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Nie J, Zhang W, Zhang H, Yu H, Li A, Luo C, Hao Y. Development and Validation of a Predictive Model for Postoperative Intracranial Infections in Neurosurgery with Risk Factor Analysis. World Neurosurg 2024:S1878-8750(24)00947-1. [PMID: 38857869 DOI: 10.1016/j.wneu.2024.05.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Currently, the diagnosis of postneurosurgical intracranial infection is mainly dependent on cerebrospinal fluid (CSF) bacterial culture, which has the disadvantages of being time-consuming, having a low detection rate, and being easily affected by other factors. These disadvantages bring some difficulties to early diagnosis. Therefore, it is very important to construct a nomogram model to predict the risk of infection and provide a basis for early diagnosis and treatment. METHODS This retrospective study analyzed postneurosurgical patient data from the Fourth Affiliated Hospital of Harbin Medical University between January 2019 and September 2023. The patients were randomly assigned in an 8:2 ratio into the training cohort and the internal validation cohort. In the training cohort, initial screening of relevant indices was conducted via univariate analysis. Subsequently, the least absolute shrinkage and selection operator logistic regression identified significant potential risk factors for inclusion in the nomogram model. The model's discriminative ability was assessed using the area under the receiver operating characteristic curve, and its calibration was evaluated through calibration plots. The clinical utility of the model was determined using decision curve analysis and further validated by the internal validation cohort. RESULTS Multivariate logistic regression analysis of the training cohort identified 7 independent risk factors for postoperative intracranial infection: duration of postoperative external drainage (odds ratio [OR] 1.19, P = 0.005), continued fever (OR 2.11, P = 0.036), CSF turbidity (OR 2.73, P = 0.014), CSF pressure (OR 1.01, P = 0.018), CSF total protein level (OR 1.26, P = 0.026), CSF glucose concentration (OR 0.74, P = 0.029), and postoperative serum albumin level (OR 0.84, P < 0.001). Using these variables to construct the final model. The area under the receiver operating characteristic curve value of the model was 0.868 in the training cohort and 0.900 in the internal validation cohort. Calibration and the decision curve analysis indicated high accuracy and clinical benefit of the nomogram, findings that were corroborated in the validation cohort. CONCLUSIONS This study successfully developed a novel nomogram for predicting postoperative intracranial infection, demonstrating excellent predictive performance. It offers a pragmatic tool for the early diagnosis of intracranial infection.
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Affiliation(s)
- Jun Nie
- Department of Neurosurgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Weiguang Zhang
- Department of Neurosurgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China.
| | - Hongyu Zhang
- Department of Neurosurgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hanyong Yu
- Department of Neurosurgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Aozhou Li
- Department of Neurosurgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chaochuan Luo
- Department of Neurosurgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yanzhe Hao
- Department of Neurosurgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
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Magrini E, Rando E, Del Giacomo P, Matteini E, Leanza GM, Sanmartin F, Carbone A, Maiuro G, Dusina A, Cingolani A. Cerebrospinal fluid drain infection caused by pandrug-resistant Staphylococcus epidermidis successfully treated with ceftaroline in combination with fosfomycin and vancomycin. Diagn Microbiol Infect Dis 2024; 109:116205. [PMID: 38422663 DOI: 10.1016/j.diagmicrobio.2024.116205] [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: 08/21/2023] [Revised: 01/09/2024] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Abstract
External ventricular drain-related cerebrospinal fluid infection represents a fearsome complication of neurosurgical interventions. Although vancomycin represents the standard of care for methicillin-resistant CoNS healthcare-associated ventriculitis, resistance phenomena have been described. We reported a case of a persistent external ventricular fluid drain infection after device removal by pandrug-resistant Staphylococcus epidermidis successfully treated with intravenous ceftaroline in combination with fosfomycin and vancomycin. No evidence regarding pandrug-resistant S. epidermidis therapy currently exists to our knowledge. In this case, the S. epidermidis phenotype emerged during the therapy course, possibly due to initial device retention, biofilm formation and the host immune impaired response. Despite being poorly studied in vivo, ceftaroline may be considered an option when other alternatives are unavailable, thanks to its described activity against CoNS in vitro. This case extends the experience with ceftaroline for central nervous system infections suggesting it could also be used in high antimicrobial resistance settings for immunocompromised people.
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Affiliation(s)
- Eugenia Magrini
- Dipartimento di Sicurezza e Bioetica - Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Emanuele Rando
- Dipartimento di Sicurezza e Bioetica - Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paola Del Giacomo
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Elena Matteini
- Dipartimento di Sicurezza e Bioetica - Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriele Maria Leanza
- Dipartimento di Sicurezza e Bioetica - Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Flavia Sanmartin
- Dipartimento di Sicurezza e Bioetica - Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Carbone
- Dipartimento di Sicurezza e Bioetica - Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Maiuro
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alex Dusina
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonella Cingolani
- Dipartimento di Sicurezza e Bioetica - Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy; Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Ponnambath DK, Divakar G, Mamachan J, Biju S, Raja K, Abraham M. Epidemiology, clinical profile, and outcomes of CSF-diversion catheter-related infections - Prospective cohort study results from a single quaternary neurosurgery referral centre. Indian J Med Microbiol 2024; 48:100534. [PMID: 38367805 DOI: 10.1016/j.ijmmb.2024.100534] [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: 09/06/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Device-associated CNS infections is a major subgroup of healthcare associated CNS infections. Healthcare-associated ventriculitis or meningitis differs considerably from community-acquired meningitis in its epidemiology, pathogenesis, clinical presentation and management. OBJECTIVES This study aimed to identify the infection rates, the associated risk factors, and outcomes of these life-threatening infections. METHODS This was a 2-year single center prospective cohort study. Patient's clinical data, laboratory parameters, treatment and their outcomes were collected using data collection tool, and device days were collected from the hospital information system (HIS). Patients were categorised using IDSA criteria as contamination or colonisation or infection. Cox regression model was used for multivariate analysis to estimate hazard risk. RESULTS A total of 578 CSF diversion catheters were inserted in 472 patients. The average rate for EVD and LD infection were 11.12 and 11.86 per 1000 device days respectively. The average infection rates for VP and LP shunts were 6% and 5.2% per procedure, respectively. The commonest etiological agent causing CSF diversion catheter-related infection (CDRI) was Klebsiella pneumoniae (n = 14, 40%). The risk factors which were independently associated with increased infection risk by cox regression analysis were drain insertion ≥7 days [HR:11.73, p -0.03], posterior approach of EVD insertion (occipital) [HR:9.53, p - 0.01], pre-OP ASA score>3 [HR:8.28, p - 0.013] presence of EVD/LD leak [HR: 17.24, p < 0.0001], male gender [HR:2.05, p-0.05] and presence of associated peri-operative scalp infections [HR:3.531, p-0.005]. Shift to narrow spectrum surgical prophylactic antibiotic [Coefficient: -1.284, p-0.03] and reduction in CSF sampling frequency [Coefficient: -1.741, p-0.02] were found to be negatively associated with CDRI. CONCLUSIONS The study demonstrated drain insertion ≥7 days, posterior approach of EVD insertion, presence of EVD/LD leak, male gender and presence of associated peri-operative scalp skin and soft tissue infections were associated with increased risk of infection.
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Affiliation(s)
- Dinoop Korol Ponnambath
- Department of Microbiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, Kerala, India.
| | - Ganesh Divakar
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, Kerala, India.
| | - Jincy Mamachan
- Department of Microbiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, Kerala, India.
| | - Shiny Biju
- Hospital Infection Control Unit (HICU), Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, Kerala, India.
| | - Kavita Raja
- Department of Microbiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, Kerala, India.
| | - Mathew Abraham
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, Kerala, India.
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Ngougni Pokem P, Liu X, Parker SL, Verroken A, Collienne C, Finet P, Wijnant GJ, Laterre PF, Roberts JA, Van Bambeke F, Wittebole X. Population pharmacokinetics and dosing simulations of total and unbound temocillin in the plasma and CSF of neurocritically ill patients with external ventricular drain-related cerebral ventriculitis. J Antimicrob Chemother 2024; 79:429-442. [PMID: 38153240 DOI: 10.1093/jac/dkad398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/12/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND Cerebral ventriculitis might be caused by Gram-negative bacteria, including ESBL producers. Temocillin may be a useful treatment option in this scenario; however, no consistent data are available regarding its penetration into the CSF. OBJECTIVES To describe the population pharmacokinetics of temocillin in plasma and CSF and to determine the probability for different simulated dosing regimens to achieve pharmacokinetic/pharmacodynamic (PK/PD) targets in the CSF. METHODS Ten post-neurosurgical critically ill adult patients requiring continuous drainage of CSF were included in this monocentric, prospective, open-label, non-randomized study. They received 2 g loading dose temocillin over 30 min IV infusion, followed by a 6 g continuous infusion over 24 h. Total and unbound concentrations were measured in plasma (n = 88 and 86) and CSF (n = 88 and 88) samples and used to build a population PK model. Monte Carlo simulations were performed to estimate the PTA at 100% Css>MIC (steady state concentration above the MIC) in CSF. RESULTS All patients were infected with Enterobacterales with temocillin MICs ≤8 mg/L. The median (min-max) temocillin penetration in CSF was 12.1% (4.3-25.5) at steady state. Temocillin unbound plasma pharmacokinetics were best described by a one-compartment model. PTA for the applied dosing regimen was >90% for bacteria with MIC ≤ 4 mg/L. CONCLUSIONS The currently approved dose of 6 g by continuous infusion may be adequate for the treatment of ventriculitis by Enterobacterales with MIC ≤ 4 mg/L if considering 100% Css>MIC as the PK/PD target to reach. Higher maintenance doses could help covering higher MICs, but their safety would need to be assessed.
