A retrospective study of central nervous system shunt infections diagnosed in a university hospital during a 4-year period

Peripheral white blood cell patterns in children with hydrocephalus as a response to ventriculo-peritoneal shunt infection

Shunt infection is one of the most common complications of conventional hydrocephalus treatment. The route of invasion of a pathogen can modify the immune response of the CNS. The aim of the study is to analyze the immune response to shunt infection caused by S. epidermidis in children with hydrocephalus. The immune response to the pathogen will be analyzed on the basis of, inter alia, simple laboratory test results, such as changes in the pattern of white blood cells, including neutrophils, monocytes, and lymphocytes. The entire study analyzes changes in general parameters of the cerebrospinal fluid (pleocytosis, protein level, glucose level) and in levels of selected interleukins (IL-6, CXCL8 / IL-8, CCL3 / MIP-1a) in the cerebrospinal fluid. The clinical material analyzed in the study was collected in 2010-2014. The study group consisted of 30 patients, who were admitted to the hospital due to their first-ever episode of valve dysfunction caused by S. epidermidis infection. The control group consisted of 30 children who also suffered from congenital hydrocephalus but had not been operated on before. The most pronounced response to CSF infection in the study group was a significant increase in the counts of all investigated WBC lines in the samples collected immediately after the patients' admission to the ward. The earliest aberration of the CSF was a significant increase in protein level. An infection of a ventriculoperitoneal shunt caused by S. epidermidis evokes a very early peripheral blood response. In children affected by a ventriculoperitoneal valve infection, the humoral immune response detected in the cerebrospinal fluid precedes the increase in the level of pleocytosis. The highest level of cytokines in the cerebrospinal fluid is achieved when the pathogens are cleared. Phagocytes, and, in particular, monocytes, play an important role in the normalization of the cerebrospinal fluid parameters after the elimination of S. epidermidis. The local immune response of the central nervous system plays an important role in extinguishment of the inflammatory process.

Clinical presentations and microbiological analysis of cerebrospinal fluid samples in cases of suspected bacterial meningitis patients attending a 1600 bedded teaching hospital from 2019 to 2022: A retrospective study

Background

Meningitis can be attributed to bacterial, fungal, or viral agents. In this study, we demonstrate the common bacterial agents causing meningitis along with their antibiotics susceptibility pattern in patients of all age groups.

Material and Methods

This retrospective, observational study was carried out in the Department of Microbiology with cerebrospinal fluid (CSF) samples collected from November 2019 to May 2022. We collected 1986 nonrepeat CSF samples from clinically suspected patients of bacterial meningitis, and clinical information about the patients was extracted from the hospital information system.

Results

Out of the 1986 CSF samples included in our study, 150 (7.55%) were found to be positive on bacterial culture. Most of our patients were in the age group of 0-20 years. Common clinical manifestations observed in our patients were: high-grade fever, 87 patients (58%); severe headache, 126 patients (84%); neck rigidity, 47 patients (31.3%); altered mental status, 76 patients (50.7%) and photophobia, 83 patients (55.3%). The most commonly isolated bacteria was Acinetobacter species (30%). The mean length of hospitalization (37.76 ± 25.30), the mean total cell count, high levels of protein (mg/dl) and low levels of glucose (mg/dl) of CSF were statistically significant in meningitis caused by multidrug-resistant bacteria.

Conclusion

We recognized the spectrum of pathogens causing meningitis at our center along with the antibiotic resistance pattern to guide and facilitate early treatment by primary health care professionals and family medicine practitioners.

Ventriculoperitoneal Shunt Infection: A Study about Age as a Risk Factor in Hydrocephalus Pediatrics

BACKGROUND: Shunt infection is one of the dreaded and serious complications following ventriculoperitoneal shunt (VP shunt) insertion, especially in a pediatric population. Numerous risk factors have been identified, particularly in developing countries, indicating that age may play an essential element in the pathogenesis of shunt infection, typically in patients <1-year-old. However, a few research demonstrate the inverse result. AIM: The purpose of this was to determine the relationship between age and shunt infection so that it can be taken into consideration when performing VP shunt insertion. METHODS: From January 2017 to December 2019, 98 pediatric patients with hydrocephalus who underwent VP shunt insertion were retrospectively reviewed to determine the relationship between age and shunt infection. We evaluated the microbiology results and management of shunt infection in patients with shunt infection. RESULTS: Fifteen (15.15%) of 98 patients developed shunt infection. Patients aged >3–6 months had a significantly increased risk of shunt infection (p = 0.04; RR = 4.15; CI 95% = 1.19–14.45). Staphylococcus aureus was the most frequently encountered pathogen in pediatric patients with shunt infection (53.3%), and the most common management for shunt infection was complete removal of the shunt and systemic antibiotics followed by re-insertion of the shunt after the cerebrospinal fluid was sterile (46.6%). CONCLUSION: We conclude that age, especially those aged >3–6 months, has a significantly higher risk of shunt infection in pediatric patients.

