Ventriculitis: Difference between revisions

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==Background==
== Clinical Presentation ==
===Microbiology===
* ''[[Staphylococcus epidermidis]]'' and other [[coagulase-negative staphylococci]]
* ''[[Staphylococcus aureus]]''
* Gram-negative bacilli, including ''[[Escherichia coli]]'', ''[[Klebsiella]]'', ''[[Proteus]]'', ''[[Pseudomonas]]'', and ''[[Acinetobacter]]''
* ''[[Cutibacterium acnes]]''

==Clinical Presentation==
* Among patients with intraventricular drains, fever (72%) and elevated CSF cell count (93%) were most predictive of ventriculitis [[CiteRef::dorresteijn2019fa]]
* Among patients with intraventricular drains, fever (72%) and elevated CSF cell count (93%) were most predictive of ventriculitis [[CiteRef::dorresteijn2019fa]]

==Diagnosis==
* Gram stain and culture of CSF fluid from shunt aspiration, or from external ventricular drain that has a pleiocytosis
** Prolonged culture of 7-10 days

==Management==
* Empiric antimicrobials are typically indicated, with [[Is treated by::vancomycin]] plus an [[antipseudomonal]] such as [[Is treated by::ceftazidime]] or [[Is treated by::meropenem]]
** If seriously ill, target a vancomycin trough of 15 to 20 μg/mL
** [[Ciprofloxacin]] or [[aztreonam]] can be used in cases of β-lactam allergy
* Narrow based on culture results
* Removal of infected shunts, drains, intrathecal pumps, and deep brain stimulators is recommended

=== Duration of Antimicrobials ===
{| class="wikitable"
!Organism
!Scenario
!Duration Without Shunt
!Duration With Shunt
!Timing of Shunt Reimplantation
|-
| rowspan="3" |[[Cutibacterium acnes]] or [[coagulase-negative staphylococci]]
|no CSF abnormalities and negative cultures within 48 hours of externalization
| colspan="2" |10 days
|as soon as day 3 following externalization
|-
|CSF abnormalities but negative repeat cultures
|10 to 14 days
|14 days
|after 7 days of antimicrobials
|-
|CSF abnormalities and positive repeat cultures
|10 to 14 days
|14 days
|after 7 to 10 days of negative cultures
|-
|[[Staphylococcus aureus]] or [[Gram-negative bacilli]]
|
|14 days
|
|after 10 days of negative cultures
|-
|any
|persistent positive CSF cultures
| colspan="2" |14 days from last positive culture
|7 to 10 days after last positive culture
|}

===Antimicrobial Selection===
{| class="wikitable sortable"
! Organism
! First-line
! Second-line
|-
| ''[[Staphylococcus aureus]]'' (methicillin-susceptible) || [[nafcillin]] or [[oxacillin]] || [[vancomycin]]
|-
| ''[[Staphylococcus aureus]]'' (methicillin-resistant) || [[vancomycin]] || [[daptomycin]], [[TMP-SMX]], or [[linezolid]]
|-
| ''[[Streptococcus pneumoniae]]'' ([[penicillin]] MIC ≤0.06) || [[penicillin G]] || third-generation cephalosporin
|-
| ''[[Streptococcus pneumoniae]]'' ([[penicillin]] MIC ≥0.12) || third-generation cephalosporin || [[cefipime]] or [[meropenem]]
|-
| ''[[Streptococcus pneumoniae]]'' ([[ceftriaxone]] MIC ≥1) || [[vancomycin]] plus a third-generation cephalosporin || [[moxifloxacin]]
|-
| ''[[Pseudomonas aeruginosa]]'' || [[cefipime]], [[ceftazidime]], or [[meropenem]] || [[aztreonam]] or [[ciprofloxacin]]
|-
| ''[[Haemophilus influenzae]]'' (β-lactamase negative) || [[ampicillin]] || third-generation cephalosporin, [[cefepime]], or a fluoroquinolone
|-
| ''[[Haemophilus influenzae]]'' (β-lactamase positive) || third-generation cephalosporin || [[cefepime]], [[aztreonam]], or a fluoroquinolone
|-
| ESBL Gram-negative bacillus || [[meropenem]] || [[cefepime]] or a fluoroquinolone
|-
| ''[[Acinetobacter baumannii]]'' || [[meropenem]] || [[colistin]] or [[polymixin B]]
|-
| Other [[Enterobacteriaceae]] || third-generation cephalosporin || [[meropenem]], [[aztreonam]], [[TMP-SMX]], or [[ciprofloxacin]]
|-
| ''[[Candida]]'' species || liposomal [[amphotericin B]] ± [[flucytosine]] || [[fluconazole]] or [[voriconazole]]
|-
| ''[[Aspergillus]]'' species || [[voriconazole]] || liposomal [[amphotericin B]] or [[posaconazole]]
|}