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Affiliation(s)
- Perrin Ngougni Pokem
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Avenue E. Mounier 73/B1.73.05, B-1200, Brussels, Belgium
| | - Xin Liu
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Suzanne L Parker
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Alexia Verroken
- Clinical Microbiology Department, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Christine Collienne
- Department of Critical Care Medicine, Cliniques universitaires St Luc, Université catholique de Louvain, Brussels, Belgium
| | - Patrice Finet
- Department of Neurosurgery, Cliniques universitaires St Luc, Université catholique de Louvain, Brussels, Belgium
| | - Gert-Jan Wijnant
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Avenue E. Mounier 73/B1.73.05, B-1200, Brussels, Belgium
| | - Pierre-François Laterre
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Françoise Van Bambeke
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Avenue E. Mounier 73/B1.73.05, B-1200, Brussels, Belgium
| | - Xavier Wittebole
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Piccirilli M, Scafa AK, Marchese E, Gallo M, Santoro A. Preventing Ventricular Catheter Displacement and Infection with the "Catheter-Locking Device-Assisted" Technique: A Retrospective Study of 231 Patients. World Neurosurg 2024; 182:e236-e244. [PMID: 38006938 DOI: 10.1016/j.wneu.2023.11.089] [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: 11/13/2023] [Accepted: 11/19/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND Inserting cerebrospinal fluid diversion devices such as external ventricular drains (EVDs) and ventriculoperitoneal shunts (VPSs) is a critical procedure. Unfortunately, complications such as catheter misplacement, dislocation, or infection can occur. Various surgical strategies aim to reduce these risks. One recent innovation is the "catheter-locking device-assisted" technique for EVD surgery. In this study, we examined its application in a larger group of cases encompassing both EVDs and VPSs over a 30-month period, with a focus on these complications. METHODS All adult patients who underwent a shunt procedure for noninfectious hydrocephalus at our institution from January 2021 to June 2023 were reviewed. We compared complications between those treated with the "standard" technique (subgroup A) and those managed with the "catheter-locking device-assisted" approach (subgroup B). RESULTS In the EVD surgical group (initial procedures, n = 161), 6 patients (3.7%) required reoperation owing to the catheter misplacement caused by inadvertent migration of the ventricular catheter within the operating room ("early" migration), while 11 patients (6.8%) experienced unintentional postoperative dislodgement ("delayed" migration). Seven patients (4.3%) developed an EVD-related infection after an average duration of 7.4 days. None of these complications were observed in subgroup B patients (P < 0.05). Among VPS patients (n = 137), 4 (2.9%), all in subgroup A, required reoperation due to intraoperative migration of the catheter (P = 0.121); no other complications were identified. CONCLUSIONS The "catheter-locking device-assisted" technique may significantly decrease the occurrence of the most common EVD complications and can also prove beneficial in VPS surgery. However, further investigation is necessary.
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Affiliation(s)
- Manolo Piccirilli
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Anthony Kevin Scafa
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy.
| | - Enrico Marchese
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy; Department of Neurosurgery, Institute of Neurosurgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Marco Gallo
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Antonio Santoro
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
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Lele AV, Bhananker AS, Fong CT, Imholt C, Walters A, Robinson EF, Souter MJ. Clinical Experience With a Dedicated Neurocritical Care Quality Improvement Program in an Academic Medical Center. Cureus 2024; 16:e52730. [PMID: 38384632 PMCID: PMC10880743 DOI: 10.7759/cureus.52730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Abstract
Background Managing neurocritical care patients encompasses many complex challenges, necessitating specialized care and continuous quality improvement efforts. In recent years, the focus on enhancing patient outcomes in neurocritical care may have led to the development of dedicated quality improvement programs. These programs are designed to systematically evaluate and refine care practices, aligning them with the latest clinical guidelines and research findings. Objective To describe the structure, processes, and outcomes of a dedicated Neurocritical Care Quality Improvement Program (NCC-QIP) at Harborview Medical Center, United States; a quaternary academic medical center, level I trauma, and a comprehensive stroke center. Materials and methods We describe the development of the NCC-QIP, its structure, function, challenges, and evolution. We examine our performance with several NCC-QI quality measures as proposed by the Joint Commission, the American Association of Neurology, and the Neurocritical Care Society, self-reported quality improvement (QI) concerns and QI initiatives undertaken because of the information obtained during our event/measure reporting process for patients admitted between 1/1/2014 and 06/30/2023. Results The NCC-QI reviewed data from 20,218 patients; mean age 57.9 (standard deviation 18.1) years, 56% (n=11,326) males, with acute ischemic stroke (AIS; 22.3%, n=4506), spontaneous intracerebral hemorrhage (ICH; 14.8%, n=2,996), spontaneous subarachnoid hemorrhage (SAH; 8.9%, n=1804), and traumatic brain injury (TBI; 16.6%, n=3352) among other admissions, 37.4% (n=7,559) were mechanically ventilated, and 13.6% (n=2,753) received an intracranial pressure monitor. The median intensive care unit length of stay was two days (Quartile 1-Quartile 3: 2-5 days), and the median hospital length of stay was seven days (Quartile 1-Quartile 3: 3-14 days); 53.9% (n=10,907) were discharged home while 11.4% (2,309) died. The three most commonly reported QI concerns were related to care coordination/communication/handoff (40.4%, n=283), medication-related concerns (14.9%, n=104), and equipment/devices-related concerns (11.7%, n=82). Hospital-acquired infections were in the form of ventilator-associated pneumonia (16.3%, n=419/2562), ventriculostomy catheter-associated infections (4%, n=102/2246), and deep venous thrombosis/pulmonary embolism (3.2%, n=647). The quality metrics documentation was as follows: nimodipine after SAH (99.8%, 1802/1810), Hunt and Hess score (36%, n=650/1804), and ICH score (58.4% n=1752/2996). In comparison, 72% (n=3244/4506) of patients with AIS had a documented National Institute of Health Stroke Scale. Admission Glasgow Coma Score was recorded in 99% of patients with SAH, ICH, and TBI. Educational modules were implemented in response to event reporting. Conclusion A dedicated NCC-QIP can be successfully implemented at a quaternary medical medical center. It is possible to monitor and review a large volume of neurocritical care patients, The three most reported NCC-QI concerns may be related to care coordination-communication/handoff, medication-related concerns, and equipment/devices-related complications. The documentation of illness severity scores and stroke measures depends upon the type of measure and ability to reliably and accurately abstract and can be challenging. The quality improvement process can be enhanced by educational modules that reinforce quality and safety.
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Affiliation(s)
- Abhijit V Lele
- Neurocritical Care/Anesthesiology, Harborview Medical Center, Seattle, USA
| | | | - Christine T Fong
- Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, USA
| | - Christine Imholt
- Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, USA
| | - Andrew Walters
- Anesthesiology and Pain Medicine, Harborview Medical Center, Seattle, USA
| | | | - Michael J Souter
- Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, USA
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Fernandez A, Uvelius E, Kronvall E. Ventriculostomy-Related Infections: Reduced Incidence by Terminating Cerebrospinal Fluid Screening. World Neurosurg 2024; 181:e820-e825. [PMID: 37923016 DOI: 10.1016/j.wneu.2023.10.139] [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: 06/12/2023] [Revised: 10/26/2023] [Accepted: 10/28/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The external ventricular drain (EVD) is an important instrument in managing patients in neurointensive care (NICU). A frequent and sometimes severe complication is ventriculostomy-related infection (VRI). This study aimed to evaluate the effects of biweekly VRI screening by CSF sampling on the clinical course and rate of VRI. METHODS Patients with implanted EVDs were retrospectively identified and a cohort screened twice per week was compared with a cohort sampled only on clinical indication. VRI was defined either as a suspected case or a culture-confirmed case. Length of stay in the NICU and CSF shunt dependency were used as outcome parameters. RESULTS A total of 562 patients were included. The overall proportion of patients treated for VRI was 22% and was not affected by screening (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.57-1.54). Screening was associated with a higher proportion of patients with culture-confirmed VRI (OR, 2.86; 95% CI, 1.36-6.73). The main risk factor for VRI was the number of days with EVD. Positive bacterial culture was associated with both a longer time in the NICU (β = 3.6; P < 0.01) and higher risk for shunt surgery (OR, 1.95; 95% CI, 1.04-3.64). CONCLUSIONS Screening was associated with a higher number of culture-confirmed VRI cases. In addition, screening did not detect VRI at an earlier stage and was not associated with a reduction in the rate of permanent hydrocephalus. No clinical benefit of screening was found. Frequent CSF sampling might contribute to infection. Based on these findings, CSF screening for VRI cannot be recommended.
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Affiliation(s)
- Antonio Fernandez
- Department of Neurosurgery, Skåne University Hospital, Lund, Sweden.
| | - Erik Uvelius
- Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| | - Erik Kronvall
- Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
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Choo YH, Shim Y, Kim H, Goh HY, Kim SJ, Kim EJ, Kang CK, Ha EJ. Significant Reduction in External Ventricular Drain-Related Infections After Introducing a Novel Bundle Protocol: A Before and After Trial. J Korean Med Sci 2023; 38:e386. [PMID: 38147836 PMCID: PMC10752748 DOI: 10.3346/jkms.2023.38.e386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 10/12/2023] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND External ventricular drain (EVD)-related infection (ERI) is a serious complication in neurosurgical patients. The estimated ERI rates range from 5 to 20 cases per 1,000 EVD catheter days. The pathophysiology of ERI is similar to central line-associated bloodstream infections (CLABSIs) stemming from skin-derived bacterial colonization. The use of bundle management can reduce CLABSI rates. Due to the pathogenic similarities between infections related to the two devices, we developed and evaluated the effectiveness of an ERI-bundle protocol based on CLABSI bundles. METHODS From November 2016 to November 2021, we conducted a study to evaluate the effectiveness of an ERI-bundle protocol. This study adopted a before-and-after trial, comparing the ERI rates for the 2 years before and 3 years after the introduction of the newly developed ERI-bundle protocol. We also analyzed the contributing factors to ERI using logistic regression analysis. RESULTS A total of 183 patients with 2,381 days of catheter use were analyzed. The ERI rate decreased significantly after the ERI-bundle protocol from 16.7% (14 of 84; 14.35 per 1,000 catheter days) to 4.0% (4 of 99; 3.21 per 1,000 catheter days) (P = 0.004). CONCLUSION Introduction of the ERI-bundle protocol was very effective in reducing ERI.
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Affiliation(s)
- Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Youngbo Shim
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Hyeseon Kim
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Hye Yeon Goh
- Center for Infection Control and Prevention, Seoul National University Hospital, Seoul, Korea
| | - Su Jung Kim
- Department of Nursing, Seoul National University Hospital, Seoul, Korea
| | - Eun Jin Kim
- Department of Nursing, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Chang Kyung Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.
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Doub JB, Chua JV. A rare case of Sphingomonas paucimobilis ventriculitis. Germs 2023; 13:254-258. [PMID: 38146376 PMCID: PMC10748845 DOI: 10.18683/germs.2023.1391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/18/2023] [Accepted: 07/09/2023] [Indexed: 12/27/2023]
Abstract
Introduction Nosocomial ventriculitis is a severe infection that habitually plagues neurological intensive care units. It is usually associated with external ventricular drains. Unfortunately, classic cerebral spinal fluid parameters are less specific and sensitive compared to community acquired meningitis. This is in part secondary to indolent bacteria commonly infecting external ventricular drains leading to ventriculitis. Case report Herein, a rare case of Sphingomonas paucimobilis ventriculitis in an immunocompetent host is reported. The patient had classic symptoms of ventriculitis, but her cerebral spinal fluid parameters were benign and initial cultures were negative. Consequently, treatment was tailored to an assumed respiratory infection only to have recurrence of her symptoms. Repeat analysis of her cerebral spinal fluid was again benign, but her cerebral spinal fluid culture grew S. paucimobilis. Subsequently, the patient was treated with cefepime, which resolved her symptoms. She completed a two-week course and has had no recurrence of her infection. Conclusions This case reinforces the need for clinicians to have heightened awareness of this emerging pathogen, its antibiotic resistance patterns, and the unique composition of this bacterium's cell wall which has ramifications on disease presentation.