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

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

Endoscopic Third Ventriculostomy for Hydrocephalus Secondary to Extraventricular Obstruction in Thalamic Hemorrhage: A Case Series

BACKGROUND

Intracranial hemorrhage carries significant morbidity and mortality, particularly if associated with hydrocephalus. Management of hydrocephalus includes temporary external ventricular drainage, with or without shunting. Thalamic location is an independent predictor of mortality and increases the likelihood of shunt dependence.

OBJECTIVE

To determine whether endoscopic third ventriculostomy (ETV) can avoid the need for shunt placement and expedite recovery.

METHODS

We prospectively identified thalamic intracranial hemorrhage patients who developed acute hydrocephalus requiring cerebrospinal fluid diversion by extraventricular drain placement from November 2017 to February 2019. Patients who failed an extraventricular drain clamping trial were then evaluated for eligibility for an ETV procedure. Patients who underwent ETV were then followed up for the development of hydrocephalus, need for shunting, and length of stay in the intensive care unit.

RESULTS

Eight patients (7 males, 1 female) were prospectively enrolled. All patients underwent an ETV successfully. None of the patients required shunting. ETV was performed despite the presence of other factors that would have prevented shunt placement, including fever, leukocytosis, and gastrostomy tube placement. Seven patients who underwent ETV were evaluated at 3-mo follow-up and did not require shunting.

CONCLUSION

ETV is a safe and effective technique for the management of hydrocephalus resulting from an extraventricular obstruction in thalamic hemorrhage. It can avoid the need for permanent shunting in this patient population. Larger studies should be conducted to validate and further analyze this intervention.

Cerebrospinal fluid (CSF) augments metabolism and virulence expression factors in Acinetobacter baumannii

In a recent report by the Centers for Disease Control and Prevention (CDC), multidrug resistant (MDR) Acinetobacter baumannii is a pathogen described as an "urgent threat." Infection with this bacterium manifests as different diseases such as community and nosocomial pneumonia, bloodstream infections, endocarditis, infections of the urinary tract, wound infections, burn infections, skin and soft tissue infections, and meningitis. In particular, nosocomial meningitis, an unwelcome complication of neurosurgery caused by extensively-drug resistant (XDR) A. baumannii, is extremely challenging to manage. Therefore, understanding how A. baumannii adapts to different host environments, such as cerebrospinal fluid (CSF) that may trigger changes in expression of virulence factors that are associated with the successful establishment and progress of this infection is necessary. The present in-vitro work describes, the genetic changes that occur during A. baumannii infiltration into CSF and displays A. baumannii's expansive versatility to persist in a nutrient limited environment while enhancing several virulence factors to survive and persist. While a hypervirulent A. baumannii strain did not show changes in its transcriptome when incubated in the presence of CSF, a low-virulence isolate showed significant differences in gene expression and phenotypic traits. Exposure to 4% CSF caused increased expression of virulence factors such as fimbriae, pilins, and iron chelators, and other virulence determinants that was confirmed in various model systems. Furthermore, although CSF's presence did not enhance bacterial growth, an increase of expression of genes encoding transcription, translation, and the ATP synthesis machinery was observed. This work also explores A. baumannii's response to an essential component, human serum albumin (HSA), within CSF to trigger the differential expression of genes associated with its pathoadaptibility in this environment.

Dental Care for a Child with Congenital Hydrocephalus: A Case Report with 12-Month Follow-Up

Hydrocephalus affects the central nervous system as a result of progressive ventricular dilatation from the accumulation of cerebrospinal fluid in the brain's lateral ventricles. This paper reports on the oral characteristics of a child with congenital hydrocephalus, discusses her complex dental care needs, and presents dental management of this case. Despite the complex and challenging dental needs, this child received dental treatment in a chairside approach without general anesthesia. A thorough knowledge of the patient's medical condition, together with expert clinical skills, was indispensable for managing the child and improving the quality and length of her life.