===Antimicrobial Dosages===
{| class="wikitable"
! Antimicrobial !! Children !! Adults
|-
| [[amikacin]] || 22.5 mg/kg divided q8h || 15 mg/kg divided q8h
|-
| [[amphotericin B]] lipid complex || colspan=2 | 5 mg/kg q24h
|-
| [[ampicillin]] || 300-400 mg/kg divided q6h || 12 g divided q4h
|-
| [[aztreonam]] || 120 mg/kg divided q6-8h || 6-8 g divided q6-8h
|-
| [[cefepime]] || 150 mg/kg divided q8h || 6 g divided q8h
|-
| [[cefotaxime]] || 300 mg/kg divided q6-8h || 8-12 g divided q4-6h
|-
| [[ceftazidime]] || 200 mg/kg divided q8h || 6 g divided q8h
|-
| [[ceftriaxone]] || 100 mg/kg divided q12-24h || 4 g divided q12h
|-
| [[ciprofloxacin]] || 30 mg/kg divided q8-12h || 800-1200 mg divided q8-12h
|-
| [[daptomycin]] || || 6-10 mg/kg divided q24h
|-
| [[fluconazole]] || 12 mg/kg divided q24h || 400-800 mg divided q24h
|-
| [[gentamicin]] || 7.5 mg/kg divided q8h || 5 mg/kg divided q8h
|-
| [[linezolid]] || 30 mg/kg divided q8h (<12 years)<br/>20 mg/kg divided q12h (≥12 years) || 1200 mg divided q12h
|-
| liposomal [[amphotericin B]] || colspan=2 | 3-5 mg/kg divided q24h
|-
| [[meropenem]] || 120 mg/kg divided q8h || 6 g divided q8h
|-
| [[moxifloxacin]] || || 400 mg divided q24h
|-
| [[nafcillin]] || 200 mg/kg divided q6h || 12 g divided q4h
|-
| [[oxacillin]] || 200 mg/kg divided q6h || 12 g divided q4h
|-
| [[penicillin G]] || 300,000 U/kg divided q4-6h || 24 million U divided q4h
|-
| [[posaconazole]] || || 800 mg divided q6-12h
|-
| [[rifampin]] || 20 mg/kg divided q24h || 600 mg divided q24h
|-
| [[tobramycin]] || 7.5 mg/kg divided q8h || 5 mg/kg divided q8h
|-
| [[TMP-SMX]] || colspan=2 | 10-20 mg/kg divided q6-12h
|-
| [[vancomycin]] || 60 mg/kg divided q6h || 30-60 mg/kg divided q8-12h
|-
| [[voriconazole]] || 16 mg/kg divided q12h || 8 mg/kg divided q12h
|}


[[Category:CNS infections]]
[[Category:CNS infections]]

Latest revision as of 15:14, 27 May 2021

Background

Microbiology

Clinical Presentation

  • Among patients with intraventricular drains, fever (72%) and elevated CSF cell count (93%) were most predictive of ventriculitis 1

Diagnosis

  • Gram stain and culture of CSF fluid from shunt aspiration, or from external ventricular drain that has a pleiocytosis
    • Prolonged culture of 7-10 days

Management

  • Empiric antimicrobials are typically indicated, with vancomycin plus an antipseudomonal such as ceftazidime or meropenem
    • If seriously ill, target a vancomycin trough of 15 to 20 μg/mL
    • Ciprofloxacin or aztreonam can be used in cases of β-lactam allergy
  • Narrow based on culture results
  • Removal of infected shunts, drains, intrathecal pumps, and deep brain stimulators is recommended

