Healthcare-Associated Meningitis or Ventriculitis in Older Adults

Mortality and prognosis in herpes simplex Virus-1 encephalitis long-term follow up study

BACKGROUND AND OBJECTIVES

Herpes simplex virus-1 (HSV-1) encephalitis is the most prevalent form of viral encephalitis worldwide. Consensus statements on the rate of mortality are lacking, with most studies emphasizing short-term mortality risks . We aimed to describe variables effecting mortality for HSV-1 encephalitis in a long term well defined HSV cohorts.

METHODS

This is a retrospective study, encephalitis patients who were HSV-positive (HSV- 1,HSV-2 and VZV) in the cerebrospinal fluid (CSF) in 23 years' time frame were compared. Clinical, electrophysiological, imaging, and laboratory data were analyzed.

RESULTS

We identified 47 HSV-1, 8 HSV-2 and 216 with VZV patients with a molecular CSF PCR diagnosis. The median age at diagnosis was 63.3 (interquartile range(IQR) 50.42-72.52) for HSV-1, 46.79 (IQR 36.55-55.05) for HSV-2 and 60.33. (IQR 33.78-74.11) for VZV (p = 0.14). The mean follow up time was 6.25 ± 5.92 years for the group as whole. Among HSV-1 patients, during the follow-up period, 26 patients (55.31 %) died. Ten deaths occurred within the first year, with a median age of death of 70.6 [63.53-75.39]. Patients who died were older (70.6 [63.53-75.39 vs. 48.59 [37.88-61.71], p < 0.001), had a longer time to treatment initiation (4.01 ± 5.69 vs. 1.96 ± 3.58 days, p = 0.026), with cancer comorbidities more prevalent (42.3 % vs. 0 %, p < 0.001). Univariate analysis showed older age (HR 1.07, 95 % CI 1.03-1.10, p < 0.01), and cancer comorbidity (HR 5.55, 95 % CI 2.31-13.33, p < 0.001) were associated with significantly higher risk for mortality. Multivariate analysis confirmed that older age (HR 1.096, 95 % CI 1.04-1.15, p < 0.001), cancer comorbidity (HR 11.02, 95 % CI 2.76-43.9, p < 0.001) and lower lymphocyte count (HR 0.97, 95 % CI 0.95-0.99, p = 0.032) influenced mortality risk. The optimal cut-off age to predict mortality based on AUC-ROC curve was 63.29 (AUC = 0.83, sensitivity = 0.76, specificity = 0.80, PPV = 0.83, NNV = 0.73, p < 0.001). Patients above this age cutoff had a significantly greater cumulative incidence of mortality than did those aged 50-63 years (p < 0.01).

DISCUSSION

Mortality due to HSV-1 was high and highest in patients >63 years or immunocompromised patients. Favorable outcomes were associated with increased lymphocyte levels in CSF, and early antiviral treatment. These finding may help explain the wide discrepancies in reported mortality rates for HSV encephalitis patients.

Current understanding of infection of the ventricles and its complications

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Ventriculitis: A Severe Complication of Central Nervous System Infections

BACKGROUND

Ventriculitis, a dreaded complication of brain abscess, meningitis, and various neurosurgical procedures, has attracted limited attention in the medical literature.

METHODS

This is a retrospective, single-center study. We screened the medical files of all patients who had a brain imaging report that included the word "ventriculitis" during years 2005-2019. Only patients with clinical, microbiological, and imaging features of ventriculitis were included. Data were collected through a standardized questionnaire.

RESULTS

Ninety-eight patients fulfilled inclusion criteria: 42 women and 56 men, and the median age was 60 years (interquartile range, 48-68). The primary mechanism for ventriculitis was classified as follows: brain abscess (n = 29, 29.6%), meningitis (n = 27, 27.6%), intraventricular catheter-related (n = 17, 17.3%), post-neurosurgery (n = 13, 13.3%), and hematogenous (n = 12, 12.2%). The main neuroimaging features were intraventricular pus (n = 81, 82.7%), ependymal enhancement (n = 70, 71.4%), and intraventricular loculations (n = 15, 15.3%). The main pathogens were streptococci (n = 44, 44.9%), Gram-negative bacilli (n = 27, 27.6%), and staphylococci (n = 15, 15.3%). In-hospital and 1-year mortality rates were 30.6% (n = 30) and 38.8% (n = 38), respectively. Neurological sequelae were reported in 34 of 55 (61.8%) survivors, including cognitive impairment (n = 11), gait disturbances (n = 9), paresis (n = 7), behavior disorder (n = 6), and epilepsy (n = 5). On multivariate analysis, age >65 years, Glasgow Coma Scale score <13 at initial presentation, status epilepticus, hydrocephalus, and positive cerebrospinal fluid culture were associated with 1-year mortality. We built a scoring system to stratify patients with ventriculitis into low risk (12.5%), intermediate risk (36.5%), and high risk (71.4%) of death.