Sonication Improves Pathogen Detection in Ventriculoperitoneal Shunt-Associated Infections

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Review of Clinically and Epidemiologically Relevant Coagulase-Negative Staphylococci in Africa

Coagulase-negative staphylococci (CoNS) have engendered substantial interest in recent years as pathogenic causes of infections in both human and veterinary medicine, especially in the immunocompromised, critically ill, long-term hospitalized and in those harboring invasive medical devices such as catheters. They have been implicated in infections such as urinary tract infections, bloodstream infections, and invasive device-related infections, and are responsible for substantial economic losses in livestock production. The advancement of diagnostic techniques has increased our understanding of their molecular mechanisms of pathogenicity, even though distinguishing between innocuousness and pathogenicity is still challenging. The incidence of CoNS varied across the continent in humans and animals (mainly cattle), ranging from 6% to 68% in suspected human infections and from 3% to 61.7% in suspected animal infections, distributed across different geographic locations. Furthermore, there were varying antibiotic resistance patterns observed in CoNS isolates, with high methicillin resistance in some cases, leading to crossresistance against many antibiotics. Staphylococcus epidermidis, Staphylococcus haemolyticus, and Staphylococcus xylosus were most commonly reported in studies herein reviewed, while the enterotoxin C gene, atl E gene, ica gene, and hemolysin virulence factors were linked with enhanced pathogenicity. Advancement in identification and typing methods, including whole genome sequencing, virulence screening, and the assessment of the immune status of subjects in studies will help to thoroughly assess the true pathogenic potential of isolated CoNS species in developing countries. Careful antibiotic stewardship guidelines should be followed due to the ability of CoNS to develop multidrug resistance.

Outcomes of post-neurosurgical ventriculostomy-associated infections

Background:

Ventriculostomy-associated infection (VAI) is a major concern to physicians. Limited studies have looked at the outcomes of external ventricular drain (EVD) infection and predictors of unfavorable outcomes. In this study, we assessed the outcomes of EVD infection and predictors of unfavorable outcomes.

Methods:

This was a retrospective medical chart review, conducted at the Aga Khan University Hospital. All the patients irrespective of age and gender, fulfilling the diagnostic criteria of VAI were included. Patients with preexisting bacterial meningitis or ventriculitis were excluded from the study. Outcome assessment was based on Glasgow outcome scale (GOS) at 1 and 3 months after procedure. Other outcomes included 30-day mortality and total length of hospital stay.

Results:

We included 256 patients in the study. 66 patients (25.8%) developed VAI. EVD was the primary procedure in 21 (31.8%) cases. Most patients, 24 (36.4%), had EVD as a secondary procedure for tumor surgery. Median interval between EVD placement and diagnosis of infection was 3 days. Mean length of stay in VAI patients was 31.85 ± 20.53 days. Seven patients required ICU care. Ten patients (15.2%) expired during hospital stay or within 30 days of discharge and further four had GOS of 2 or 3. A total of 52 patients had a favorable outcome after 6 months.

Conclusions:

Rate of VAI in this cohort was high. VAI is associated with increased morbidity, mortality, and prolonged hospital stay.

Management of Ventriculoperitoneal Shunt Infections in Adults: Analysis of Risk Factors Associated With Treatment Failure

Background

Little is known regarding the optimal treatment of ventriculoperitoneal (VP) shunt infections in adults. Our aim was to assess the efficacy of treatment strategies and to identify factors that predict failure.

Methods

Retrospective, observational study of patients aged ≥12 years with VP shunt infections (1980 -2014). Therapeutic approaches were classified under 4 headings: only antibiotics (OA), one-stage shunt replacement (OSSR), two-stage shunt replacement (TSSR), and shunt removal without replacement (SR). The primary endpoint was failure of the treatment strategy, defined as the absence of definite cerebrospinal fluid (CSF) sterilization or related mortality. The parameters that predicted failure were analyzed using logistic regression.

Results

Of 108 episodes (51% male, median age 50 years), 86 were analyzed. Intravenous antibiotics were administered for a median of 19 days. Eighty episodes were treated using strategies that combined antibiotic and surgical treatment (37 TSSR, 24 SR, 19 OSSR) and 6 with OA. Failure occurred in 30% of episodes, mostly due to lack of CSF sterilization in OSSR and OA groups. Twelve percent died of related causes and 10% presented superinfection of the CSF temporary drainage/externalized peritoneal catheter. TSSR was the most effective strategy when VP shunt replacement was attempted. The only independent risk factor that predicted failure was retention of the VP shunt, regardless of the strategy.

