Healthcare-associated ventriculitis and meningitis (IDSA 2017) - Revision history

Aidan at 21:52, 12 August 2020

2020-08-12T21:52:40Z

Aidan at 19:33, 15 August 2019

2019-08-15T19:33:28Z

← Older revision		Revision as of 19:33, 15 August 2019
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	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.		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.

	= Signs and Symptoms =		== Signs and Symptoms ==

	== Ventriculoperitoneal/ventriculopleural shunts ==		=== Ventriculoperitoneal/ventriculopleural shunts ===

	* Headache, nausea, lethargy, or altered mental status		* Headache, nausea, lethargy, or altered mental status
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	* Glomerulonephritis		* Glomerulonephritis

	== External ventricular drains (EVD) ==		=== External ventricular drains (EVD) ===

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

	== Head trauma ==		=== Head trauma ===

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

	== Intrathecal infusion pumps ==		=== Intrathecal infusion pumps ===

	* New fever and drainage from the surgical site		* New fever and drainage from the surgical site

	= CSF Findings =		== CSF Findings ==

	== Basic chemistry ==		=== Basic chemistry ===

	* Cell count, glucose, and protein		* Cell count, glucose, and protein
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	* False positives, and false normals		* False positives, and false normals

	== Cultures ==		=== Cultures ===

	* Culture the CSF! And probably blood (especially if ventriculoatrial)		* Culture the CSF! And probably blood (especially if ventriculoatrial)
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	* Try to obtain cultures before antibiotics, if safe		* Try to obtain cultures before antibiotics, if safe

	== Neurosurgery or head trauma ==		=== Neurosurgery or head trauma ===

	* Elevated cell count, positive culture, and symptoms of infection indicate ventriculitis or meningitis		* Elevated cell count, positive culture, and symptoms of infection indicate ventriculitis or meningitis
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	* Fungal cultures positive indicate infection		* Fungal cultures positive indicate infection

	== Specific tests ==		=== Specific tests ===

	* CSF lactate or procalcitonin may be useful		* CSF lactate or procalcitonin may be useful
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	* β-D-glucan and galactomannan may be helpful for fungal infections		* β-D-glucan and galactomannan may be helpful for fungal infections

	= Imaging =		== Imaging ==

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

	= Antimicrobials =		== Antimicrobials ==

	== Empiric regimens ==		=== Empiric regimens ===

	* Vanco for gram positives plus anti-pseudomonal beta-lactam (cefipime, ceftazidime, or meropenem) for gram negatives		* Vanco for gram positives plus anti-pseudomonal beta-lactam (cefipime, ceftazidime, or meropenem) for gram negatives
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	* Second-line agents for gram-negative coverage include aztreonam and ciprofloxacin		* Second-line agents for gram-negative coverage include aztreonam and ciprofloxacin

	== Specific regimens ==		=== Specific regimens ===

	* Staphylococci		* Staphylococci
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	** ''Aspergillus'' and ''Exserohilum'': voriconazole		** ''Aspergillus'' and ''Exserohilum'': voriconazole

	== Intraventricular therapy ==		=== Intraventricular therapy ===

	* Should be considered if poor response to systemic therapy		* Should be considered if poor response to systemic therapy
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	* Adjust dose based on MIC (target 10-20 times the MIC), ventricular size, and daily drain output		* Adjust dose based on MIC (target 10-20 times the MIC), ventricular size, and daily drain output

	== Duration ==		=== Duration ===

	* CNST or ''P. acnes'': 10 to 14 days		* CNST or ''P. acnes'': 10 to 14 days
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	* If repeatedly positive cultures, continued for 10-14 days after the last positive culture		* If repeatedly positive cultures, continued for 10-14 days after the last positive culture

	= Catheter Removal =		== Catheter Removal ==

	* Shunt removal and EVD placement is recommended for infected CSF shunts		* Shunt removal and EVD placement is recommended for infected CSF shunts
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	* Drain or pump removal is recommended for infected drains or pumps		* Drain or pump removal is recommended for infected drains or pumps

	= Monitoring =		== Monitoring ==

	* Response to therapy can be monitored clinically		* Response to therapy can be monitored clinically

Aidan: /* Healthcare-associated ventriculitis and meningitis (IDSA 2017) */

2019-08-12T17:34:32Z

Healthcare-associated ventriculitis and meningitis (IDSA 2017)

← Older revision		Revision as of 17:34, 12 August 2019
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		⚫	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.
	= 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 =		= Signs and Symptoms =

Aidan at 17:34, 12 August 2019

2019-08-12T17:34:12Z

← Older revision		Revision as of 17:34, 12 August 2019
Line 3:		Line 3:
	<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>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>		</blockquote>
	== Signs and Symptoms ==		= Signs and Symptoms =