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Affiliation(s)
- James B. Doub
- MD, Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, 725 west Lombard Street, Baltimore, Maryland, 21201, USA
| | - Joel V. Chua
- MD, Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, 725 west Lombard Street, Baltimore, Maryland, 21201, USA
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10
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Yue Z, Zhi X, Bi L, Zhao L, Ji J. Treatment and prognostic risk factors for intracranial infection after craniocerebral surgery. Neurosurg Rev 2023; 46:199. [PMID: 37568062 DOI: 10.1007/s10143-023-02106-0] [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: 05/25/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023]
Abstract
The objective of this study was to determine risk factors of pejorative evolution course in patients suffering from postoperative cranial infection. The data of patients who developed an intracranial infection after craniocerebral surgery in the neurosurgical intensive care unit of the First Affiliated Hospital of Nanjing Medical University in Nanjing, Jiangsu, China, from February 2018 to August 2019 were retrospectively analyzed. Logistic regression was used to analyze the factors influencing the prognosis of intracranial infection treatment. Sixty-four patients developed an infection after craniocerebral surgery, and 48 of them with negative CSF cultures received experimental anti-infectives. In 16 patients, cerebrospinal fluid culture showed pandrug-resistant pathogens, including 11 Acinetobacter baumannii (11), Klebsiella pneumoniae (3), Escherichia coli (1), and Candida glabrata (1). Nine patients received intraventricular or intrathecal injections of polymyxin B. The mean duration of infection treatment was 22.2 ± 9.9 days, and the clinical cure rate was 85.9% (55/64). Logistic multivariate regression analysis showed that inadequate CSF drainage (OR, 6.839; 95% CI, 1.130-41.383; P = 0.036) and infection with drug-resistant bacteria (OR, 24.241; 95% CI, 2.032-289.150; P = 0.012) were independent risk factors for postoperative intracranial infection. Intracranial infection with positive CSF culture and inadequate CSF drainage are factors contributing to the poor prognosis of intracranial infection. Moreover, early anti-infection treatment and adequate CSF drainage may improve patient outcomes. In particular, intraventricular or intrathecal injection of polymyxin B may be a safe and effective treatment strategy for MDR/XDR gram-negative bacilli infection.
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Affiliation(s)
- Zhen Yue
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaohui Zhi
- Department of Rehabilitation, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Liqing Bi
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lin Zhao
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jing Ji
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
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11
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Deng H, Puccio DJ, Anand SK, Yue JK, Hudson JS, Legarreta AD, Wei Z, Okonkwo DO, Puccio AM, Nwachuku EL. Power Drill Craniostomy for Bedside Intracranial Access in Traumatic Brain Injury Patients. Diagnostics (Basel) 2023; 13:2434. [PMID: 37510178 PMCID: PMC10378508 DOI: 10.3390/diagnostics13142434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Invasive neuromonitoring is a bedrock procedure in neurosurgery and neurocritical care. Intracranial hypertension is a recognized emergency that can potentially lead to herniation, ischemia, and neurological decline. Over 50,000 external ventricular drains (EVDs) are performed in the United States annually for traumatic brain injuries (TBI), tumors, cerebrovascular hemorrhaging, and other causes. The technical challenge of a bedside ventriculostomy and/or parenchymal monitor placement may be increased by complex craniofacial trauma or brain swelling, which will decrease the tolerance of brain parenchyma to applied procedural force during a craniostomy. Herein, we report on the implementation and safety of a disposable power drill for bedside neurosurgical practices compared with the manual twist drill that is the current gold standard. Mechanical testing of the drill's stop extension (n = 8) was conducted through a calibrated tensile tester, simulating an axial plunging of 22.68 kilogram (kg) or 50 pounds of force (lbf) and measuring the strength-responsive displacement. The mean displacement following compression was 0.18 ± 0.11 mm (range of 0.03 mm to 0.34 mm). An overall cost analysis was calculated based on the annual institutional pricing, with an estimated $64.90 per unit increase in the cost of the disposable electric drill. Power drill craniostomies were utilized in a total of 34 adult patients, with a median Glasgow Coma Scale (GCS) score of six. Twenty-seven patients were male, with a mean age of 50.7 years old. The two most common injury mechanisms were falls and motor vehicle/motorcycle accidents. EVDs were placed in all subjects, and additional quad-lumen neuromonitoring was applied to 23 patients, with no incidents of plunging events or malfunctions. One patient developed an intracranial infection and another had intraparenchymal tract hemorrhaging. Two illustrative TBI cases with concomitant craniofacial trauma were provided. The disposable power drill was successfully implemented as an option for bedside ventriculostomies and had an acceptable safety profile.
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Affiliation(s)
- Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - David J Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Sharath K Anand
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
| | - Joseph S Hudson
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Andrew D Legarreta
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Enyinna L Nwachuku
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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12
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Rojas-Lora M, Corral L, Zabaleta-Carvajal I, López-Ojeda P, Fuentes-Mila V, Romera-Peregrina I, Lerma-Briansò C, Plata-Menchaca E, Pavón A, Sabater J, Cabellos C. External ventriculostomy-associated infection reduction after updating a care bundle. Ann Clin Microbiol Antimicrob 2023; 22:59. [PMID: 37454149 DOI: 10.1186/s12941-023-00612-z] [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: 09/23/2022] [Accepted: 07/07/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Despite the clinical benefits of external ventricular drains (EVD), these devices can lead to EVD-related infections (EVDRI). The drainage insertion technique and standardized guidelines can significantly reduce the risk of infection, mainly caused by gram-positive bacteria. However, gram-negative microorganisms are the most frequent causative microorganisms of EVDRI in our hospital. We aimed to determine whether a new bundle of measures for the insertion and maintenance of a drain could reduce the incidence of EVDRI. This cohort study of consecutive patients requiring EVD from 01/01/2015 to 12/31/2018 compared the patients' characteristics before and after introducing an updated protocol (UP) for EVD insertion and maintenance in 2017. RESULTS From 204 consecutive patients, 198 requiring EVD insertion were included (54% females, mean age 55 ± 15 years). The before-UP protocol included 87 patients, and the after-UP protocol included 111 patients. Subarachnoid (42%) and intracerebral (24%) hemorrhage were the main diagnoses at admission. The incidence of EVDRI fell from 13.4 to 2.5 episodes per 1000 days of catheter use. Gram-negative bacteria were the most frequent causative microorganisms. Previous craniotomy remained the only independent risk factor for EVDRI. EVDRI patients had increased mechanical ventilation durations, hospital and ICU stays, and percutaneous tracheostomy requirements. CONCLUSIONS A care bundle focusing on fewer catheter sampling and more accurate antiseptic measures can significantly decrease the incidence of EVDRI. After implementing the management protocol, a decreased incidence of infections caused by gram-negative and gram-positive bacteria and reduced ICU and hospital lengths of stay were observed.
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Affiliation(s)
- Mariel Rojas-Lora
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Luisa Corral
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
- Departament de Ciències Clíniques, Universitat de Barcelona, Av. Mare de Déu de Bellvitge, 3, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
| | - Ivan Zabaleta-Carvajal
- Neurosurgery Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Pau López-Ojeda
- Neurosurgery Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Verónica Fuentes-Mila
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Iluminada Romera-Peregrina
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Cristina Lerma-Briansò
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Erika Plata-Menchaca
- Vall d'Hebron Research Institute, Passeig de La Vall d'Hebron, 129, 08035, Barcelona, Spain
- Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Alba Pavón
- Departament de Ciències Clíniques, Universitat de Barcelona, Av. Mare de Déu de Bellvitge, 3, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Joan Sabater
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Carmen Cabellos
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Barcelona, Spain
- Departament de Ciències Clíniques, Universitat de Barcelona, Av. Mare de Déu de Bellvitge, 3, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Centro de Investigación Biomédica de Enfermedades Infecciosas (CIBERINFEC, ISCIII), Madrid, Spain
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13
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Widén J, Cederberg D, Linder A, Westman G. Heparin-binding protein as a marker of ventriculostomy related infection and central nervous system inflammation in neuro-intensive care. Clin Neurol Neurosurg 2023; 229:107752. [PMID: 37156040 DOI: 10.1016/j.clineuro.2023.107752] [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: 12/12/2022] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Diagnosis of ventriculostomy related infections (VRI) in the neuro-intensive care unit remains challenging and current biomarkers lack adequate precision. The aim of this study was to explore the potential of Heparin-binding protein (HBP) in cerebrospinal fluid (CSF) as a diagnostic biomarker of VRI. METHODS All patients treated with an external ventricular drain (EVD) between January 2009 and March 2010 at Skåne university hospital in Lund, Sweden, were consecutively included. CSF samples obtained during routine care were analyzed for HBP. VRI was defined as a positive bacterial microbiology test result on a CSF sample with an erythrocyte-corrected leukocyte count of > 50 × 106/l. HBP levels at VRI diagnosis was compared to peak HBP levels in non-VRI controls. RESULTS In total, 394 CSF samples from 103 patients were analyzed for HBP. Seven patients (6.8%) fulfilled VRI criteria. Levels of HBP were significantly higher in VRI subjects (31.7 ng/mL [IQR 26.9-40.7 ng/mL]) compared to non-VRI controls (7.7 ng/mL [IQR 4.1-24.5 ng/mL]) (p = 0.024). The AUC of the receiver operating characteristic (ROC) curve was 0.76 (95% confidence interval [CI], 0.62-0.90). Among non-VRI patients, HBP was highest in patients with acute bacterial meningitis. Patients with subarachnoid hemorrhage displayed higher HBP levels than those with traumatic brain injury or shunt dysfunction. CONCLUSIONS HBP levels were higher in VRI subjects and varied between patients and different diagnoses. To validate the clinical usefulness and added value of HBP as a biomarker for VRI, the results need to be confirmed in larger studies with head-to-head comparisons to current biomarkers.