Conclusions

This is the largest series of VP shunt infections in adults reported to date. VP shunt removal, particularly TSSR when the patient is shunt dependent, remains the optimal choice of treatment and does not increase morbidity.

Cryptococcal Infection of the Ventriculoperitoneal Shunt in an HIV-Infected Patient with an Excellent Immunovirologic Status

BACKGROUND

Cryptococcus spp. is a rare cause of ventriculoperitoneal shunt (VPS) infection, with a variable clinical presentation. Diagnosis and treatment of this entity are challenging.

CASE DESCRIPTION

A cryptococcal VPS infection occurred in a human immunodeficiency virus-infected patient with an excellent immunovirologic status, with an abdominal mass as the only clinical sign at presentation. Microbiologic diagnosis was confirmed when Cryptococcus neoformans was isolated in 4 cerebrospinal fluid samples on different days. The patient was treated with dual antifungal therapy (liposomal amphotericin B plus flucytosine). The VPS was initially externalized and then removed. At 12-month follow-up, the patient remained asymptomatic, and no replacement VPS was required.

CONCLUSIONS

This is the first reported case of cryptococcal VPS infection in a patient with human immunodeficiency virus infection. Clinical outcome was excellent after dual antifungal therapy plus device withdrawal. Diagnosis and treatment of this entity remain a challenge for clinicians.

Management of infections associated with neurosurgical implanted devices

INTRODUCTION

Neurosurgical devices are increasingly used. With it, neurosurgical device-related infections gain relevance. As biofilms are involved in implant-associated infections the diagnosis and treatment is challenging and requires specific anti-biofilm concepts and management algorithms. Areas covered: The literature concerning the management of neurosurgical device-associated infections is scarce and heterogeneous treatment concepts are discussed, but no standardized diagnostic and treatment procedures exist. Therefore, we emphasize extrapolating management strategies predominantly from orthopedic device-associated infections, where the concept is better established and clinically validated. This review covers infections associated with craniotomy fixation devices, cranioplasties, external ventricular and lumbar drainages, internal shunts and neurostimulators. Expert commentary: Sonication of the removed implants significantly improves microbiological diagnosis. A combined surgical and antimicrobial management is crucial for successful treatment: appropriate surgical intervention is combined with prolonged anti-biofilm therapy of usually 12 weeks. In selected patients, new treatment algorithms enable cure of neurosurgical device-associated infections without implant removal or with a one-stage implant exchange, considerably improving the quality of patient lives.

Ventriculoatrial Shunts in Adults, Incidence of Infection, and Significant Risk Factors: A Single-Center Experience

BACKGROUND

In recent years, the number of ventriculoatrial (VA) shunt insertions has decreased worldwide, the major cause being the risk of shunt infection. VA shunts remain as an alternative option to ventriculoperitoneal shunts. We describe our 10-year experience with VA shunts by analyzing the incidence of shunt infections and predisposing cofactors.

METHODS

During a median follow-up of 15.3 months, 259 shunt insertions, performed on 255 patients, were analyzed. The infection rate was calculated and the predisposing cofactors age, gender, cause of the hydrocephalus, previous external ventricle drainage, antibiotic-impregnated catheters, the number of revisions, the educational level of the surgeons, and the duration of the operations were analyzed. Two observation times were stratified.

RESULTS

We found overall infections in 18 patients (7.1%), 16 deep infections (6.3%) including 1 shunt nephritis (0.4%) and 2 superficial infections (0.8%). Wound dehiscence occurred in 17 patients (6. 6%). Analyzing follow-up time, the infection rate was 3.65% (95% confidence interval, 0.9%-5.9%) at survival time 1, 3.38% (95% confidence interval, 1.1%-6.2%) at survival time 2. In the first 6 months, 95% of patients were free of infection. Only the number of revision procedures was associated with the number of infections (P value < 0.0005).

CONCLUSIONS

In our patient cohort, the infection rate related to VA shunt insertion is low; the only statistically significant risk factor was the number of revisions. If the VA shunt is applied following a standardized protocol, the infection risk does not represent an argument for reluctance towards the VA draining concept.

