Challenges in Managing Post-Neurosurgical Meningitis & Ventriculitis and CSF Shunt Infections

Challenges in managing post-neurosurgical meningitis & ventriculitis and CSF shunt infections

Adarsh Bhimraj Section of Neurologic Infectious Diseases Cleveland Clinic Foundation, Cleveland, Ohio, US

ECCMID 2018 Update on CNS infections ESCMIDApril 24 th 2018eLibrary 13;30-15;30 © by author Conflict of interests

• No financial COI”s

ESCMID eLibrary © by author ESCMID eLibrary © by author Burden of Healthcare associated meningitis & ventriculitis

• 493 episodes of acute bacterial meningitis, of which 197 (40 percent) were postneurosurgical. Durand et al. N Engl J Med 1993; 328:21-28

• 157 patients with acute bacterial meningits 68.2% (107/157) postneurosurgical meningitis Incidence in 2008 was 49% and 2000 was 25% - Lien CY et al. J Clin Neurosci. 2017 Aug;42:59-65

• Decreasing incidence of CABM pathogens, but no significant decrease in post-neurosurgical meningitis pathogens - Castelblanco R.L. et al. Lancet Infect Dis 2014; 14: pp. 813-819

Epidemiology of bacterial meningitis in the USA from 1997 to 2010: a population-based observational study

ESCMID eLibrary © by author A Tale of Two Patients

Senora Acabm and Senor Haivam ESCMID eLibrary © by author Senora Acabm’s story…

42 Year-old woman with no prior medical problems presents in December with fever, chills, headache, and lethargy that developed over two days. Vital signs: Temp 101° F/ 38.3 C, P 110, RR 24, BP 80/50 mmHg On exam patient is obtunded and has neck stiffness

CSF analysis: WBC 2000 cells/µl (200 x 10 6) 90% neutrophils Glucose 10 mg/dl (0.56 mmol/L) Protein 400 mg/dL (6000 mg/L)

CSF gram stain: Many Gram-positive diplococci ESCMID eLibrary © by author Does senora ACABM have… …Acute community acquired bacterial meningitis?

Does she have inflammation in the meninges? Yes… Menigeal symptoms, signs and CSF with an elevated WBC count and low glucose

Is the cause an infectious organism? Yes…The CSF gram stain had Gram positive diplococci Cultures eventually grew Streptococcus pneumoniae ESCMID eLibrary © by author Usual pathogens for CABM

S. pneumonia, N. meningitidis, H. influenza, Listeria & other Strep species

• Virulent pathogens • Evoke a profuse inflammatory response • Not usually contaminants in the CSF

ESCMID eLibrary © by author Compare and contrast that to Senor HAIVM’s story

ESCMID eLibrary © by author Senor HAIVM’s story… 54 YO male S/p craniotomy & right hemispherectomy • External Ventricular Drain x 4 days • Temp 101° F/ 38.3 C but no leukocytosis • CSF parameters are as follows:

CSF SI RBC, CSF (µL) 14400 1440 x 106 /L WBC, CSF (µL) 123 12.3 x 106 /L Neut%, CSF 90 Protein, CSF mg/dl 545 5450/L Glucose, CSF mg/dl 21 1.17 mmol/L

CSF culture No growth ESCMID eLibrary © by author Deos Senor HAIVM have… …Healthcare associated infectious ventriculitis or meningitis?

Does he have Inflammation in meninges or cerebral ventricles? Yes… CSF with an elevated WBC count and low glucose

Is the cause an infectious organism? Not sure… as there are other causes for elevated CSF inflammatory markers

ESCMID eLibrary © by author “Other” or non infectious causes of CSF inflammation in the neurosurgical patient –”Chemical meningitis”

• Subarachnoid, intraparenchymal or intraventricular bleeds cause fever, meningeal signs and CSF pleocytosis/ leukocytosis

• Craniotomies, especially posterior fossa surgeries cause CSF pleocytosis & low CSF glucose

ESCMID eLibrary © by author CSF profiles after neurosurgery

“Chemical” meningitis – from the neurosurgery itself. Can also be caused by hemorrhage & rarely tumors

CSF WBC count CSF glucose CSF protein

ForgacsESCMIDP, Geyer CA, Freidberg SR. Characterization of chemical meningitiseLibrary after neurological surgery. Clin Infect Dis 2001; 32:179 -85. © by author How do we differentiate chemical meningo-ventriculitis from infectious meningo-ventriculitis? Cut-off

Chemical Infectious meningoventriculitis meningoventriculitis

CSF parameter (WBC, lactate, procalcitonin) ESCMID eLibrary © by author Diagnostic accuracy for CSF parameters in EVD ventriculitis-ROC curves

Routine CSF studies can’t easily differentiate chemical from infectious ventriculitis

ROC curves a good diagnostic test

ROC curves 0f a bad diagnostic test ESCMID eLibrary © by author Can a CSF cell Index predict HAIVAM?