Duration of Antimicrobials

Organism Scenario Duration Without Shunt Duration With Shunt Timing of Shunt Reimplantation
Cutibacterium acnes or coagulase-negative staphylococci no CSF abnormalities and negative cultures within 48 hours of externalization 10 days as soon as day 3 following externalization
CSF abnormalities but negative repeat cultures 10 to 14 days 14 days after 7 days of antimicrobials
CSF abnormalities and positive repeat cultures 10 to 14 days 14 days after 7 to 10 days of negative cultures
Staphylococcus aureus or Gram-negative bacilli 14 days after 10 days of negative cultures
any persistent positive CSF cultures 14 days from last positive culture 7 to 10 days after last positive culture

Antimicrobial Selection

Organism First-line Second-line
Staphylococcus aureus (methicillin-susceptible) nafcillin or oxacillin vancomycin
Staphylococcus aureus (methicillin-resistant) vancomycin daptomycin, TMP-SMX, or linezolid
Streptococcus pneumoniae (penicillin MIC ≤0.06) penicillin G third-generation cephalosporin
Streptococcus pneumoniae (penicillin MIC ≥0.12) third-generation cephalosporin cefipime or meropenem
Streptococcus pneumoniae (ceftriaxone MIC ≥1) vancomycin plus a third-generation cephalosporin moxifloxacin
Pseudomonas aeruginosa cefipime, ceftazidime, or meropenem aztreonam or ciprofloxacin
Haemophilus influenzae (β-lactamase negative) ampicillin third-generation cephalosporin, cefepime, or a fluoroquinolone
Haemophilus influenzae (β-lactamase positive) third-generation cephalosporin cefepime, aztreonam, or a fluoroquinolone
ESBL Gram-negative bacillus meropenem cefepime or a fluoroquinolone
Acinetobacter baumannii meropenem colistin or polymixin B
Other Enterobacteriaceae third-generation cephalosporin meropenem, aztreonam, TMP-SMX, or ciprofloxacin
Candida species liposomal amphotericin B ± flucytosine fluconazole or voriconazole
Aspergillus species voriconazole liposomal amphotericin B or posaconazole

Antimicrobial Dosages

Antimicrobial Children Adults
amikacin 22.5 mg/kg divided q8h 15 mg/kg divided q8h
amphotericin B lipid complex 5 mg/kg q24h
ampicillin 300-400 mg/kg divided q6h 12 g divided q4h
aztreonam 120 mg/kg divided q6-8h 6-8 g divided q6-8h
cefepime 150 mg/kg divided q8h 6 g divided q8h
cefotaxime 300 mg/kg divided q6-8h 8-12 g divided q4-6h
ceftazidime 200 mg/kg divided q8h 6 g divided q8h
ceftriaxone 100 mg/kg divided q12-24h 4 g divided q12h
ciprofloxacin 30 mg/kg divided q8-12h 800-1200 mg divided q8-12h
daptomycin 6-10 mg/kg divided q24h
fluconazole 12 mg/kg divided q24h 400-800 mg divided q24h
gentamicin 7.5 mg/kg divided q8h 5 mg/kg divided q8h
linezolid 30 mg/kg divided q8h (<12 years)
20 mg/kg divided q12h (≥12 years)		 1200 mg divided q12h
liposomal amphotericin B 3-5 mg/kg divided q24h
meropenem 120 mg/kg divided q8h 6 g divided q8h
moxifloxacin 400 mg divided q24h
nafcillin 200 mg/kg divided q6h 12 g divided q4h
oxacillin 200 mg/kg divided q6h 12 g divided q4h
penicillin G 300,000 U/kg divided q4-6h 24 million U divided q4h
posaconazole 800 mg divided q6-12h
rifampin 20 mg/kg divided q24h 600 mg divided q24h
tobramycin 7.5 mg/kg divided q8h 5 mg/kg divided q8h
TMP-SMX 10-20 mg/kg divided q6-12h
vancomycin 60 mg/kg divided q6h 30-60 mg/kg divided q8-12h
voriconazole 16 mg/kg divided q12h 8 mg/kg divided q12h

References

  1. ^  Kirsten R.I.S. Dorresteijn, Korné Jellema, Diederik van de Beek, Matthijs C. Brouwer. Factors and measures predicting external CSF drain-associated ventriculitis. Neurology. 2019;93(22):964-972. doi:10.1212/wnl.0000000000008552.

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