Cryptococcal Infection of the Ventriculoperitoneal Shunt in an Immunocompetent Patient

Patient: Male, 52

Final Diagnosis: Cryptococcal ventriculoperitoneal shunt infection

Symptoms: Confusion • fever • Lethargy

Medication: Amphotericin B • Flucytosine

Clinical Procedure: Ventriculoperitoneal shunt removal

Specialty: Infectious disease

How frequently external ventricular drainage device should be changed in children with ventriculoperitonel shunt infection?

Objective:

The purpose of the presenting study was to determine how frequently external ventricular drainage (EVD) device should be changed in children with ventriculopertienal shunt (VPS) infection during prolonged intravenous antimicrobial therapy.

Methods:

In this retrospective study, 25 children with VPS infection were evaluated between January 2012 and December 2013. In these children VPS was surgically removed and appropriate antimicrobial therapy was administered according to cerebrospinal culture results. Data noted about how frequently EVD device had been changed, the number of cells on direct observation of cerebrospinal fluid (CSF), glucose and protein levels of CSF, and CSF culture results were obtained from patients’ records.

Results:

Total 25 children were included in the study. The median age was three months (1 and 65 months). In 44% of children, Staphylococcus epidermidis was isolated. During treatment period, EVD catheter has changed one to six times. A total of 68 EVD catheters were changed in these patients. When the duration of ventriculostomy catheter and leukocyte count in CSF were evaluated on daily basis, leukocyte count was decreased 5 units per day in children whose catheter remained less than 10 days. However, in children whose catheter remained more than 10 days leukocyte count was decreased 2.21 units per day.

Conclusions:

In children with VPS infection, EVD device should be changed at every 10 days for the rapid resolution of the infection.

An updated approach to healthcare-associated meningitis

Among hospital-associated infections, healthcare-associated central nervous system infections are quite important because of high morbidity and mortality rates. The causative agents of healthcare-associated meningitis differ according to the status of immune systems and underlying diseases. The most frequent agents are Gram-negative bacilli (Pseudomonas spp., Acinetobacter spp., Escherichia coli and Klebsiella pneumoniae) and Gram-positive cocci (Staphylococcus aureus and coagulase-negative staphylococci). There are currently several problems in the treatment strategies of healthcare-associated meningitis due to a globally increasing resistance problem. Strategies targeting multidrug-resistant pathogens are especially limited. This review focuses on healthcare-associated meningitis and the current treatment strategies with a particular focus on methicillin-resistant Staphylococcus aureus (MRSA) meningitis.

Predictors of positive cerebrospinal fluid cultures in infants with bacteremia

BACKGROUND

Meningitis causes substantial morbidity and mortality in hospitalized infants. There is no consensus on the ability of blood cultures to predict results from cerebrospinal fluid (CSF) cultures in hospitalized infants.

METHODS

We used the Pediatrix Medical Group database of infants discharged from 333 neonatal intensive care units between 1997 and 2011. We identified all infants with a positive blood culture and a CSF culture obtained within 3 days. We evaluated the odds of a concordant blood-CSF culture pair, controlling for severity of illness, organism type, gestational age, day of blood culture and blood-CSF culture pairing, exposure to CSF-penetrating antibiotics and the presence of a ventriculo-peritoneal shunt.

RESULTS

We identified 8839 infants with 9408 blood-CSF culture pairs. Serratia marcescens (24/227, 11%) and Streptococcus pneumoniae (7/64, 11%) had the highest proportion of concordant blood-CSF culture pairs. The presence of a ventriculo-peritoneal shunt, as well as timing of the CSF culture on the same day as the blood culture, were associated with increased odds of blood-CSF culture pair concordance-odds ratio = 3.87 (95% confidence interval; 2.59-5.78) and 6.11 (2.81-13.24), respectively.

CONCLUSION

The frequency of blood-CSF culture pair concordance is related to organism type and to the timing of the CSF culture in relation to the blood culture.