ESCMID eLibrary © by author Rising CSF WBC: RBC ratio is predictive of an “infectious ventriculitis”

ESCMID eLibrary © by author Back to Senor HAIVM: Does he have an “infectious” ventriculitis ?

54 YO male S/p right hemispherectomy, with an EVD. CSF parameters:

Post-OP day Day 1 Day 2 Day 3 Day 4 RBC, CSF 14400 4450 6600 510 WBC, CSF 123 110 98 10 Neut%, CSF 90 88 90 92 Protein, CSF 545 1584 1826 858 Glucose, CSF 21 62 56 68

CSF culture No growth No growth No growth No growth ESCMID eLibrary © by author Other diagnostic tests: Healthcare associated ventriculitis and meningitis

Serum CSF Procalcitonin Procalcitonin CRP Lactate

• Elevated in ventriculomenigitis, but also in other neurologic conditions and other infections • Studies are supportive, but are small and need further validation

• Elevated CSF lactate or CSF procalcitonin or serum procalcitonin may be useful in diagnosis ESCMID eLibrary © by author CSF cultures in HAIVM

ESCMID eLibrary © by author Etiologic agents

Skin colonizers and organisms in the healthcare environment

Organism % in Literature

Staphylococci (Staph epi & Staph aureus) 65–85 Gram-negative bacteria 6–20

Corynebacteria (mostly Cutibacterium acnes) 1–14

ESCMID eLibrary © by author Pathogenesis of health care associated meningitis & ventriculitis

Image modified ESCMIDfrom Van De Beek et al. N Engl J Med 2010; 362:146-154 eLibrary © by author False negative & False positive CSF cultures

• Some are indolent pathogens ( can take 10 days and may need anaerobic cx)-False negative if only aerobic cx are done & held for 2-3 days

• Skin commensals and can be contaminants in the CSF, so can be “false positive” if improperly collected

ESCMID eLibrary © by author Cultures and PCR’s identify an organism, but it is up to the clinician to determine if they are pathogens in the specific instance

ESCMID eLibrary © by author Challenges in diagnosis of “Infectious” ventriculitis or meningitis

Establishing causality is not easy (unlike community acquired bacterial meningitis)

Non-Infectious mimics • Neurosurgery • Neuro comorbidities (SAH)

Low virulence pathogens (Minimal inflammation) • Staph epidermidis • P acnes

Difficult to detect in the lab CSF aerobic and anaerobic cultures for 10 days (Slow growing) Or CSF PCR • Staph epidermidis ESCMID eLibrary• P acnes © by author A practical approach to diagnosis of Healthcare associated meningitis or ventriculitis Contamination: • An isolated positive CSF culture or Gram stain for non-virulent organisms (espl.if just in enrichment broth) • Normal CSF cell count, glucose, lactate & protein concentrations

Exceptions to contamination-virulent organisms: Isolated CSF culture for S. aures, Aerobic GNB’s & fungi ( clinical judgment needed, but often treated)

Infectious meningitis or ventriculitis: • Single culture for a virulent organism or multiple positive CSF cultures • With CSF pleocytosis and/or hypoglycorrhachia, • Or a progressively increasing CSF cell count/CSF cell index, or decreasing CSF glucose even with negative CSF cultures ESCMID eLibrary © by author CSF Drain ventriculitis & Craniotomy related ventriculo-meningits

Treatment

ESCMID eLibrary © by author “Evidence” in Healthcare-associated meningitis and ventriculits?

ESCMID eLibrary © by author ESCMID eLibrary © by author 24 YO man with a craniopharyngioma s/p total resection • with severe headache, lethargy, fever and blurred vision • CT brain shows larger ventricles s/p emergent EVD placement • CSF parameters: SI units RBC, CSF (µL) 200 WBC, CSF (µL) 20,076 2007 x 106 /L Neut%, CSF 90 Protein, CSF 1386 mg/dl 13860 mg/L Glucose, CSF <2 mg/dl <0.11 mmol/L

CSF gram stain Many gram negative bacilli CSF cultures In process ESCMIDWhat antimicrobial would eLibrary you tell the Neuro ICU to start? © by author How to chose an antimicrobials for meningitis (type, dose & route)

• Not just “good CSF penetration” (% of the serum concentration that gets in to CSF)

• Achieve target pharmacodynamics in CSF: • Time above MIC for betalactams • C max or AUC above MIC for most other antimicrobials ESCMID eLibrary © by author Vancomycin level in the CSF & serum with IV vancomycin (7 studies, 12 data points)

Is this “good CSF penetration”?