	=== Ventriculoperitoneal/ventriculopleural shunts ===		== Ventriculoperitoneal/ventriculopleural shunts ==

	* Headache, nausea, lethargy, or altered mental status		* Headache, nausea, lethargy, or altered mental status
Line 15:		Line 15:
	* Glomerulonephritis		* Glomerulonephritis

	=== External ventricular drains (EVD) ===		== External ventricular drains (EVD) ==

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

	=== Head trauma ===		== Head trauma ==

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

	=== Intrathecal infusion pumps ===		== Intrathecal infusion pumps ==

	* New fever and drainage from the surgical site		* New fever and drainage from the surgical site

	== CSF Findings ==		= CSF Findings =

	=== Basic chemistry ===		== Basic chemistry ==

	* Cell count, glucose, and protein		* Cell count, glucose, and protein
Line 37:		Line 37:
	* False positives, and false normals		* False positives, and false normals

	=== Cultures ===		== Cultures ==

	* Culture the CSF! And probably blood (especially if ventriculoatrial)		* Culture the CSF! And probably blood (especially if ventriculoatrial)
Line 44:		Line 44:
	* Try to obtain cultures before antibiotics, if safe		* Try to obtain cultures before antibiotics, if safe

	=== Neurosurgery or head trauma ===		== Neurosurgery or head trauma ==

	* Elevated cell count, positive culture, and symptoms of infection indicate ventriculitis or meningitis		* Elevated cell count, positive culture, and symptoms of infection indicate ventriculitis or meningitis
Line 53:		Line 53:
	* Fungal cultures positive indicate infection		* Fungal cultures positive indicate infection

	=== Specific tests ===		== Specific tests ==

	* CSF lactate or procalcitonin may be useful		* CSF lactate or procalcitonin may be useful
Line 60:		Line 60:
	* β-D-glucan and galactomannan may be helpful for fungal infections		* β-D-glucan and galactomannan may be helpful for fungal infections

	== Imaging ==		= Imaging =

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

	== Antimicrobials ==		= Antimicrobials =

	=== Empiric regimens ===		== Empiric regimens ==

	* Vanco for gram positives plus anti-pseudomonal beta-lactam (cefipime, ceftazidime, or meropenem) for gram negatives		* Vanco for gram positives plus anti-pseudomonal beta-lactam (cefipime, ceftazidime, or meropenem) for gram negatives
Line 73:		Line 73:
	* Second-line agents for gram-negative coverage include aztreonam and ciprofloxacin		* Second-line agents for gram-negative coverage include aztreonam and ciprofloxacin

	=== Specific regimens ===		== Specific regimens ==

	* Staphylococci		* Staphylococci
Line 95:		Line 95:
	** ''Aspergillus'' and ''Exserohilum'': voriconazole		** ''Aspergillus'' and ''Exserohilum'': voriconazole

	=== Intraventricular therapy ===		== Intraventricular therapy ==

	* Should be considered if poor response to systemic therapy		* Should be considered if poor response to systemic therapy
Line 101:		Line 101:
	* Adjust dose based on MIC (target 10-20 times the MIC), ventricular size, and daily drain output		* Adjust dose based on MIC (target 10-20 times the MIC), ventricular size, and daily drain output

	=== Duration ===		== Duration ==

	* CNST or ''P. acnes'': 10 to 14 days		* CNST or ''P. acnes'': 10 to 14 days
Line 107:		Line 107:
	* If repeatedly positive cultures, continued for 10-14 days after the last positive culture		* If repeatedly positive cultures, continued for 10-14 days after the last positive culture

	== Catheter Removal ==		= Catheter Removal =

	* Shunt removal and EVD placement is recommended for infected CSF shunts		* Shunt removal and EVD placement is recommended for infected CSF shunts
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	* Drain or pump removal is recommended for infected drains or pumps		* Drain or pump removal is recommended for infected drains or pumps

	== Monitoring ==		= Monitoring =

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

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

Aidan: Aidan moved page IDSA Healthcare-associated ventriculitis and meningitis 2017 to Healthcare-associated ventriculitis and meningitis (IDSA 2017) without leaving a redirect

2019-08-12T17:33:33Z

Aidan moved page IDSA Healthcare-associated ventriculitis and meningitis 2017 to Healthcare-associated ventriculitis and meningitis (IDSA 2017) without leaving a redirect

← Older revision		Revision as of 17:33, 12 August 2019
(No difference)

Maintenance script: Imported from text file

2019-08-11T18:05:52Z

Imported from text file

New page

= 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 & ''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
*