Intraventricular and intrathecal colistin as the last therapeutic resort for the treatment of multidrug-resistant and extensively drug-resistant Acinetobacter baumannii ventriculitis and meningitis: a literature review

Acinetobacter baumannii ventriculitis/meningitis due to the emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains has become a clinical entity of considerable importance in recent years. A review of the available literature regarding intraventricular (IVT) or intrathecal (ITH) administration of colistin in MDR and XDR A. baumannii ventriculitis/meningitis was conducted and a total of 83 episodes in 81 patients were identified (71 cases in adults and 10 in children and neonates). Colistin was administered via the IVT and ITH route in 52 and 22 cases, respectively, whilst in 7 cases the exact route was not identified. The median dose of local colistin was 125000 IU (10mg) with a range of 20000 IU (1.6 mg) to 500000 IU (40 mg) in adults, whilst a dose of 2000 IU/kg (0.16 mg/kg) up to 125000 IU (10mg) was used in the paediatric population. The median duration of treatment of IVT/ITH polymyxin E was 18.5 days, whilst the median time to achieve sterilisation of cerebrospinal fluid was 4 days. The rate of successful outcome was 89%, and toxicity related to treatment mainly manifested as reversible chemical ventriculitis/meningitis was reported in nine cases (11%). Nowadays, IVT and ITH colistin represents the last resort treatment of MDR and XDR A. baumannii ventriculitis/meningitis, offering a unique, rather safe and successful mode of therapy.

Determinants and outcomes of ventriculoperitoneal shunt infections in Enugu, Nigeria

BACKGROUND

To evaluate the determinants and outcomes of shunt infection (SI).

METHODS

One hundred ninety-eight pediatric hydrocephalic patients treated with a ventriculoperitoneal (VP) shunt between January 2008 and August 2012 were retrospectively studied. Patients with SI were compared to those without SI in terms of the occurrence of risk factors and outcomes. Data was analyzed using Statistical Package for the Social Sciences software (version 15).

RESULTS

The age range was 2 weeks to 13 years, with a mean age of 3.1 ± 0.19 years for the SI group versus 2.7 ± 0.2 years for those without SI. One hundred and twelve patients were female and 86 were male. SI was recorded in 17 (8.6%) patients. Postinfective hydrocephalus (n = 6) was the most common cause of hydrocephalus in the SI group. Individuals in the SI group, compared to those without infection, were more likely to be underweight (χ2 = 23.4, p < 0.01). The mean interval between VP shunt placement and SI was 1.83 ± 1.25 months. Coagulase-negative Staphylococcus (29.4%) was the most common pathogen. The mortality rate in our series was 21.4% in patients with SI compared to 2.7% in those without SI.

CONCLUSION

Coagulase-negative Staphylococcus is currently the most common cause of SI and underweight children appear have a higher risk.

Prototheca wickerhamii as a cause of neuroinfection in a child with congenital hydrocephalus. First case of human protothecosis in Poland

This report describes a rare case of neuroinfection due to Prototheca wickerhamii in a child with severe, congenital hydrocephalus. The infection resolved completely after the patient was treated with oral ketoconazole, followed by intravenous fluconazole and amphotericin B. A probable source of infection was contamination during ventriculoperitoneal drain care procedures.

Pharmacokinetics of doripenem in CSF of patients with non-inflamed meninges

OBJECTIVES

To investigate intact blood-brain barrier (BBB) penetration by doripenem and characterize doripenem pharmacokinetics in CSF using a pharmacokinetic model.

PATIENTS AND METHODS

Thirty-eight neurological patients with no active neurological disease or CNS infection received a single 500 mg doripenem dose before pump implantation surgery, or lumbar puncture, for intrathecal baclofen administration. In most cases single CSF and blood samples were collected per patient and analysed for doripenem with HPLC. A two-stage pharmacokinetic analysis was performed to estimate: (i) empirical Bayesian estimates (EBEs) of individual doripenem plasma pharmacokinetic parameters, using plasma doripenem concentrations and literature population priors for a two-compartment model; and (ii) doripenem CSF pharmacokinetic parameters using simulated plasma concentrations from stage (i) as a forcing function. The mean values of the structural model parameters, k(CSF) (distribution rate constant) and PC (CSF/plasma partition coefficient), and the residual variability were estimated.

RESULTS

The mean estimates of the parameters were k(CSF)= 0.105 h(-1) and PC= 0.053, corresponding to mean steady-state doripenem CSF concentrations of 0.20 mg/L and 0.40 mg/L for regimens of 3 × 500 mg daily and 3 × 1000 mg daily, respectively, and a mean equilibrium half-life of 6.6 h. The model was validated internally using a visual predictive check (VPC) and bootstrap. Simulating two dosing scenarios gave doripenem levels in the CSF above or close to the literature MIC values.

