecal (IVT) antibiotics were administered. Eleven patients died (30.6%) during hospitalization. Patients who died had higher rates of EVDAI by GNB (p=0.011) and higher rates of treatment with intravenous colistin (p=0.019 for empirical and p=0.006 for definitive colistin). Compared to EVDAI by other pathogens, patients with EVDAI by GNB had longer catheter-days before infection (p<0.001) and higher mortality (p=0.011). In our study, GNB were a frequent cause of EVDAI, and were related with high rates of inactive treatment and mortality. Intravenous colistin alone is not effective and treatment should include IVT antibiotics and intravenous antibiotics that achieve adequate CSF levels.
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Affiliation(s)
- Constantinos Tsioutis
- Department of Internal Medicine/Infectious Diseases, University Hospital of Heraklion, Crete, Greece; School of Medicine, European University, Cyprus.
| | - Spyridon A Karageorgos
- Department of Internal Medicine/Infectious Diseases, University Hospital of Heraklion, Crete, Greece
| | - Soultana Stratakou
- Department of Internal Medicine/Infectious Diseases, University Hospital of Heraklion, Crete, Greece
| | - Stella Soundoulounaki
- Department of Internal Medicine/Infectious Diseases, University Hospital of Heraklion, Crete, Greece
| | | | - George Kouyentakis
- Department of Neurosurgery, University Hospital of Heraklion, Crete, Greece
| | - Achilleas Gikas
- Department of Internal Medicine/Infectious Diseases, University Hospital of Heraklion, Crete, Greece
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Comparing External Ventricular Drains-Related Ventriculitis Surveillance Definitions. Infect Control Hosp Epidemiol 2017; 38:574-579. [PMID: 28219470 DOI: 10.1017/ice.2017.21] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To evaluate the agreement between the current National Healthcare Safety Network (NHSN) definition for ventriculitis and others found in the literature among patients with an external ventricular drain (EVD) DESIGN Retrospective cohort study from January 2009 to December 2014 SETTING Neurology and neurosurgery intensive care unit of a large tertiary-care center PATIENTS Patients with an EVD were included. Patients with an infection prior to EVD placement or a permanent ventricular shunt were excluded. METHODS We reviewed the charts of patients with positive cerebrospinal fluid (CSF) cultures and/or abnormal CSF results while they had an EVD in place and applied various ventriculitis definitions. RESULTS We identified 48 patients with a total of 52 cases of ventriculitis (41 CSF culture-positive cases and 11 cases based on abnormal CSF test results) using the NHSN definition. The most common organisms causing ventriculitis were gram-positive commensals (79.2%); however, 45% showed growth of only 1 colony on 1 piece of media. Approximately 60% of the ventriculitis cases by the NHSN definition met the Honda criteria, approximately 56% met the Gozal criteria, and 23% met Citerio's definition. Cases defined using Honda versus Gozal definitions had a moderate agreement (κ=0.528; P<.05) whereas comparisons of Honda versus Citerio definitions (κ=0.338; P<.05) and Citerio versus Gozal definitions (κ=0.384; P<.05) had only fair agreements. CONCLUSIONS The agreement between published ventriculostomy-associated infection (VAI) definitions in this cohort was moderate to fair. A VAI surveillance definition that better defines contaminants is needed for more homogenous application of surveillance definitions between institutions and better comparison of rates. Infect Control Hosp Epidemiol 2017;38:574-579.
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Humphreys H, Jenks P, Wilson J, Weston V, Bayston R, Waterhouse C, Moore A. Surveillance of infection associated with external ventricular drains: proposed methodology and results from a pilot study. J Hosp Infect 2017; 95:154-160. [DOI: 10.1016/j.jhin.2016.09.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 09/09/2016] [Indexed: 11/16/2022]
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Soavi L, Rosina M, Stefini R, Fratianni A, Cadeo B, Magri S, Latronico N, Fontanella M, Signorini L. Post-neurosurgical meningitis: Management of cerebrospinal fluid drainage catheters influences the evolution of infection. Surg Neurol Int 2016; 7:S927-S934. [PMID: 28031985 PMCID: PMC5180437 DOI: 10.4103/2152-7806.195228] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 10/01/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In order to better define the pathogenic role of cerebrospinal fluid (CSF) drainage catheters in postoperative patients, we comparatively analyze the clinical course of device and non-device-related meningitis. METHODS This is an observational, partially prospective, study on consecutive adult patients who developed meningitis after undergoing neurosurgical procedures at the Neurosurgery and Neurointensive care Departments, Spedali Civili, Brescia, Italy, between January 1999 and August 2007. RESULTS All 77 consecutive post-neurosurgical meningitis events in 65 patients were included in the analysis. Most were classified as external ventricular drainage (EVD)-related meningitis (23 cases, group A), external spinal drainage (ESD)-related meningitis (12 cases, group B), and non-device-related post-neurosurgical meningitis (30 cases, group C). Proven meningitis was identified in 78.3%, 91.7% and 56.7% of the events, respectively. ESD-related meningitis had a shorter onset time vs EVD and non-device-associated meningitis (3 days versus 6 and 7 days, respectively). Median antibiotic treatment duration was 20, 17, and 22.5 days in groups A, B, and C, respectively. Overall, 8 patients (34.8%) in group A, 3 (25.0%) in group B, and 3 (10.0%) in group C died. Median time to become afebrile was shorter in group C than in group A (10 days versus 12 days, P = 0.04). Removal of the device later than 48 hours after meningitis onset, as well as implantation of a second device were associated with a slower time of meningitis resolution. CONCLUSIONS Early device removal and avoiding implantation of a second device were associated with short illness duration. Larger studies are warranted to confirm the conclusions of this study.
