View source for Healthcare-associated ventriculitis and meningitis (IDSA 2017)

= Healthcare-associated ventriculitis and meningitis (IDSA 2017) =

<blockquote>Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Michael Scheld W, van de Beek D, Bleck TP, Garton HJ, Zunt JR. [https://doi.org/10.1093/cid/ciw861 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis]. ''Clin Infect Dis''. 2017.
</blockquote>
= 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 &amp; ''P. acnes'' with normal CSF: reimplant as soon as 3 days if repeat cultures are negative at 48 hours
** CNST &amp; ''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

[[Category:IDSA guidelines]]
[[Category:CNS infections]]