CONCLUSIONS

The present NONMEM software analysis shows that doripenem crosses intact BBB significantly and suggests that the drug should be further evaluated as a candidate to treat certain CNS infections, since drug penetration through BBB is enhanced by meningeal inflammation.

Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children

Evidence-based guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by health care providers who care for adult and pediatric patients with MRSA infections. The guidelines discuss the management of a variety of clinical syndromes associated with MRSA disease, including skin and soft tissue infections (SSTI), bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system (CNS) infections. Recommendations are provided regarding vancomycin dosing and monitoring, management of infections due to MRSA strains with reduced susceptibility to vancomycin, and vancomycin treatment failures.

CSF shunt complications in infants--an experience from Pakistan

AIMS AND OBJECTIVE

The main aim of the study was to find out the postoperative complications and long-term outcome of cerebrospinal fluid-shunted patients in an infantile age group with a poor socioeconomic background.

MATERIAL AND METHODS

A prospective study of 100 cases of infantile hydrocephalus was conducted at Pakistan Institute of Medical Sciences, Islamabad, Pakistan. All selected patients suffering from congenital and post-meningitic hydrocephalus were operated on for ventriculoperitoneal shunt. However, cases of hydrocephalus secondary to myelomeningocele were not included. Patients were followed postoperatively for 2 years. Prior consent for surgery was taken from all parents and the study was approved by the hospital's academic and ethical council.

RESULTS

The majority of patients were brought quite late to the medical facilities because of social taboos and socioeconomic conditions. Early signs and symptoms of hydrocephalus were either ignored or misunderstood. Shunt infection and shunt failure rates remained at 14 and 10%, respectively. 50% of shunt blocks occurred in the first postoperative year and another 50% within 2 years. The highest percentage (40-45%) of death occurred in patients suffering from congenital hydrocephalus, in the first postoperative year.

CONCLUSIONS

This study concluded that the outcome and prognosis of shunted infantile hydrocephalus in developing countries is suboptimal due to different socioeconomic conditions. However, under such circumstances, careful selection of patients, timely intervention and adherence to meticulous aseptic surgical techniques can alter the prognosis of cerebrospinal fluid-shunted infants.

A randomised control trial on the use of topical methicillin in reducing post-operative ventriculoperitoneal shunt infection

BACKGROUND

A double-blind randomised control study was conducted on all patients who were admitted or referred to the Department of Neurosurgery, Sultanah Aminah Hospital, Johor Bahru, with a diagnosis of hydrocephalus where a ventriculoperitoneal shunt was indicated.

METHODS

The period of study was from November 2005 to May 2007, and the follow-up period was 3 months after surgery. Randomisation was carried out in the operating room prior to the procedure. The scrub nurse selected a sealed envelope, which contained the assignment of each patient to 1 of 2 treatment groups: Group 1 patients were treated with topical methicillin, and Group 2 patients were not treated with topical methicillin. Prophylactic antibiotic, cefuroxime (25 mg/kg) was given intravenously at induction. Standard sterile operative technique was followed in preparing and draping the patients.

RESULTS

A total of 90 patients were recruited in the study, and 13 (14.4%) patients developed an infection within 3 months post-operation. Group 1 had a 8.9% risk of infection, and Group 2 had a 20% risk; however, there was no statistically significant post-operative ventriculoperitoneal shunt (VPS) infection reduction with the use of topical methicillin in VPS surgery (P = 0.230). Multivariate analysis showed that only duration of surgery had a significant influence on the incidence of post-operative VPS infection in the non-methicillin group (P = 0.02). The non-methicillin group had an 8 times greater risk of developing post-operative VPS infection than the methicillin group if surgery lasted longer than 1 hour.

CONCLUSION

Topical methicillin had no significance in the reduction of post-operative VPS infection.

A retrospective study of infections after primary VP shunt placement in the newborn with myelomeningocele without prophylactic antibiotics

PURPOSE

We aim to correlate the frequency of infections after ventriculoperitoneal (VP) shunt placement in neonates with myelomeningocele (MMC) who did not receive prophylactic antibiotics to the timing of VP shunt placement and the frequency of cerebrospinal fluid (CSF) leakage at the MMC wound.

METHODS

Fifty-nine newborns with MMC underwent VP shunt insertion in the period 1983-2007. We reviewed retrospectively all records.

