Healthcare-associated ventriculitis and meningitis (IDSA 2017)

Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Michael Scheld W, van de Beek D, Bleck TP, Garton HJ, Zunt JR. 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis. 2017;64(6);e34-e65. doi: 10.1093/cid/ciw861

Signs and Symptoms

Ventriculoperitoneal/ventriculopleural shunts

• Headache, nausea, lethargy, or altered mental status
• Erythema and tenderness over the shunt tubing
• Fever without a focus
• Peritonitis or acute abdomen, if peritoneal shunt
• Pleuritis, if pleural shunt
• Bacteremia without focus
• Glomerulonephritis

External ventricular drains (EVD)

• New or worsening mental status
• New fever and increased CSF white cell count

Head trauma

• New headache, fever, meningeal irritation, seizures, or worsening mental status
• Fever without a focus

Intrathecal infusion pumps

• New fever and drainage from the surgical site

CSF Findings

Basic chemistry

• Cell count, glucose, and protein
• May not be reliable
• False positives, and false normals

Cultures

• Culture the CSF! And probably blood (especially if ventriculoatrial)
• If initial cultures are negative, keep growing them for at least 10 days to identify Cutibacterium acnes
• If removing the shunt or drain, send it for culture
• Try to obtain cultures before antibiotics, if safe

Neurosurgery or head trauma

• Elevated cell count, positive culture, and symptoms of infection indicate ventriculitis or meningitis
• Low glucose and high protein suggests ventriculitis or meningitis
• Positive culture is possible to be contaminant if low colony count, normal CSF, no fever
• Multiple organisms in a single sample may be contaminant if no other findings
• Staph. aureus or aerobic gram-negative bacilli indicate infection
• Fungal cultures positive indicate infection

Specific tests

• CSF lactate or procalcitonin may be useful
• Procalcitonin, specifically, may be able to differentiate surgery/hemorrhage from bacterial infection
• NAAT (e.g. PCR) may be helpful
• β-D-glucan and galactomannan may be helpful for fungal infections

Imaging

• MRI with gad and DWI is best
• If VP shunt and abdo symptoms, get abdo US or CT

Antimicrobials

Empiric regimens

• Vanco for gram positives plus anti-pseudomonal beta-lactam (cefipime, ceftazidime, or meropenem) for gram negatives
  • Target vanco trough 15-20
• Second-line agents for gram-negative coverage include aztreonam and ciprofloxacin

Specific regimens

• Staphylococci
  • MSSA: nafcillin or oxacillin (vanco as second-line) ± rifampin
  • MRSA: vanco, unless MIC ≥1, ± rifampin
  • Coag-negative Staph: vanco ± rifampin
  • If susceptible, consider adding rifampin
  • If hardware, recommend rifampin
  • If cannot use vanco, then use linezolid, dapto, or TMP-SMX
• P. acnes: penicillin G
• Gram-negatives:
  • In general, based on susceptibilities
  • Ceftriaxone recommended, if susceptible
  • If meropenem, preference for long-infusion (over 3 hours)
  • Pseudomonas: cefepime, ceftazidime, or meropenem
    • Alternatives include aztreonam or fluoroquinolone
  • Acinetobacter: meropenem
    • If resistant, colistimethate sodium or polymixin B
• Fungi
  • Candida: liposomal ampho B ± 5-flucytosine, stepped down to fluconazole when improved
  • Aspergillus and Exserohilum: voriconazole

Intraventricular therapy

• Should be considered if poor response to systemic therapy
• Clamp drain for 15-60 minutes after administration
• Adjust dose based on MIC (target 10-20 times the MIC), ventricular size, and daily drain output

Duration

• CNST or P. acnes: 10 to 14 days
• Staph. aureus and Gram-negatives: 10-14 days, up to 21 days
• If repeatedly positive cultures, continued for 10-14 days after the last positive culture

Catheter Removal

• Shunt removal and EVD placement is recommended for infected CSF shunts
  • CNST & P. acnes with normal CSF: reimplant as soon as 3 days if repeat cultures are negative at 48 hours
  • CNST & P. acnes with abnormal CSF: after 7 days of antibiotics if repeat cultures are negative
    • If repeat cultures are positive, wait for 7-10 days of negative culture before reimplanting
  • Staph. aureus and GNBs: reimplant after 10 days of negative cultures
  • Don't stop antibiotics to verify clearance of infection before reimplanting
• Drain or pump removal is recommended for infected drains or pumps

Monitoring

• Response to therapy can be monitored clinically
• If there's an EVD, can monitor serial CSF cultures
• If no clinical improvement, check CSF again