Ventriculitis: Difference between revisions
From IDWiki
(Created page with "== Clinical Presentation == * Among patients with intraventricular drains, fever (72%) and elevated CSF cell count (93%) were most predictive of ventriculitis CiteRef::dorre...") |
No edit summary |
||
| Line 1: | Line 1: | ||
==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 antibiotic]] 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 |
|||
* Infected shunts should be removed and replaced with an EVD |
|||
** ''[[Cutibacterium acnes]]'' or [[coagulase-negative staphylococci]] |
|||
*** No CSF abnormalities and negative cultures within 48 hours of externalization: reimplant as soon as the third day after removal |
|||
*** CSF abnormalities but negative repeat cultures: reimplant after 7 days of antimicrobials |
|||
*** CSF abnormalities and positive repeat cultures: reimplant after 7 to 10 days of negative cultures |
|||
** ''[[Staphylococcus aureus]]'' or [[Gram-negative bacillus]]: reimplant after 10 days of negative cultures |
|||
===First- and second-line antimicrobials by organism=== |
|||
{| 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]] |
|||
|} |
|||
===Recommended 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]] |
||
Revision as of 00:13, 30 June 2020
Background
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 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 antibiotic 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
- Infected shunts should be removed and replaced with an EVD
- Cutibacterium acnes or coagulase-negative staphylococci
- No CSF abnormalities and negative cultures within 48 hours of externalization: reimplant as soon as the third day after removal
- CSF abnormalities but negative repeat cultures: reimplant after 7 days of antimicrobials
- CSF abnormalities and positive repeat cultures: reimplant after 7 to 10 days of negative cultures
- Staphylococcus aureus or Gram-negative bacillus: reimplant after 10 days of negative cultures
- Cutibacterium acnes or coagulase-negative staphylococci
First- and second-line antimicrobials by organism
Recommended 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
- ^ 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.