15mg/kg load+60 Depends on the mg/kg/day organism and MIC!

Open circles: clinical studies that used dexamethasone Open square,: experimental studies with dexamethasone Solid circles: clinical studies in which treatment did not include use of dexamethasone ESCMIDRicard et al. CID 2007:44 eLibrarySolid squares: experimental studies without dexamethasone © by author Goal of treatment: Optimizing CSF pharmacokineticspharmacokinetics & pharmacodynamics

Cmax (Peak) Does not reach target AUC: MIC

S. aureus vancomycin MIC >1 AUC

Acheives target AUC: MIC Concentration MIC S. aureus vancomycin MIC 0.5

Time (hours) ESCMID eLibrary © by author Probability of target (AUC:MIC) attainment in the CSF Vs MIC

PK/PD monto carloESCMIDsimulation courtesy Andras Farkas, Pharm D, Mt. Sinai NY eLibraryLi X et al J Pharm Sci 2016 Nov;105(11):3425 - 3431, Ricard et al. CID 2007:44 © by author Intravenous antimicrobials for healthcare acquired ventriculo-meningitis

Gram-positive bacteria (Staph epi, Staph aureus, & P acnes)

• Vancomycin – goal troughs 15-20 • Linezolid 600 mg IV/PO q 12 hrs • Oxacillin 2 g IV q 4 hrs /Nafcillin /Flucloxacillin for MSSA or MSSE

Gram-negative bacteria ( Enterobacteriace, Pseudomonas, & Acinetobacter)

• Ceftazidime 2g IV q 8 hrs • Cefepime 2 g IV Q 8 hrs • Meropenem ESCMID2g IV Q 8 hrs eLibrary © by author 24 YO man with a craniopharyngioma s/p total resection • with severe headache, lethargy, fever and blurred vision • CT brain shows larger ventricles s/p emergent EVD placement • CSF parameters:

RBC, CSF (µL) 200 WBC, CSF (µL) 20,076 Neut%, CSF 90 Protein, CSF 1386 mg/dl Glucose, CSF <2 mg/dl

CSF gram stain Many gram negative bacilli

CSF cultures In process

What antibiotic would you tell the Neuro ICU to start? ESCMID eLibrary © by author Patient was started on IV meropenem 2 g IV Q 8 hrs

ESCMID eLibrary © by author While on meropenem had persistent positive CSF cultures x 4 days with ESBL Kebsiella • susceptibilities : Ampicillin >=32 R Ampicillin sulbact >=32 R Cefepime resistant Ceftriaxone >=64 R Ciprofloxacin >=4 R Gentamicin >=16 R Tobramycin >=16 R Meropenem <=0.25 S Colistin – etest – mic 0.25 ESCMIDWhat would eLibrary you do next ? © by author Intraventricular colistin 11/13

ESCMID eLibrary © by author Intraventricular and intrathecal antimicrobials

• Small studies • Several adult studies: Good PK/PD profiles, safety and efficacy (CSF parameters)

• Wang JH, Lin PC, Chou CH, et al. Intraventricular antimicrobial therapy in postneurosurgical gram-negative bacillary meningitis or ventriculitis: a hospital-based retrospective study. J Microbiol Immunol Infect 2012; 47:204-10. • Wilkie MD, Hanson MF, Statham PF, Brennan PM. Infections of cerebrospinal fluid diversion devices in adults: The role of intraventricular antimicrobial therapy. J Infect 2013; 66:239-46. • Ng K, Mabasa VH, Chow I, Ensom MH. Systematic review of efficacy, pharmacokinetics, and administration of intraventricular vancomycin in adults. Neurocrit Care 2014; 20:158-71. • Imberti R, Cusato M, Accetta G, et al. Pharmacokinetics of colistin in cerebrospinal fluid after intraventricular administration of colistin methanesulfonate. Antimicrob Agents Chemother 2012; 56:4416-21. • Tangden T, Enblad P, Ullberg M, Sjolin J. Neurosurgical gram-negative bacillary ventriculitis and meningitis: A retrospective study evaluating the efficacy of intraventricular gentamicin therapy in 31 consecutive cases. Clin Infect Dis 2011; 52:1310-6. • Chen K, Wu Y, Wang Q, et al. The methodology and pharmacokinetics study of intraventricular administration of vancomycin in patients with intracranial infections ESCMID after craniotomy. J Crit Care 2015; 30:218.e1-218.e5 eLibrary © by author Indications for intraventricular antimicrobials