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Affiliation(s)
- Johan Widén
- Department of Clinical Sciences Lund, Division of Infection Medicine, Lund University, Lund, Sweden; Department of Medical Sciences Uppsala, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden.
| | - David Cederberg
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden; Department of Medical Sciences Uppsala, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Adam Linder
- Department of Clinical Sciences Lund, Division of Infection Medicine, Lund University, Lund, Sweden; Department of Medical Sciences Uppsala, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Gabriel Westman
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden; Department of Medical Sciences Uppsala, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
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14
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Almohaimede K, Zaccagna F, Kumar A, da Costa L, Wong E, Heyn C, Kapadia A. Arachnoid granulations may be protective against the development of shunt dependent chronic hydrocephalus after aneurysm subarachnoid hemorrhage*. Neuroradiol J 2023; 36:189-193. [PMID: 35993411 PMCID: PMC10034694 DOI: 10.1177/19714009221122249] [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] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND PURPOSE Chronic hydrocephalus may develop as a sequela of aneurysmal subarachnoid hemorrhage, requiring long-term cerebrospinal fluid shunting. Several clinical predictors of chronic hydrocephalus and shunt dependence have been proposed. However, no anatomical predictors have been identified. MATERIALS AND METHODS A retrospective cohort study was performed including 61 patients with aneurysmal subarachnoid hemorrhage. Clinical characteristics were noted for each patient including presentation World Federation of Neurosurgical Societies grade, modified Fischer grade, aneurysm characteristics, requirement for acute and chronic cerebrospinal fluid diversion, and 3-month modified Rankin scale. CT images were evaluated to determine the Evans' index and to enumerate the number of arachnoid granulations. Association between the clinical characteristics with ventriculoperitoneal shunt insertion and the 3-month modified Rankin scale were assessed. RESULTS The initial Evans' index was positively associated with mFisher grade and age, but not the number of arachnoid granulations. 16.4% patients required insertion of a ventriculoperitoneal shunt. The number of arachnoid granulations were a significant negative predictor of ventriculoperitoneal shunt insertion [OR: 0.251 (95% CI:0.073-0.862; p = 0.028)]. There was significant difference in the number of arachnoid granulations between those with and without ventriculoperitoneal shunt (p = 0.002). No patient with greater than 4 arachnoid granulations required a ventriculoperitoneal shunt, irrespective of severity of initial grade. CONCLUSION Arachnoid granulations may be protective against the development of shunt dependent chronic hydrocephalus after aneurysmal subarachnoid hemorrhage. This is irrespective of presenting hemorrhage severity. This is a potentially novel radiologic biomarker and anatomic predictor of shunt dependence.
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Affiliation(s)
- Khaled Almohaimede
- Department of Medical Imaging, 7938University of Toronto, Toronto, ON, Canada
- Department of Medical Imaging, 71545Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Fulvio Zaccagna
- Department of Biomedical and Neuromotor Sciences, 9296Alma Mater Studiorum - University of Bologna, Bologna, Italy
- IRCCS Institute of Neurological Sciences, Functional and Molecular Neuroimaging Unit, Bellaria Hospital, Bologna, Italy
| | - Ashish Kumar
- Department of Neurosurgery, 71545Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Leodante da Costa
- Department of Neurosurgery, 71545Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Erin Wong
- Department of Medical Imaging, 7938University of Toronto, Toronto, ON, Canada
- Department of Medical Imaging, 71545Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Chris Heyn
- Department of Medical Imaging, 7938University of Toronto, Toronto, ON, Canada
- Department of Medical Imaging, 71545Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Anish Kapadia
- Department of Medical Imaging, 7938University of Toronto, Toronto, ON, Canada
- Department of Medical Imaging, 71545Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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15
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Chadwick S, Donaldson L, Janin P, Darbar A, Sutherland R, Flower O, Hammond N, Parkinson J, Delaney A. The association between ventriculostomy - Related infection and clinical outcomes: A systematic review and meta-analysis. J Clin Neurosci 2023; 110:80-91. [PMID: 36827759 DOI: 10.1016/j.jocn.2023.02.005] [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: 08/18/2022] [Revised: 01/14/2023] [Accepted: 02/07/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Ventriculostomy - related infection (VRI) is a common complication of patients who require placement of an external ventricular drain (EVD). The clinical outcomes of people who are diagnosed with VRI is poorly characterised. We performed a systematic review and meta-analysis to assess the association between VRI, and clinical outcomes and resource use, in patients treated with an EVD. METHODS We searched MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of clinical trials to identify clinical trial and cohort studies that reported outcomes including mortality, functional outcome, duration of EVD insertion, and intensive care and hospital length of stay. Inclusion criteria and data extraction were conducted in duplicate. Where sufficient data were available, data synthesis was conducted using a random effects model to provide a pooled estimate of the association between VRI and clinical outcomes and resource use. We also pooled data to provide an estimate of the incidence of VRI in this population. RESULTS Nineteen studies including 38,247 patients were included in the meta-analysis. There were twelve different definitions of VRI in the included studies. The pooled estimate of the incidence of VRI was 11 % (95 % confidence interval (CI), 9 % to 14 %). A diagnosis of VRI was not associated with an increase in the estimated odds ratio (OR) for mortality (OR 1.07, 95 % CI 0.59 to 1.92, p = 0.83 I2 = 83.5 %), nor was a diagnosis of VRI associated with changes in neurological outcome (OR 1.42, 95 % CI 0.36 to 5.56, p = 0.89, I2 = 0.3 %). Those diagnosed with VRI had longer intensive care unit length of stay (estimated pooled mean difference 8.4 days 95 % CI 3.4 to 13.4 days, p = 0.0009, I2 = 78.7 %) an increase in hospital length of stay (estimated mean difference 16.4 days. 95 % CI 11.6 to 21.2 days, p < 0.0005, I2 = 76.6 %), a prolonged duration of EVD placement (mean difference 5.24 days, 95 % CI 3.05 to 7.43, I2 = 78.2 %, p < 0.01), and an increased requirement for an internal ventricular shunt (OR 1.80, 95 % CI 1.32 to 2.46, I2 = 8.92 %, p < 0.01). CONCLUSIONS Ventriculostomy related infection is not associated with increased mortality or an increased risk of poor neurological outcome, but is associated with prolonged duration of EVD placement, prolonged duration of ICU and hospital admission, and an increased rate of internal ventricular shunt placement.
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Affiliation(s)
- Simon Chadwick
- Northern Clinical School, Faculty of Health and Medicine, University of Sydney, USA; Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, USA.
| | - Lachlan Donaldson
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, USA; Division of Critical Care, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, USA
| | - Pierre Janin
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, USA
| | - Archie Darbar
- Department of Infectious Disease, Royal North Shore Hospital, USA
| | - Rosie Sutherland
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, USA
| | - Oliver Flower
- Northern Clinical School, Faculty of Health and Medicine, University of Sydney, USA; Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, USA
| | - Naomi Hammond
- Northern Clinical School, Faculty of Health and Medicine, University of Sydney, USA; Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, USA; Division of Critical Care, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, USA
| | | | - Anthony Delaney
- Northern Clinical School, Faculty of Health and Medicine, University of Sydney, USA; Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, USA; Division of Critical Care, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, USA
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16
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Jiang LZ, Shen Y, Liang F, Ye XM, Chen J, Yu YM. Intracranial Myroides odoratimimus Infection After EVD Successfully Treated with Intravenous Plus Intraventricular Tigecycline: A Case Report. Infect Drug Resist 2023; 16:1955-1963. [PMID: 37034395 PMCID: PMC10075215 DOI: 10.2147/idr.s403088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/16/2023] [Indexed: 04/03/2023] Open
Abstract
Intracranial infections are the most serious and common postoperative complications with significant mortality and morbidity. Myroides odoratimimus (M. odoratimimus), a Gram-negative environmental species and an opportunistic microorganism, predominantly infects immunocompromised individuals. Limited clinical experiences and documented multidrug resistance have resulted in a scarcity of data on the treatment of M. odoratimimus infections. As far as we know, this is the first reported case of an intracranial M. odoratimimus infection with external ventricular drains (EVD) that was effectively treated with a combination of intravenous and intraventricular tigecycline in an immunocompetent adult host.
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Affiliation(s)
- Ling-Zhi Jiang
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, People’s Republic of China
| | - Ye Shen
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, People’s Republic of China
| | - Feng Liang
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, People’s Republic of China
| | - Xiang-Ming Ye
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, People’s Republic of China
- Correspondence: Xiang-Ming Ye, Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, People’s Republic of China, Tel +86-13750814756, Email
| | - Jing Chen
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, People’s Republic of China
| | - Yan-Mei Yu
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, People’s Republic of China
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17
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Viola GM, Szvalb AD, Malek AE, Chaftari AM, Hachem R, Raad II. Prevention of device-related infections in patients with cancer: Current practice and future horizons. CA Cancer J Clin 2023; 73:147-163. [PMID: 36149820 PMCID: PMC9992006 DOI: 10.3322/caac.21756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
Over the past several years, multifaceted advances in the management of cancer have led to a significant improvement in survival rates. Throughout patients' oncological journeys, they will likely receive one or more implantable devices for the administration of fluids and medications as well as management of various comorbidities and complications related to cancer therapy. Infections associated with these devices are frequent and complex, often necessitating device removal, increasing health care costs, negatively affecting quality of life, and complicating oncological care, usually leading to delays in further life-saving cancer therapy. Herein, the authors comprehensively review multiple evidence-based recommendations along with best practices, expert opinions, and novel approaches for the prevention of diverse device-related infections. The authors present many general principles for the prevention of these infections followed by specific device-related recommendations in a systematic manner. The continuous involvement and meaningful cooperation between regulatory entities, industry, specialty medical societies, hospitals, and infection control-targeted interventions, along with primary care and consulting health care providers, are all vital for the sustained reduction in the incidence of these preventable infections.
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Affiliation(s)
- George M Viola
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ariel D Szvalb
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexandre E Malek
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anne-Marie Chaftari
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ray Hachem
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Issam I Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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18
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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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External Ventricular Drainage: A Practical Guide for Neuro-Anesthesiologists. Clin Pract 2023; 13:219-229. [PMID: 36826162 PMCID: PMC9955739 DOI: 10.3390/clinpract13010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023] Open
Abstract
External ventricular drainage is often considered a life-saving treatment in acute hydrocephalus. Given the large number of discussion points, the ideal management of EVD has not been completely clarified. The objective of this study was to review the most relevant scientific evidence about the management of EVD in its main clinical scenarios. We reviewed the most recent and relevant articles about indications, timing, management, and complications of EVD in neurocritical care, with particular interest in patients with subarachnoid hemorrhage (SAH), severe traumatic brain injury (TBI), and intraventricular hemorrhage (IVH) using the following keywords alone or matching with one another: intracranial pressure, subarachnoid hemorrhage, traumatic brain injury, intraventricular hemorrhage, external ventricular drainage, cerebrospinal shunt, intracranial pressure monitoring, and ventriculoperitoneal shunt. In the management of EVD in SAH, the intermittent drainage strategy is burdened with an elevated risk of complications (e.g., clogged catheter, hemorrhage, and need for replacement). There seems to be more ventriculoperitoneal shunt dependency in rapid weaning approach-managed patients than in those treated with the gradual weaning approach. Although there is no evidence in favor of either strategy, it is conventionally accepted to adopt a continuous drainage approach in TBI patients. Less scientific evidence is available in the literature regarding the management of EVD in patients with severe TBI and intraparenchymal/intraventricular hemorrhage. EVD placement is a necessary treatment in several clinical scenarios. However, further randomized clinical trials are needed to clarify precisely how EVD should be managed in different clinical scenarios.