CONCLUSIONS

Ventriculitis is a severe complication of brain abscess, meningitis, or neurosurgery, with an in-hospital mortality rate of 30% and neurological sequelae in 60% of survivors.

Clinical Epidemiology, Risk Factors, and Outcomes of Encephalitis in Older Adults

BACKGROUND

Encephalitis is associated with significant morbidity and mortality, with unknown etiologies in the majority of patients. Large prognostic studies evaluating elderly patients are currently lacking.

METHODS

We performed a retrospective cohort of encephalitis cases in 19 hospitals from New Orleans, Louisiana, and Houston, Texas, between the years 2000 and 2017.

RESULTS

A total of 340 adult (aged ≥17 years) patients with confirmed encephalitis were enrolled, and 194 (57%) had unknown etiologies. A cerebrospinal fluid polymerase chain reaction (PCR) for herpes simplex virus (HSV) and varicella zoster virus was done in 237 (69%) and 82 (24%) patients, respectively. Furthermore, an arboviral serology was done in 169 (49%) patients and measurements of anti-N-methyl-D-aspartate receptor antibodies were taken in 49 (14%) patients. A total of 172 out of 323 patients (53%) had adverse clinical outcomes (ACOs) at discharge. Older individuals (>65 years of age) had a lower prevalence of human immunodeficiency virus, had a higher number of comorbidities, were less likely to receive adjuvant steroids, were more likely to have a positive arbovirus serology, were more likely to have a positive HSV PCR, were more likely to have abnormal computerized tomography findings, and were more likely to have to have an ACO (all P values < .05). Prognostic factors independently associated with an ACO were age ≥65, fever, Glasgow Coma Scale (GCS) score <13, and seizures (all P values ≤0.01).

CONCLUSIONS

Encephalitis in adults remain with unknown etiologies and adverse clinical outcomes in the majority of patients. Independent prognostic factors include age ≥65 years, fever, GCS score <13, and seizures.

Healthcare-associated ventriculitis: current and emerging diagnostic and treatment strategies

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.

Impact of an educational program on reducing health care-associated meningitis or ventriculitis in the neurosurgical intensive care unit

BACKGROUND

Health care-associated meningitis or ventriculitis (HCAMV) is a serious complication in different neurosurgical procedures and is associated with significant morbidity and mortality. We aimed to investigate whether an educational intervention program could reduce the HCAMV incidence in patients undergoing postsurgery external ventricular drainage and wound management.

METHODS

We enrolled 2,904 patients from the neurosurgery intensive care unit between January 1, 2016 and December 31, 2018. The medical staff undertook an educational program developed by a multidisciplinary team on correct external ventricular drainage insertion and maintenance. The program included a 9-page self-learning module on the HCAMV risk factors and operational improvements. Each participant completed a pre- and posttest on their HCAMV knowledge.

RESULTS

We found that 38 of 693 (5.48%) patients presented with infection in the preintervention 9-month period. In the 27-month postintervention period, the proportion of HCAMV incidence dropped by 52.19% (P < .0001) to 58 of 2,211 (2.62%) patients.

CONCLUSIONS

Educational intervention aimed at the neurosurgery intensive care unit staff could significantly reduce the HCAMV rate, leading to a significant decline in the cost, morbidity, and mortality caused by neurosurgical procedures.

Impact of Antibiotic Therapy in the Microbiological Yield of Healthcare-Associated Ventriculitis and Meningitis

The impact of antibiotic therapy on the diagnosis of healthcare-associated ventriculitis and meningitis (HCAVM) is unknown. Antibiotics were administered before obtaining cerebrospinal fluid (CSF) in 217 out of 326 (66%) patients with HCAVM, and they impacted the sensitivity of the cerebrospinal fluid Gram stain and culture (P ≤ .004).