• Ventriculitis not responding to systemic antimicrobials

• Antimicrobial resistant organims • high MIC for systemic antimicrobials • Cannot achieve target pharmacodynamics in CSF with intravenous route ESCMID eLibrary © by author Intraventricular antimicrobials; How to dose?

Initial Dose : ventricular size/ volume Slit ventricles Normal ventricles Hydrocephalous

Frequency : volume of CSF drainage/ 24-hour ESCMID eLibrary © by author Intraventricular antimicrobials

Dosage: Ventricle size/ volume

-Slit ventricles: 5 mg vancomycin and 2 mg gentamicin -Normal size :10 mg vancomycin and 3 mg gentamicin -Enlarged ventricles:15- 20 mg vancomycin and 4 - 5mg gentamicin

Frequency: EVD output/ 24 hrs

-50 mL/24 h : every third day -50-100 mL/24 h : every second day -100-150 mL/24 h : once daily -150-200 mL/24 h : increase the dosage by 5 mg of vancomycin and 1 mg of gentamicin and give once daily -200-250 mL/24 h : Increase the dosage by 10 mg of vancomycin and 2 mg ESCMIDof gentamicin and give once -eLibrarytwice daily © by author Intaventricular antimicrobial dosing

Antimicrobial Agent Daily Intraventricular Dose Amikacin 5-50 mg Colistin (colistimethate sodium) 10 mg CMS Daptomycin 2-5 mg Gentamicin 1-8 mg Polymyxin B 5 mg Quinupristin/dalfopristin 2-5 mg Tobramycin 5-20 mg Vancomycin 5-20 mg ESCMID eLibrary © by author Intraventricular antimicrobials: Therapeutic drug monitoring ( vancomycin & aminoglycosides)

• Check CSF level after 24 hrs of the intra-vent dose

• Next dose based on CSF concentration

• Goal to achieve CSF PD -levels 10-20 times higher than MIC

ESCMID eLibrary © by author CSF cultures are clearing, but clinically not improving (febrile & comatose)

What would you do next ?

MRI brain W contrast & diffusion weighted imaging ESCMID eLibrary © by author MRI Diffusion weighted imaging 11/14

ESCMID eLibrary © by author ESCMID eLibrary © by author ESCMID eLibrary © by author ESCMIDIntraventricular eLibrary empyema © by author Video Courtesy Pablo Recinos MD Ventrticulits Endoscopic drainage and debridement

ESCMID eLibrary © by author Before evacuation After evacuation

J Clin Neurosci. ESCMID2018 Jan;47:323-327 eLibrary © by author Before evacuation After evacuation

J Clin Neurosci. ESCMID2018 Jan;47:323-327 eLibrary © by author CSF Shunt (VP shunt) ventriculitis Diagnosis

ESCMID eLibrary © by author Senora Acabm’s story continues…

She survives pneumococcal meningitis but develops hydrocephalous s/p VP shunt a month ago who now presents with • Severe headache, nausea & neck pain • No fever • CT head and shunt series are normal • CRP is 3 Does she have a VP shunt ventriculitis? ESCMID eLibrary © by author Clinical features of shunt infections

Signs & Symptoms Percent Fever 52% Headache 31% Mental status change 29% Shunt malfunction 32% Meningismus 4% Erythema over shunt tubing

ESCMIDMoores E,L, Ellenbogen G, R CSF shunt Infections; Infections in Neurosurgery:141eLibrary-153 © by author What is the next diagnostic step?