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Affiliation(s)
- Laura Soavi
- Clinic of Infectious and Tropical Diseases, Spedali Civili Hospital, Brescia, Italy
| | - Manuela Rosina
- Clinic of Infectious and Tropical Diseases, Spedali Civili Hospital, Brescia, Italy
| | - Roberto Stefini
- Department of Neurosurgery, ASST - Ovest Milanese, Legnano, Italy
| | | | - Barbara Cadeo
- Clinic of Infectious and Tropical Diseases, Spedali Civili Hospital, Brescia, Italy
| | - Silvia Magri
- Clinic of Infectious and Tropical Diseases, Spedali Civili Hospital, Brescia, Italy
| | - Nicola Latronico
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili Hospital, Brescia, Italy
| | - Marco Fontanella
- Department of Neurosurgery, Spedali Civili Hospital, Brescia, Italy
| | - Liana Signorini
- Clinic of Infectious and Tropical Diseases, Spedali Civili Hospital, Brescia, Italy
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Lewis A, Czeisler BM, Lord AS. Variations in Strategies to Prevent Ventriculostomy-Related Infections: A Practice Survey. Neurohospitalist 2016; 7:15-23. [PMID: 28042365 DOI: 10.1177/1941874416663281] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE The ideal strategy to prevent infections in patients with external ventricular drains (EVDs) is unclear. METHODS We conducted a cross-sectional survey of members of the Neurocritical Care Society on infection prevention practices for patients with EVDs between April and July 2015. RESULTS The survey was completed by 52 individuals (5% response rate). Catheter selection, use of prolonged prophylactic systemic antibiotics (PPSAs), cerebrospinal fluid (CSF) collection policies, location of EVD placement, and performance of routine EVD exchanges varied. Antibiotic-impregnated catheters (AICs) and conventional catheters (CCs) were used with similar frequency, but no respondents reported routine use of silver-impregnated catheters (SICs). The majority of respondents were either neutral or disagreed with the need for PPSA with all catheter types (CC: 75%, AIC: 85%, and SIC: 87%). Despite this, 55% of the respondents reported PPSAs were routinely administered to patients with EVDs at their institutions. The majority (80%) of the respondents reported CSF collection only on an as-needed basis. The EVD placement was restricted to the operating room at 27% of the respondents' institutions. Only 2 respondents (4%) reported that routine EVD exchanges were performed at their institution. CONCLUSION Practice patterns demonstrate that institutions use varying strategies to prevent ventriculostomy-related infections. Identification and further study of optimum care for these patients are essential to decrease the risk of complications and to aid development of practice standards.
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Affiliation(s)
- Ariane Lewis
- Division of Neurocritical Care, Department of Neurology, NYU Langone Medical Center, NY, USA; Department of Neurosurgery, NYU Langone Medical Center, NY, USA
| | - Barry M Czeisler
- Division of Neurocritical Care, Department of Neurology, NYU Langone Medical Center, NY, USA; Department of Neurosurgery, NYU Langone Medical Center, NY, USA
| | - Aaron S Lord
- Division of Neurocritical Care, Department of Neurology, NYU Langone Medical Center, NY, USA; Department of Neurosurgery, NYU Langone Medical Center, NY, USA
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Kim SO, Song WJ, Won YS, Yang JY, Choi CS. Outcome of External Ventricular Drainage according to the Operating Place: the Intensive Care Unit versus Operating Room. Korean J Crit Care Med 2016. [DOI: 10.4266/kjccm.2016.31.1.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Si On Kim
- Department of Critical Care Medicine, Sungkyunkwan University, Kangbuk Samsung Hospital, Seoul, Korea
| | - Won Jun Song
- Department of Critical Care Medicine, Sungkyunkwan University, Kangbuk Samsung Hospital, Seoul, Korea
| | - Yu Sam Won
- Department of Neurosurgery, Sungkyunkwan University, Kangbuk Samsung Hospital, Seoul, Korea
| | - Jae Young Yang
- Department of Neurosurgery, Sungkyunkwan University, Kangbuk Samsung Hospital, Seoul, Korea
| | - Chun Sik Choi
- Department of Neurosurgery, Sungkyunkwan University, Kangbuk Samsung Hospital, Seoul, Korea
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Scheithauer S, Schulze-Steinen H, Höllig A, Lopez-Gonzalez L, Hilgers RD, Reinges MHT, Marx G, Lemmen S. Significant Reduction of External Ventricular Drainage–Associated Meningoventriculitis by Chlorhexidine-Containing Dressings: A Before-After Trial: Table 1. Clin Infect Dis 2015; 62:404-5. [DOI: 10.1093/cid/civ887] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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