View source for 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. [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;64(6);e34-e65. doi: [https://doi.org/10.1093/cid/ciw861 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 &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]]