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Hoefnagel D, Volovici V, Dos Santos Rubio EJ, Voor In't Holt AF, Dirven CMF, Vos MC, Dammers R. Impact of an external ventricular shunt (EVD) handling protocol on secondary meningitis rates: a historical cohort study with propensity score matching. BMC Neurol 2023; 23:36. [PMID: 36690947 PMCID: PMC9869497 DOI: 10.1186/s12883-023-03080-2] [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: 05/31/2022] [Accepted: 01/11/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND External ventricular drainage (EVD) is frequently used in neurosurgical procedures for cerebrospinal fluid (CSF) drainage. It is, however, associated with high infection rates, namely secondary meningitis and ventriculitis. Based on a previous high prevalence of these infections among patients with EVDs, we have proposed and implemented a protocol in an effort to decrease the infection rate. The aim of this study was to measure the effect of hospital-wide implementation of the EVD handling protocol on secondary EVD infections. PATIENTS AND METHODS We included 409 consecutive patients who received a new EVD for other indications than infectious pathologies from January 2000 until June 2012. Patients above 18 years of age were divided into pre- (n = 228) and post-protocol (n = 181) groups. Patient and disease demographics, as well as EVD data together with confounders for secondary meningitis were recorded in a database. Propensity score matching was then performed to create groups matched for sex, age, reason for drainage, type of shunt, time in situ and duration of surgery to place the EVD. Binomial logistic regression for confounder adjustment and regression discontinuity analyses were then performed on the matched cohort. RESULTS Infections occurred more frequently in the pre-protocol group (23% vs 9%, p < 0.001). The incidence of infection was 33/1000 drain-days pre-protocol and 9/1000 drain-days post-protocol. Regression analysis in a propensity score-matched cohort (n = 103 in the pre- and n = 178 in the post-protocol groups) showed that the pre-protocol period was independently associated with more infections (OR 2.69; 95%-CI 1.22-5.95, p = 0.01). CONCLUSIONS The incidence of secondary EVD infections can be reduced significantly by the implementation of a strict hospital-wide EVD handling protocol.
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Affiliation(s)
- Daphna Hoefnagel
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Center, Doctor Molewaterplein 40 Room-#: Na-2112, 3015 GD, Rotterdam, the Netherlands
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Center, Doctor Molewaterplein 40 Room-#: Na-2112, 3015 GD, Rotterdam, the Netherlands.
- Department of Public Health, Center for Medical Decision Making, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
| | | | - Anne F Voor In't Holt
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Center, Doctor Molewaterplein 40 Room-#: Na-2112, 3015 GD, Rotterdam, the Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Center, Doctor Molewaterplein 40 Room-#: Na-2112, 3015 GD, Rotterdam, the Netherlands
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Haldrup M, Mohamad N, Rasmussen M, Thorup L, Dyrskog S, Simonsen CZ, Miscov R, Bjarkam CR, Grønhøj M, Poulsen FR, Korshøj AR. Study protocol for ACTIVE study: safety and feasibility evaluation of external ventricular drainage with ACTIVE fluid exchange in intraventricular hemorrhage-a phase 2, multi-center, randomized controlled trial. Trials 2022; 23:1062. [PMID: 36581996 PMCID: PMC9798588 DOI: 10.1186/s13063-022-07043-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/20/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Primary intraventricular hemorrhage (IVH) or IVH secondary to intracerebral (ICH) and subarachnoid hemorrhage (SAH) are known to have a very poor prognosis, with an expected mortality between 50 and 80% (Hinson et al. Current Neurology and Neuroscience Reports 10:73-82, 2010). Clearance of IVH might improve patient outcome. METHODS The study is designed as an investigator-initiated, comparative, prospective, multi-center, 1:1 randomized phase 2 trial evaluating the efficacy and safety of active irrigation in external ventricular drainage (intervention arm-IRRAflow) compared to passive external ventricular drainage (control arm-EVD). The trial will enroll 58 patients with primary or secondary IVH. Major eligibility criteria include age ≥18 years of age, IVH documented on head CT or MRI scan (Graeb score ≥3), need of cerebrospinal fluid drainage, deterioration of consciousness or medical sedation at the time of enrollment, and indication for active treatment evaluated by the treating physicians. Exclusion criteria included patients with fixed and dilated pupils and pregnant or nursing women. The primary endpoint of the study is catheter occlusion evaluated by time to first observed occlusion from VC placement. Secondary endpoints include clearance of ventricular blood as measured by head CT scan, rates of catheter-related infection and shunt dependency, length of intensive care unit stay, functional status-Extended Glascow Outcome Scale (eGOS) and modified Rankin scale (mRS) at discharge to rehabilitation and 90 days-and mortality rates at 30 days and 90 days. DISCUSSION With no standardized treatment for IVH and a poor prognosis, new treatments are needed. IVH patients often need CSF drainage to treat hydrocephalus and to decrease ICP. Standard treatment with passive external ventricular drainage is related to an increased risk of infections which is found in up to 22% of treated cases. The passive VC is known to have a risk of occlusion and is seen in 19-47% of the cases. We hypothesize that the use of active fluid change using the IRRAflow system will be safe and feasible and will reduce the occlusion and infection rates in patients with IVH. TRIAL REGISTRATION ClicalTrials.gov NCT05204849. Registered 15 December 2021. Updated 24 January 2022.
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Affiliation(s)
- Mette Haldrup
- grid.154185.c0000 0004 0512 597XDepartment of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N Aarhus, Denmark
| | - Niwar Mohamad
- grid.154185.c0000 0004 0512 597XDepartment of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Mads Rasmussen
- grid.154185.c0000 0004 0512 597XDepartment of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Line Thorup
- grid.154185.c0000 0004 0512 597XDepartment of Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N Aarhus, Denmark
| | - Stig Dyrskog
- grid.154185.c0000 0004 0512 597XDepartment of Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N Aarhus, Denmark
| | - Claus Ziegler Simonsen
- grid.154185.c0000 0004 0512 597XDepartment of Neurology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N Aarhus, Denmark ,grid.7048.b0000 0001 1956 2722Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N Aarhus, Denmark
| | - Rares Miscov
- grid.27530.330000 0004 0646 7349Department of Neurosurgery, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark
| | - Carsten Reidies Bjarkam
- grid.27530.330000 0004 0646 7349Department of Neurosurgery, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark
| | - Mads Grønhøj
- grid.7143.10000 0004 0512 5013Department of Neurosurgery, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Frantz Rom Poulsen
- grid.7143.10000 0004 0512 5013Department of Neurosurgery, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Anders Rosendal Korshøj
- grid.154185.c0000 0004 0512 597XDepartment of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N Aarhus, Denmark ,grid.7048.b0000 0001 1956 2722Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N Aarhus, Denmark
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Brooks M, Duong D, Shivapathasundram G, Sheridan M. Cerebrospinal fluid white cell count to red cell count ratio as a predictor of ventriculitis in patients with external ventricular drains. ANZ J Surg 2022; 92:3278-3282. [PMID: 35437927 DOI: 10.1111/ans.17725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/04/2022] [Accepted: 04/03/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION External ventricular drain (EVD) associated ventriculitis is a complication of EVD placement associated with significant morbidity and mortality. Gold-standard for EVD associated bacterial ventriculitis diagnosis involves cerebrospinal fluid (CSF) sampling from the EVD with microscopy, culture and sensitivity testing. The ratio of white blood cells to red blood cells has anecdotally been considered a predictive factor in diagnosing EVD associated ventriculitis, however no study has been done demonstrating this. METHODS A retrospective cross-sectional study was designed to assess whether the ratio of CSF white blood cells to red blood cells could be used to diagnose EVD associated ventriculitis. Data was collected for all patients undergoing EVD insertion at a major neurosurgical unit in Sydney, Australia. A receiver operator characteristics (ROC) curve was used to determine if this ratio was useful, and Youden's index was calculated to determine the appropriate cut-off point. RESULTS This sample of n = 157 consecutive patients a total of 29 patients were diagnosed with ventriculitis. The area under the ROC curve was significant (0.706, P <0.001), and Youden's index demonstrated an appropriate cut-off point was a ratio of 1:106. DISCUSSION CSF parameters have long been considered predictive of EVD associated ventriculitis. We demonstrated that using a component of routine testing it is possible to accurately predict a ventriculitis diagnosis. As the ratio is used, it enables discrimination in a raised white blood cell count due to local trauma with interventricular bleeding. CONCLUSION CSF white blood cell to red blood cell ratio is an appropriate diagnostic test for ventriculitis.
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Affiliation(s)
- Michael Brooks
- Department of Neurosurgery, Liverpool Hospital, Elizabeth, New South Wales, Australia.,South West Sydney Clinical School, School of Medicine, University of New South Wales (UNSW), Randwick, New South Wales, Australia
| | - Dannielle Duong
- Department of Intensive Care, Liverpool Hospital, Elizabeth, New South Wales, Australia.,School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | | | - Mark Sheridan
- Department of Neurosurgery, Liverpool Hospital, Elizabeth, New South Wales, Australia
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Use of α-Defensins to Help Diagnose Nosocomial Ventriculitis. Neurocrit Care 2022; 38:225-228. [PMID: 36450974 PMCID: PMC9713076 DOI: 10.1007/s12028-022-01643-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/08/2022] [Indexed: 12/02/2022]
Abstract
Ventriculitis is a severe complication of indwelling neurosurgical devices that is associated with significant morbidity and mortality. The incidence rate of ventriculitis is approximately 10% with external ventricular drains. Obstinately, patients with these indwelling neurosurgical devices are prone to have traditional cerebral spinal fluid parameters that lack sensitivity and specificity in diagnosing nosocomial ventriculitis. In addition, diagnosis can be arduous given that indolent pathogens are commonly implicated. Therefore, diagnosis is difficult but paramount to thwart the morbidity and mortality associated with this infectious condition as well as to reduce the prolonged use of broad-spectrum antibiotics. As we extrapolate from prosthetic joint infections, for which diagnosis can also be challenging, we learn that the use of α-defensins as a diagnostic biomarker for nosocomial ventriculitis may hold promise. Herein, the viewpoint of using α-defensins as a diagnostic biomarker for nosocomial ventriculitis is discussed.