“Shunt tap” to get CSF from the shunt reservoir

• CSF aerobic and anaerobic cultures –held for 10 days • Routine CSF analysis

ESCMID eLibrary © by author Shunt tap Vs lumbar puncture

• Direct aspiration of the shunt yields a positive culture in 92% to 95% of cases • Lumbar puncture yields a positive culture in only 58%- 79% of cases • LP may be hazardous in obstructive HCP with a nonfunctional shunt • In a pediatric study with 266 children & 542 shunt aspirations, there was no evidence of shunt infection

Noetzel M.J., Baker R.P.: Shunt fluid examination: risks and benefits in the evaluation of shunt malfunction and infection. J Neurosurg 61. 328-332.1984; Spiegelman L, Asija R, Da Silva SL, Krieger MD, McComb JG. What is the risk of infecting a cerebrospinal fluid-diverting shunt with percutaneous ESCMID tapping? J Neurosurg Pediatr. 2014;14:336-339. eLibrary © by author How to interpret CSF WBC counts in shunt meningo-ventriculits?

Take site of sampling in to consideration while interpreting CSF WBC counts

Conen A, Walti LN, Merlo A, et al: Characteristics and treatment outcome of cerebrospinal fluid shunt-associated infections in adults: a retrospective analysis over an 11-year ESCMIDperiod. Clin Infect Dis 2008; 47:73-82 eLibrary © by author A practical approach to diagnosis of VP shunt ventriculiits

• CSF WBC count (shunt tap) elevated • CSF: serum glucose ration <0.4 ( hypoglycorrachia) • with a positive CSF culture and attributable symptoms

• CSF WBC count & glucose normal • with multiple CSF cultures ( from multiple shunt taps or explanted proximal shunt components ) and attributable symptoms Conen et al. Clin Infect Dis 2008; 47:73-82 CSF white blood cell counts and lactate concentrations were normal in approximately 20% of episodes ESCMID eLibrary © by author CSF Shunt (VP shunt) ventriculitis Treatment & management

Cure Rates Infected VP Shunt

¶ $ ¶ $ ¶ $ 96% / 88% 65% / 65% 36% / 34%

Two stage method One stage Antibiotics alone Remove infected Remove infected shunt No shunt removal shunt Immediate new shunt Abx Temp EVD/ABX Abx Replace shunt after –ve CSF Cx

ESCMID¶ Yogev R et al Pediatr Infect Dis 1985.4:113–118 eLibrary $ Schreffler R T et al Pediatr Infect Dis 2002. 21:7;632 -636 © by author Infection prevention Do’s • Antimicrobial impregnated EVD’s and VPS reduce ventriculitis rates • Perioperative antimicrobial prophylaxis (just around procedure time) • Combined interventions or “bundles” reduced infection rates

Don’ts • Prolonged IV antimicrobials for the duration of the EVD • Routine exchange of EVD’s at fixed time intervals • Routine or “surveillance” CSF cultures in EVD’s • Culture of CSF shunt components when there is no suspicion of infection ESCMID eLibrary © by author We need more research in Healthcare associatedWe meningitis …

No good studies available on burden, diagnosis and management Need for standardized and accepted surveillanceneed and clinical definitions YOU! ESCMID eLibrary © by author EXTRA SLIDES

• 157 patients with acute bacterial meningits 68.2% (107/157) postneurosurgical meningitis • Incidence in 2008 was 49% and 200 was 25%. Lien CY et al. J Clin Neurosci. 2017 Aug;42:59-65 Craniotomy associated meningitis (4.8%), Gram-negative pathogens (Acinetobacter spp., Klebsiella spp., Pseudomonas aeruginosa, Enterobacter cloaceae, Proteus mirabilis) represented 88% of the pathogens. Kourbeti IS et al. J Neurosurg 2015 May;122(5):1113-9

Ventricolostomy or ventricular drain infections: `meta-analysis of 35 studies 752 CSF drain related infections • pooled incidence:11.4 per 1000 catheter-days (95% CI 9.3–13.5) • high-quality studies: 10.6 per 1000 catheter-days (95% CI 8.3–13) Ramanan M et al BMC Infect Dis. 2015;15:3 ESCMID• CSF shunt infections 4-17% eLibrary © by author Clinical scenario

• 52 yo with a VP shunt s/p multiple revisions since 1 yr age – proximal ventricular part placed 30 yrs ago presents with headaches and multiple serial CSF cultures from a shut tap positive for coagulase negative staph. VPS cannot be removed, as it is too risky. ESCMIDWhat doeLibrary you do next? © by author Can we avoid major surgery in shunt infections? • Trend towards conservative management

• McLaurin et al : temporary externalization of peritoneal shunt catheter with subsequent replacement was effective in 10 (91%) of 11 patients

• Brown et al :conservative management without surgical intervention 43 shunt-associated infections caused by CoNS: success rate was 93%.

• Thompson et al Similar results in P. acnes infections.