RESULTS

After MMC closure, 24 out of 59 newborns had an infection. The relative risk (RR; 95%) of having an infection is significantly higher [RR = 4,69 (1.145397-19.23568; P = .03761817)], and neuroinfection showed a tendency towards RR = 3.5 (.7067445-17.03112; P = .15414095) in newborns without symptomatic hydrocephalus at birth when we had a wait-and-watch policy (late shunt placement) compared with newborns with prompt shunt placement. The RR (95%) of having an infection [RR = 6,8 (3.314154-13.95228; P = 1.235e-07)] and also neuroinfections [RR = 4,76 (2.043019-11.09025; P = .00044478)] was highly significant if the child presented with MMC wound with CSF leakage before VP shunt insertion (Table 3).

CONCLUSIONS

Centers with a conservative antibiotic policy should be even more careful to avoid CSF leakage before shunt placement as this gives a highly significant increased risk of both infections in total and neuroinfections, and they should reconsider this conservative policy in newborns with MMC due to the significantly high infection rate.

Management of meningitis due to antibiotic-resistant Acinetobacter species

Acinetobacter meningitis is becoming an increasingly common clinical entity, especially in the postneurosurgical setting, with mortality from this infection exceeding 15%. Infectious Diseases Society of America guidelines for therapy of postneurosurgical meningitis recommend either ceftazidime or cefepime as empirical coverage against Gram-negative pathogens. However, assessment of the pharmacodynamics of these cephalosporins in cerebrospinal fluid suggests that recommended doses will achieve pharmacodynamic targets against fewer than 10% of contemporary acinetobacter isolates. Thus, these antibiotics are poor options for suspected acinetobacter meningitis. From in vitro and pharmacodynamic perspectives, intravenous meropenem plus intraventricular administration of an aminoglycoside may represent a superior, albeit imperfect, regimen for suspected acinetobacter meningitis. For cases of meningitis due to carbapenem-resistant acinetobacter, use of tigecycline is not recommended on pharmacodynamic grounds. The greatest clinical experience rests with use of polymyxins, although an intravenous polymyxin alone is inadvisable. Combination with an intraventricularly administered antibiotic plus removal of infected neurosurgical hardware appears the therapeutic strategy most likely to succeed in this situation. Unfortunately, limited development of new antibiotics plus the growing threat of multidrug-resistant acinetobacter is likely to increase the problems posed by acinetobacter meningitis in the future.

Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures

OBJECTIVE

The objective of this study was to evaluate whether the rigid application of a sterile protocol for shunt placement was applicable on a routine basis and allowed the reduction of shunt infections (SI) in children.

MATERIALS AND METHODS

Since 2001, a rigid sterile protocol for shunt placement in children using neither antibiotic-impregnated catheters nor laminar airflow was prospectively applied at Erasme Hospital, Brussels, Belgium. For assessing the protocol efficacy before continuation, we preliminarily analyzed the results of the first 100 operated children (43 females, 57 males, 49 aged <12 months; 115 consecutive shunt placement/revision procedures). All procedures were performed by the same senior surgeon, one assistant, one circulating nurse, one anesthesiologist. The sterile protocol was rigidly imposed to these four staff members: uniformed surgical technique; limited implant and skin edge manipulation; minimized human circulation in the room; scheduling surgery as first morning operation; avoiding postoperative cerebrospinal fluid (CSF) leak; double gloving; procedures of less than 30-min duration; systemic antibiotics prophylaxis. We analyzed separately: (1) children carrying an increased risk of SI (n = 38) due to preoperative external ventricular drainage, CSF leak, meningitis, glucocorticoids, chemotherapy; (2) children aged <12 months; (3) procedures for shunt revision.

RESULTS

Errors in protocol application were recorded in 71/115 procedures. They were mainly done by non-surgical staff, decreased with time and were medically justified in some young children. Surprisingly, no SI occurred (follow-up, 4 to 70 months). One child developed an appendicitis with peritonitis (Streptococcus faecalis) after 6 months. No SI was found. After peritonitis was cured, shunt reinsertion was uneventful.

CONCLUSION

These preliminary results suggest that a uniform and drastic sterile surgical technique for shunt placement: (1) can be rigidly applied on a routine basis; (2) can lower the early SI rate below 1%; (3) might have a stronger impact to reduce SI than using antibiotic-impregnated catheters and optimizing the operative environment such as using laminar airflow and reducing the non-surgical staff. This last issue will be evaluated further in the present ongoing protocol.