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Jesuyajolu D, Aremu G, Olukoya O, Obiekwe K, Okeke C, Edeh E, Moti T, Zubair A. A Scoping Review of the Use of Improvised External Ventricular Drains in Africa. Cureus 2022; 14:e28748. [PMID: 36105897 PMCID: PMC9447936 DOI: 10.7759/cureus.28748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2022] [Indexed: 11/05/2022] Open
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Meropenem Population Pharmacokinetics and Simulations in Plasma, Cerebrospinal Fluid, and Brain Tissue. Antimicrob Agents Chemother 2022; 66:e0043822. [PMID: 35862739 PMCID: PMC9380529 DOI: 10.1128/aac.00438-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Meropenem is a broad spectrum carbapenem used for the treatment of cerebral infections. There is a need for data describing meropenem pharmacokinetics (PK) in the brain tissue to optimize therapy in these infections. Here, we present a meropenem PK model in the central nervous system and simulate dosing regimens. This was a population PK analysis of a previously published prospective study of patients admitted to the neurointesive care unit between 2016 and 2019 who received 2 g of meropenem intravenously every 8 h. Meropenem concentration was determined in blood, cerebrospinal fluid (CSF), and brain microdialysate. Meropenem was described by a six-compartment model: two compartments in the blood, two in the CSF, and two in the brain tissue. Creatinine clearance and brain glucose were included as covariates. The median elimination rate constant was 1.26 h-1, the central plasma volume was 5.38 L, and the transfer rate constants from the blood to the CSF and from the blood to the brain were 0.001 h-1 and 0.02 h-1, respectively. In the first 24 h, meropenem 2 g, administered every 8 h via intermittent and extended infusions achieved good target attainment in the CSF and brain, but continuous infusion (CI) was better at steady-state. Administering a 3 g loading dose (LD) followed by 8 g CI was beneficial for early target attainment. In conclusion, a meropenem PK model was developed using blood, CSF, and brain microdialysate samples. An 8 g CI may be needed for good target attainment in the CSF and brain. Giving a LD prior to the CI improved the probability of early target attainment.
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Second- and Third-Tier Therapies for Severe Traumatic Brain Injury. J Clin Med 2022; 11:jcm11164790. [PMID: 36013029 PMCID: PMC9410180 DOI: 10.3390/jcm11164790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 12/04/2022] Open
Abstract
Intracranial hypertension is a common finding in patients with severe traumatic brain injury. These patients need treatment in the intensive care unit, where intracranial pressure monitoring and, whenever possible, multimodal neuromonitoring can be applied. A three-tier approach is suggested in current recommendations, in which higher-tier therapies have more significant side effects. In this review, we explain the rationale for this approach, and analyze the benefits and risks of each therapeutic modality. Finally, we discuss, based on the most recent recommendations, how this approach can be adapted in low- and middle-income countries, where available resources are limited.
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Plasma and Cerebrospinal Fluid Population Pharmacokinetics of Meropenem in Neurocritical Care Patients: a Prospective Two-Center Study. Antimicrob Agents Chemother 2022; 66:e0014222. [PMID: 35862757 PMCID: PMC9380572 DOI: 10.1128/aac.00142-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Morbidity and mortality related to ventriculitis in neurocritical care patients remain high. Antibiotic dose optimization may improve therapeutic outcomes. In this study, a population pharmacokinetic model of meropenem in infected critically ill patients was developed. We applied the final model to determine optimal meropenem dosing regimens required to achieve targeted cerebrospinal fluid exposures. Neurocritical care patients receiving meropenem and with a diagnosis of ventriculitis or extracranial infection were recruited from two centers to this study. Serial plasma and cerebrospinal fluid samples were collected and assayed. Population pharmacokinetic modeling and Monte Carlo dosing simulations were performed using Pmetrics. We sought to determine optimized dosing regimens that achieved meropenem cerebrospinal fluid concentrations above pathogen MICs for 40% of the dosing interval, or a higher target ratio of meropenem cerebrospinal fluid trough concentrations to pathogen MIC of ≥1. In total, 53 plasma and 34 cerebrospinal fluid samples were obtained from eight patients. Meropenem pharmacokinetics were appropriately described using a three-compartment model with linear plasma clearance scaled for creatinine clearance and cerebrospinal fluid penetration scaled for patient age. Considerable interindividual pharmacokinetic variability was apparent, particularly in the cerebrospinal fluid. Percent coefficients of variation for meropenem clearance from plasma and cerebrospinal fluid were 41.7% and 89.6%, respectively; for meropenem, the volume of distribution in plasma and cerebrospinal fluid values were 63.4% and 58.3%, respectively. High doses (up to 8 to 10 g/day) improved attainment of meropenem cerebrospinal fluid target exposures, particularly for less susceptible organisms (MICs, ≥0.25 mg/L). Standard meropenem doses of 2 g every 8 h may not achieve effective concentrations in cerebrospinal fluid in all critically ill patients. Higher doses, or alternative dosing methods (e.g., loading dose followed by continuous infusion) may be required to optimize cerebrospinal fluid exposures. Doses of up to 8 to 10 g/day either as intermittent boluses or continuous infusion would be suitable for patients with augmented renal clearance; lower doses may be considered for patients with impaired renal function as empirical suggestions. Ongoing dosing should be tailored to the individual patient circumstances. Notably, the study population was small and dosing recommendations may not be generalizable to all critically ill patients.
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Dakson A, Kameda-Smith M, Staudt MD, Lavergne P, Makarenko S, Eagles ME, Ghayur H, Guo RC, Althagafi A, Chainey J, Touchette CJ, Elliott C, Iorio-Morin C, Tso MK, Greene R, Bargone L, Christie SD. A nationwide prospective multicenter study of external ventricular drainage: accuracy, safety, and related complications. J Neurosurg 2022; 137:249-257. [PMID: 34826821 DOI: 10.3171/2021.7.jns21421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 07/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE External ventricular drainage (EVD) catheters are associated with complications such as EVD catheter infection (ECI), intracranial hemorrhage (ICH), and suboptimal placement. The aim of this study was to investigate the rates of EVD catheter complications and their associated risk factor profiles in order to optimize the safety and accuracy of catheter insertion. METHODS A total of 348 patients with urgently placed EVD catheters were included as a part of a prospective multicenter observational cohort. Strict definitions were applied for each complication category. RESULTS The rates of misplacement, ECI/ventriculitis, and ICH were 38.6%, 12.2%, and 9.2%, respectively. Catheter misplacement was associated with midline shift (p = 0.002), operator experience (p = 0.031), and intracranial length (p < 0.001). Although mostly asymptomatic, ICH occurred more often in patients receiving prophylactic low-molecular-weight heparin (LMWH) (p = 0.002) and those who required catheter replacement (p = 0.026). Infectious complications (ECI/ventriculitis and suspected ECI) occurred more commonly in patients whose catheters were inserted at the bedside (p = 0.004) and those with smaller incisions (≤ 1 cm) (p < 0.001). ECI/ventriculitis was not associated with preinsertion antibiotic prophylaxis (p = 0.421), catheter replacement (p = 0.118), and catheter tunneling length (p = 0.782). CONCLUSIONS EVD-associated complications are common. These results suggest that the operating room setting can help reduce the risk of infection, but not the use of preoperative antibiotic prophylaxis. Although EVD-related ICH was associated with LMWH prophylaxis for deep vein thrombosis, there were no significant clinical manifestations in the majority of patients. Catheter misplacement was associated with operator level of training and midline shift. Information from this multicenter prospective cohort can be utilized to increase the safety profile of this common neurosurgical procedure.
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Affiliation(s)
- Ayoub Dakson
- 1Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Michael D Staudt
- 3Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - Pascal Lavergne
- 4Université de Laval, CHU de Québec Hôpital-Enfant-Jésus, Laval, Québec, Canada
| | - Serge Makarenko
- 5Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew E Eagles
- 6Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - Huphy Ghayur
- 2Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Ru Chen Guo
- 5Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alwalaa Althagafi
- 1Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jonathan Chainey
- 7Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada; and
| | - Charles J Touchette
- 8Division of Neurosurgery, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Cameron Elliott
- 7Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada; and
| | | | - Michael K Tso
- 6Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - Ryan Greene
- 1Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Laurence Bargone
- 4Université de Laval, CHU de Québec Hôpital-Enfant-Jésus, Laval, Québec, Canada
| | - Sean D Christie
- 1Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Solo-Peleteiro A, Diéguez P, Pérez-Rodríguez MT, Galárraga RA, Pérez-Landeiro A, Álvarez-Fernández M. Cerebrospinal fluid drainage-related ventriculitis due to multidrug-resistant microorganisms. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2022; 40:322-325. [PMID: 35680350 DOI: 10.1016/j.eimce.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/31/2020] [Indexed: 06/15/2023]
Abstract
INTRODUCTION The aim of the study was to analyze the clinical and microbiological characteristics of adult patients with cerebrospinal fluid (CSF) drainage-related ventriculitis. METHODS Retrospective study from January 2010 to June 2019 performed in the Complexo Hospitalario Universitario de Vigo (Spain). Cases of CSF drainage-related ventriculitis in patients ≥18-year-old were gathered. Clinical characteristics of patients, type of drainage devices, management and microbiological isolates were analyzed. RESULTS Ninety-one episodes of CSF drainage-related ventriculitis were identified. The most frequent organisms isolated were Gram-positive cocci (65%), mainly Staphylococcus epidermidis (48%). Multidrug-resistant microorganisms were detected in 21 episodes (23%). In multivariate analysis, the independent factors related with multidrug-resistant ventriculitis were the length of hospital stay >14 days (HR 6.7; 95%CI 1.75-25.86, p=0.006) and previous antimicrobial therapy (HR 5.58; 95%CI 1.44-21.65, p=0.013). CONCLUSIONS Our study shows a large number of drainage-related ventriculitis episodes caused by multidrug-resistant organisms and reinforce the importance of a judicious use of antibiotics.
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Affiliation(s)
- Adriana Solo-Peleteiro
- Infectious Diseases Unit, Department of Internal Medicine, Complexo Hospitalario Universitario de Vigo, Spain
| | - Patricia Diéguez
- Infectious Diseases Unit, Department of Internal Medicine, Complexo Hospitalario Universitario de Vigo, Spain
| | - María Teresa Pérez-Rodríguez
- Infectious Diseases Unit, Department of Internal Medicine, Complexo Hospitalario Universitario de Vigo, Spain; Instituto de Investigación Biomédica Galicia Sur, Spain.
| | - Raul A Galárraga
- Department of Neurosurgery, Complexo Hospitalario Universitario de Vigo, Spain
| | | | - Maximiliano Álvarez-Fernández
- Instituto de Investigación Biomédica Galicia Sur, Spain; Department of Microbiology, Complexo Hospitalario Universitario de Vigo, Spain
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Rienecker C, Kiprillis N, Jarden R, Connell C. Effectiveness of interventions to reduce ventriculostomy-associated infections in adult and paediatric patients with an external ventricular drain: A systematic review. Aust Crit Care 2022:S1036-7314(22)00045-5. [DOI: 10.1016/j.aucc.2022.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 03/17/2022] [Accepted: 03/20/2022] [Indexed: 11/25/2022] Open
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Mehreen SF, Padmaja K, Sudhaharan S, Teja VD, Saradhi MV, Krishna YV. Clinical and microbiological spectrum of external ventricular drain related infections (EVDRIs) from a tertiary care center. IRANIAN JOURNAL OF MICROBIOLOGY 2022; 14:168-173. [PMID: 35765554 PMCID: PMC9168257 DOI: 10.18502/ijm.v14i2.9183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background and Objectives Insertion of an External Ventricular Drain (EVD) is a common and important lifesaving procedure that can lead to morbidity and mortality. This study was conducted to assess the infection rate, risk factors, causative organisms, and outcome of EVDs. Materials and Methods A prospective study was undertaken in a tertiary care centre from August 1st to October 30th, 2020. Over 192 patients had undergone insertion of EVDs in the neurosurgical intensive care unit. CSF samples were collected in sterile containers and transported to the laboratory. Results A total of 214 EVDs were inserted in 192 patients for 691 days. The median duration for EVD in situ and the mean time between catheter insertion and onset of infection were 14.5 days and 8 days. EVD related infection rate was 19.4 for 1000 EVD days. The most common risk factor for EVD insertion were tumors (55%) followed by hydrocephalus (40%).We identified 25 patients out of 192 (12%) who had clinical signs and symptoms with deranged CSF counts. A total of 13/25 (52%) specimens were culture positives out of which 10 (76.9%) were Gram negative pathogens and 3 (23%) were Gram positive pathogens and 3/10 (30%) Gram negative pathogens were Multidrug resistant organisms (MDROs). Conclusion It was observed that longer duration of catheter in situ was an important risk factor for EVD-related infections (ERIs) and also higher frequency of CSF sampling. A proper EVD infection prevention and control protocol must be followed in the form of a checklist at the time of EVD insertion.