Brown EM, Edwards RJ, Pople IK. Conservative management of patients with cerebrospinal fluid shunt infections. Neurosurgery 2006; 58:657-65

McLaurin RL, Frame PT. Treatment of infections of cerebrospinal fluid shunts. Rev Infect Dis 1987; 9:595-603 ESCMIDThompson T, Albright AL. Propionibacterium acnes infections eLibrary of cerebrospinal fluid shunts. Childs Nerv Syst 1998; 14:378 -80. © by author Antimicrobial administration in to the reservoir

Reservoir

Valve

ESCMID eLibrary © by author Brown et al : Conservative management without surgical intervention -CoNS: 93% cure rate • IV abx Plus • Intraventricular abx via a VAD (ventricular access device) Plus • Rifampin

Brown EM, Edwards RJ, Pople IK. Conservative management of patients with ESCMIDcerebrospinal fluid shunt infections. eLibraryNeurosurgery 2006; 58:657-65 © by author Prolonged systemic antibiotics to prevent EVD ventriculitis

ROC curves a good diagnostic test

CSF CSF MIC90 mg/L Concentration Penetraton Antibiotic mg/L (range) (% ) SP (S/R) SA HI EC PA Penicillin G 0.8-9.6 7.8 0.03/2.0 ------Ampicillin 0.3-38 4-65 0.06/2.0 ------Nafcillin 9.5-29 8-27 -- 0.25 ------Cefotaxime 1.2-83 4-55 0.03/2.0 4.0 0.06 0.12 >32 Ceftriaxone 2.1-7.2 1.5-7 0.06/2.0 4.0 0.01 0.25 >32 Ceftazidime 2.5-30 14-45 -- 16 0.12 0.25 16 Cefepime 5.7 11.8 0.06/2.0 4.0 0.12 0.06 64 Imipenem 1.4-26 15.6-41 0.02/1.0 0.03 2.0 0.1 4.0 Meropenem 1.2-32.3 10.7 0.02/1.0 0.03 0.1 0.03 2.0 Ciprofloxacin 0.4-0.56 26-37 4.0 2.0 0.06 0.25 8.0 Vancomycin 0.1-4.8 0-22 0.5 1.0 ------Metronidazole 6-27 42-90 ------Rifampin 0.3-5.1 4-21 1.0 0.015 ------Amikacin 0.4-6.1 20-34 ------1.0 64 Chloramphenicol 2-23 20-66 2.0/16 8.0 0.5 256 --

SP = S. pneumoniae; (S/R) = penicillifn-susceptible/penicillin-resistant; SA = S. aureus; HI = H. influenzae; EC = E. coli; PA = P. aeruginosa;

.Andes DR, Craig WA: Pharmacokinetics and pharmacodynamics of antibiotics in meningitis. Infect Dis Clin North Am. 1999 ESCMID Sep;13(3):595eLibrary-618 © by author Proximal ventricular tip

Proximal ventricular tip

External ventricular VP shunt drain (EVD)

Distal Peritoneal tip

Distal tip to an external ESCMIDdrainage system eLibrary © by author “Evidence” in Healthcare-associated meningitis and ventriculits?

Even when good studies are sparse

Parachutes reduce risk of injury, but their effectiveness …we can still makehas meaningful not been proved clinical with RCT’s decisions & guidelines

Individuals who insist all interventions need to be tested in a RCT need to come down to earth with a bump ESCMID eLibrary © by author Definitions: Healthcare associated ventriculitis & meningitis Vs “Nosocomial meningitis”

Topics covered in today’s talk

• External ventricular drain & post craniotomy ventriculo-meningitis • Diagnosis • Management including intraventicular antimicrobials

• CSF Shunt (VP shunt) ventriculo-meningitis • Diagnosis • Management including surgical management • InfectionESCMID prevention eLibrary © by author BACKGROUND: Pathogenesis & Etiology

Diagnosis

ESCMID eLibrary © by author 28 YO male with Rasmussen encephalitis S/p right hemispherectomy • EVD x 4 days • No fever or leukocytosis • CSF parameters are as follows:

Post-OP day Day 1 Day 2 Day 3 Day 4 RBC, CSF (µL) 14400 4450 6600 510 WBC, CSF (µL) 123 110 98 10 Neut%, CSF 90 88 90 92 Protein, CSF mg/dl 545 1584 1826 858 Glucose, CSF mg/dl 21 62 56 68

CSF culture No growth No growth No growth No growth DoesESCMID he have an “infectious” eLibraryventriculitis ? © by author