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Affiliation(s)
- Syeda Fakiha Mehreen
- Department of Microbiology, Nizams Institute of Medical Sciences, Hyderabad, Telangana
| | - Kanne Padmaja
- Department of Microbiology, Nizams Institute of Medical Sciences, Hyderabad, Telangana
| | - Sukanya Sudhaharan
- Department of Microbiology, Nizams Institute of Medical Sciences, Hyderabad, Telangana
| | - Vijay D Teja
- Department of Microbiology, Nizams Institute of Medical Sciences, Hyderabad, Telangana
| | - Mudumba Vijay Saradhi
- Department of Neurosurgery, Nizams Institute of Medical Sciences, Hyderabad, Telangana
| | - Y. Vamsi Krishna
- Department of Neurosurgery, Nizams Institute of Medical Sciences, Hyderabad, Telangana
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Hallan DR, Eberly H, Rizk E. Appendicitis and Presence of a Ventriculoperitoneal (VP) Shunt. Cureus 2022; 14:e23491. [PMID: 35494990 PMCID: PMC9038592 DOI: 10.7759/cureus.23491] [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: 02/05/2022] [Accepted: 03/25/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Appendicitis can cause ventriculoperitoneal (VP) shunt infection. However, little data is available on the incidence of shunt infections and shunt revisions with appendicitis. Therefore, we sought to determine the rates of shunt infection and revision in patients with VP shunt and appendicitis using large database data and review the literature. METHODS We used a de-identified database network (TriNetX) to retrospectively query via ICD-10 and current procedural terminology codes to evaluate all patients with the presence of a VP shunt and appendicitis. Primary outcomes included shunt infection and shunt revision at 90 days, with secondary outcomes of sepsis and seizure. RESULTS 396 patients with VP shunt and subsequent appendicitis were identified. The average age was 27.02+-20.94 years. Shunt infection was identified in 43 (10.859%) patients within 90 days of appendicitis, and shunt externalization or revision was performed in 66 (16.667%) patients. Sepsis was identified in 49 (12.374%) patients and seizures occurred in 56 (14.141%) patients. The literature review revealed eight relevant articles, with 49 total patients. Ten (20.408%) patients had shunts externalized, four of which occurred after shunt infection was identified. Shunt infection occurred in a total of 11 (22.449%) patients. Two (4.082%) patients died, one of which had their shunt externalized pre-emptively, and the other after ventriculitis was identified. Shunt revisions were performed in 16 (32.653%) Conclusion: Our results demonstrate that shunt externalization should be strongly considered in patients with appendicitis, given high shunt infection rates.
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Affiliation(s)
- David R Hallan
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Hanel Eberly
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Elias Rizk
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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Updates on techniques and technology to optimize external ventricular drain placement: A review of the literature. Clin Neurol Neurosurg 2022; 213:107126. [DOI: 10.1016/j.clineuro.2022.107126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 11/23/2022]
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Pratt KA, Peacock SH, Yost KD, Freeman WD, Collins CI, McLaughlin DC. Zero-Calibrating External Ventricular Drains: Exploring Practice. J Neurosci Nurs 2022; 54:2-5. [PMID: 34882617 DOI: 10.1097/jnn.0000000000000622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT BACKGROUND: Guidelines call for the removal of the nonvented cap (NVC) on the flushless transducer applied to the external ventricular drain (EVD) to zero the device to atmospheric pressure. Some hospitals have abandoned this practice to prevent opening the system to air. No data exist to determine the safest, most effective method of EVD zero-calibration. METHODS: A multidisciplinary team was assembled to use reflective practice to evaluate current zero-calibration of EVD practice. RESULTS: Clinical Nursing Focus showed recommendations largely out of date without detailed rationale or a high level of evidence. Manufacturer recommendations were fragmented and did not address rationale for technique. Bedside trial showed equivalence when comparing intracranial pressure (ICP) tidal, ICP after EVD zero with NVC removal, and ICP after EVD zero without NVC removal. CONCLUSION: Institutional guidelines were changed to reflect zero-calibration of EVD without NVC removal in systems that are amendable to this procedure. Further study is needed to determine best practice.
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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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Polster SP, Carrión-Penagos J, Awad IA. Management of Intraventricular Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00073-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Neurosurgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00037-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Khalaveh F, Fazel N, Mischkulnig M, Vossen MG, Reinprecht A, Dorfer C, Roessler K, Herta J. Risk Factors Promoting External Ventricular Drain Infections in Adult Neurosurgical Patients at the Intensive Care Unit-A Retrospective Study. Front Neurol 2021; 12:734156. [PMID: 34858309 PMCID: PMC8631749 DOI: 10.3389/fneur.2021.734156] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/05/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives: Multiple risk factors have been described to be related to external ventricular drain (EVD) associated infections, with results varying between studies. Former studies were limited by a non-uniform definition of EVD associated infection, thus complicating a comparison between studies. In this regard, we assessed risk factors promoting EVD associated infections and propose a modified practice-oriented definition of EVD associated infections. Methods: We performed a retrospective, single-center study on patients who were treated with an EVD, at the neurosurgical intensive care unit (ICU) at a tertiary center between 2008 and 2019. Based on microbiological findings and laboratory results, patients were assigned into an infection and a non-infection group. Patient characteristics and potential risk factors were compared between the two groups (p < 0.05). Receiver operating characteristics (ROC) for significant clinical, serum laboratory and cerebrospinal fluid (CSF) parameters were calculated. Results: In total, 396 patients treated with an EVD were included into the study with a mean age of 54.3 (range: 18–89) years. EVD associated infections were observed in 32 (8.1%) patients. EVD insertion at another hospital (OR 3.86), and an increased CSF sampling frequency of more than every third day (OR 12.91) were detected as major risk factors for an EVD associated infection. The indication for EVD insertion, surgeon's experience, the setting of EVD insertion (ICU vs. operating room) and the operating time did not show any significant differences between the two groups. Furthermore, ROC analysis showed that clinical, serum laboratory and CSF parameters did not provide specific prediction of EVD associated infections (specificity 44.4%). This explains the high overtreatment rate in our cohort with the majority of our patients who received intrathecal vancomycin (63.3%), having either negative microbiological results (n = 12) or were defined as contaminations (n = 7). Conclusions: Since clinical parameters and blood analyzes are not very predictive to detect EVD associated infections in neurosurgical patients, sequential but not too frequent microbiological and laboratory analysis of CSF are still necessary. Furthermore, we propose a uniform classification for EVD associated infections to allow comparability between studies and to sensitize the treating physician in determining the right treatment.
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Affiliation(s)
- Farjad Khalaveh
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Nadia Fazel
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Mario Mischkulnig
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Matthias Gerhard Vossen
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Andrea Reinprecht
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Johannes Herta
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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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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Garg K, Verma SK, Singh PK, Singh M, Chandra PS, Kale SS. Effect of External Ventricular Drain Tunnel Length on Cerebrospinal Fluid Infection Rates-A Bayesian Network Meta-Analysis. World Neurosurg 2021; 158:268-278.e4. [PMID: 34774808 DOI: 10.1016/j.wneu.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND External ventricular drain (EVD)-associated cerebrospinal fluid infection (EACI) remains a major complication associated with EVD. Length of EVD tunnel, an overlooked but modifiable factor, can be associated with increased risk of EACI. The aim of this study is to find the tunnel length associated with least chances of EACI by performing a network meta-analysis. METHODS A comprehensive search of different databases was performed to retrieve studies that studied the rates of EACI with different EVD tunnel lengths and a Bayesian network meta-analysis was performed. RESULTS Six studies met the inclusion criteria and were included in the network meta-analysis. With 0 cm tunnel length as reference, the odds ratio (OR) for developing EACI was minimum for tunnel length 5-10 cm (OR, 0.027). It was followed by tunnel length of 5 cm (OR, 0.060) and 10 cm (OR, 0.075). The surface under the cumulative ranking curve plot showed that the probability of the tunnel length 5-10 cm (ranked first), 5 cm (ranked second), and 10 cm (ranked third) for being the best EVD tunnel length was found to be 86%, 64%, and 61%, respectively. CONCLUSIONS The length for which an EVD is tunneled may have an impact on the rate of EACI. Our network meta-analyses showed that the tunnel length of 5-10 cm was associated with the lowest rates of EACI, with 86% probability of being the best EVD tunnel length. The probability of a patient with 5-10 cm EVD length developing EACI was 2.7% compared with zero tunnel length.
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Affiliation(s)
- Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Satish Kumar Verma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Kumar Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - P Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank S Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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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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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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Updating External Ventricular Drainage Care and Intrahospital Transport Practices at a Community Hospital. J Neurosci Nurs 2021; 52:273-276. [PMID: 32956133 DOI: 10.1097/jnn.0000000000000553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Frontline neurointensive care nurses from 1 community hospital were invited to assess the current state of care related to use of external ventricular drains (EVDs) and intrahospital transport (IHT) policies, investigate and plan practice changes, and implement skills review for nurses caring for the adult patient with an acute brain injury. PROJECT Our team researched best practices related to EVD care and IHT procedures, updated current EVD insertion checklists, developed nurse role cards to assist with EVD insertion at the bedside, revised current EVD care policies and procedures, and created a new IHT policy. The same nurses shared updated information and skills review for neuroscience nurse peers. CONCLUSION The goals for the project were met, and practice variation is being reduced.
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Sweid A, Weinberg JH, Abbas R, El Naamani K, Tjoumakaris S, Wamsley C, Mann EJ, Neely C, Head J, Nauheim D, Hauge J, Gooch MR, Herial N, Zarzour H, Alexander TD, Missios S, Hasan D, Chalouhi N, Harrop J, Rosenwasser RH, Jabbour P. Predictors of ventriculostomy infection in a large single-center cohort. J Neurosurg 2021; 134:1218-1225. [DOI: 10.3171/2020.2.jns192051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 02/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. The aim of this retrospective, single-center large series was to assess the rate and independent predictors of ventriculostomy-associated infection (VAI).
METHODS
The authors performed a retrospective chart review of consecutive patients who underwent EVD placement between January 2012 and January 2018.
RESULTS
A total of 389 patients were included in the study. The infection rate was 3.1% (n = 12). Variables that were significantly associated with VAI were EVD replacement (OR 10, p = 0.001), bilateral EVDs (OR 9.2, p = 0.009), duration of EVD placement (OR 1.1, p = 0.011), increased CSF output/day (OR 1.0, p = 0.001), CSF leak (OR 12.9, p = 0.001), and increased length of hospital stay (OR 1.1, p = 0.002). Using multivariate logistic regression, independent predictors of VAI were female sex (OR 7.1, 95% CI 1.1–47.4; p = 0.043), EVD replacement (OR 8.5, 95% CI 1.44–50.72; p = 0.027), increased CSF output/day (OR 1.01, 95% CI 1.0–1.02; p = 0.023), and CSF leak (OR 15.1, 95% CI 2.6–87.1; p = 0.003).
CONCLUSIONS
The rate of VAI was 3.1%. Routine CSF collection (every other day or every 3 days) and CSF collection when needed were not associated with VAI. The authors recommend CSF collection when clinically needed rather than routinely.
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Affiliation(s)
- Ahmad Sweid
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Joshua H. Weinberg
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Rawad Abbas
- 2American University of Beirut Faculty of Medicine, Beirut, Lebanon
| | - Kareem El Naamani
- 3Gilbert and Rose-Marie Chagoury School of Medicine, Beirut, Lebanon
| | - Stavropoula Tjoumakaris
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Christine Wamsley
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Erica J. Mann
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Christopher Neely
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Jeffery Head
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Nauheim
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Julie Hauge
- 4University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - M. Reid Gooch
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nabeel Herial
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Hekmat Zarzour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Tyler D. Alexander
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Symeon Missios
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- 5Department of Neurosurgery, University of Iowa, Iowa City, Iowa
| | - Nohra Chalouhi
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - James Harrop
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H. Rosenwasser
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Abstract
PURPOSE OF REVIEW We have highlighted the recent advances in infection in neurocritical care. RECENT FINDINGS Central nervous system (CNS) infections, including meningitis, encephalitis and pyogenic brain infections represent a significant cause of ICU admissions. We underwent an extensive review of the literature over the last several years in order to summarize the most important points in the diagnosis and treatment of severe infections in neurocritical care. SUMMARY Acute brain injury triggers an inflammatory response that involves a complex interaction between innate and adaptive immunity, and there are several factors that can be implicated, such as age, genetic predisposition, the degree and mechanism of the injury, systemic and secondary injury and therapeutic interventions. Neuroinflammation is a major contributor to secondary injury. The frequent and challenging presence of fever is a common denominator amongst all neurocritical care patients.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Hospital Clinic, IDIBAPS, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - Alan Blake
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
| | - Daniel Collins
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
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Effect of a bundle approach on external ventricular drain-related infection. Acta Neurochir (Wien) 2021; 163:1135-1142. [PMID: 33427989 DOI: 10.1007/s00701-020-04698-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/28/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Emergency placement of an external ventricular drain (EVD) is one of the most frequently performed neurosurgical procedures. EVD-related infection continues to be a major challenge causing significant morbidity and costs. Bundle approaches have been shown to reduce infection rates; however, they are still not widely used, and observation periods often were rather short. METHODS The present study evaluated the effect of a multi-item bundle approach for EVD placement and care on the occurrence of EVD-related infection. A before/after approach was used to compare groups of consecutive patients over 5-year epochs to control for bias and secondary confounding variables. RESULTS The number of patients in the group before implementation of the bundle approach was 141 and 208 thereafter. There were no statistical differences in demographic and other variables. While 41/141 patients (29.1%) had an EVD-related infection before, this was the case in only 10/208 patients (4.8%) thereafter (p < 0.0001). The EVD-related infection rate was reduced from 13.7/1000 catheter days to 3.2/1000, and the 50% probability of an EVD-related infection in correlation to the mean duration of EVD placement was significantly lower (p < 0.0001). Routine EVD replacement was not helpful to reduce EVD-related infection. EVD-related infection rates remained low also over the next 8 years after the study was finished. CONCLUSIONS The introduction of a multi-item bundle approach for EVD insertion and care resulted in a marked reduction of EVD-related infection. Long observation periods over 5 years and beyond confirm that short-term changes are sustained with continued use of such protocols.
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Solo-Peleteiro A, Diéguez P, Pérez-Rodríguez MT, Galárraga RA, Pérez-Landeiro A, Álvarez-Fernández M. Cerebrospinal fluid drainage-related ventriculitis due to multidrug-resistant microorganisms. Enferm Infecc Microbiol Clin 2021; 40:S0213-005X(21)00012-4. [PMID: 33593611 DOI: 10.1016/j.eimc.2020.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/26/2020] [Accepted: 12/31/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The aim of the study was to analyze the clinical and microbiological characteristics of adult patients with cerebrospinal fluid (CSF) drainage-related ventriculitis. METHODS Retrospective study from January 2010 to June 2019 performed in the Complexo Hospitalario Universitario de Vigo (Spain). Cases of CSF drainage-related ventriculitis in patients ≥18-year-old were gathered. Clinical characteristics of patients, type of drainage devices, management and microbiological isolates were analyzed. RESULTS Ninety-one episodes of CSF drainage-related ventriculitis were identified. The most frequent organisms isolated were Gram-positive cocci (65%), mainly Staphylococcus epidermidis (48%). Multidrug-resistant microorganisms were detected in 21 episodes (23%). In multivariate analysis, the independent factors related with multidrug-resistant ventriculitis were the length of hospital stay >14 days (HR 6.7; 95%CI 1.75-25.86, p=0.006) and previous antimicrobial therapy (HR 5.58; 95%CI 1.44-21.65, p=0.013). CONCLUSIONS Our study shows a large number of drainage-related ventriculitis episodes caused by multidrug-resistant organisms and reinforce the importance of a judicious use of antibiotics.
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Affiliation(s)
- Adriana Solo-Peleteiro
- Infectious Diseases Unit, Department of Internal Medicine, Complexo Hospitalario Universitario de Vigo, Spain
| | - Patricia Diéguez
- Infectious Diseases Unit, Department of Internal Medicine, Complexo Hospitalario Universitario de Vigo, Spain
| | - María Teresa Pérez-Rodríguez
- Infectious Diseases Unit, Department of Internal Medicine, Complexo Hospitalario Universitario de Vigo, Spain; Instituto de Investigación Biomédica Galicia Sur, Spain.
| | - Raul A Galárraga
- Department of Neurosurgery, Complexo Hospitalario Universitario de Vigo, Spain
| | | | - Maximiliano Álvarez-Fernández
- Instituto de Investigación Biomédica Galicia Sur, Spain; Department of Microbiology, Complexo Hospitalario Universitario de Vigo, Spain
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Is External Ventricular Drain Infection Predictable in Neurosurgery Patients? A Following-up Study in Iran. ARCHIVES OF NEUROSCIENCE 2021. [DOI: 10.5812/ans.103075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: External ventricular drains (EVDs) infection is a life-threatening complication. Objectives: To investigate the rate of EVDs infection and its predictive factors in neurosurgery patients hospitalized at a tertiary teaching hospital in Iran. Methods: In this survey, all patients referred to a subspecialty hospital in Tehran (Iran) with an external ventricular drain (EVDs) from Jun 23, 2018, to Jun 23, 2019, are monitored within 30 days of EVDs placement for infection. Data on demographic information, underlying diseases, number of EVD replacements, length of hospital stay, type consumed antibiotic before neurosurgery, length of tunneling, type of airway, duration of mechanical ventilation, duration of surgery(hours), surgeon name, APACHE II score, length of intensive care unit stay are collected. The diagnosis was based on the Center for Diseases Control and Prevention criteria for meningitis/ventriculitis and clinical vision of infectious or critical care specialists. A logistic regression model was developed to identify factors that can predict the infection. Results: Of 81 patients with EVDs, 39 (48.1%) were infected. The mean age of patients was 44.33 ± 19.5 years, and 55.6% of them were male. According to the multiple logistic regression analysis, mechanical ventilation for more than 6 days (OR: 2.5, 95% CI: 1.6 - 3.56, P = 0.04) and length of tunneling > 5 cm (OR: 1.98, 95%CI: 1.87 - 4.76, P = 0.02) were identified as factors that could predict EVD infection. Also, consuming ceftazidime + vancomycin, as a prophylaxis agent, had a lower odds ratio for EVD infection (OR:0.4, 95% CI: 0.08 - 0.84, P = 0.04). Conclusions: Regarding the predictive factors of EVDs infection, either in the present study or other studies, there should be strategies to manage this life-threatening infection in neurosurgery patients.
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Kurdyumova NV, Savin IA, Ershova ON, Shifrin MA, Danilov GV, Usachev DY. [Risk factors of nosocomial meningitis in neurological intensive care unit. Results of a five-year prospective study]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2021; 85:83-91. [PMID: 34951764 DOI: 10.17116/neiro20218506183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
UNLABELLED Nosocomial meningitis (NM) is a serious complication in neurosurgery. Understanding the risk factors of nosocomial meningitis is important for their prevention. OBJECTIVE To determine the main risk factors of NM in neurological intensive care unit. MATERIAL AND METHODS A prospective study included all patients (n=2140) treated at the neurological intensive care unit for more than 48 hours between October 1, 2010 and October 31, 2015. Cases of nosocomial meningitis were registered. We analyzed risk factors in 2 groups of patients (with and without NM). RESULTS AND DISCUSSION The incidence of NM in neurological intensive care unit was 8.4% (95% CI 6.8-10.0) (n=180). Relative risk of NM under external ventricular drainage was 3.98 (99 cases of NM, p<0.05). Relative risk of NM in patients with CSF leakage (including nasal CSF leakage after transsphenoidal surgery) was 5.2 (49 cases of NM, p<0.05). The incidence of nosocomial meningitis was significantly higher among patients with surgery time ≥8 hours (17.68%, p<0.01). Nosocomial meningitis was also significantly more common after redo surgery (13.07%, p<0.05). Insertion of intracranial pressure sensor was not a significant risk factor of NM. The risk of meningitis was 2.67% if the above-mentioned factors were absent. Extracranial factors are not specific for NM. No significant relationship between certain neurosurgical disease and NM was found. CONCLUSION We found higher risk of NM in ICU patients with the following factors: external ventricular drainage, CSF leakage, redo surgery and surgery time.
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Affiliation(s)
| | - I A Savin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - O N Ershova
- Burdenko Neurosurgical Center, Moscow, Russia
| | - M A Shifrin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - G V Danilov
- Burdenko Neurosurgical Center, Moscow, Russia
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